Significance of Intermediate Values of Fractional Flow Reserve in Patients With Coronary Artery Disease

Adjedj, Julien; Bruyne, Bernard De; Floré, Vincent; Gioia, Giuseppe Di; Ferrara, Angela; Pellicano, Mariano; Tóth, Gábor G.; Bartúnek, Jozef; Vanderheyden, Marc; Heyndrickx, Guy R.; Wijns, William; Barbato, Emanuele

doi:10.1161/circulationaha.115.018747

Cited by 125 publications

(81 citation statements)

References 34 publications

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“…The majority of the existing data from clinical trials relate to the use of intravascular imaging guidance during PCI and are discussed in section 16. The use of intravascular imaging to evaluate patients with stent failure is discussed in section 13. Regarding the assessment of intermediate-grade stenosis, a number of studies have evaluated the optimal cut-off of minimal lumen area for the identification of haemodynamically relevant lesions.…”

Section: Use Of Intravascular Imaging For the Diagnostic Assessment Omentioning

confidence: 99%

2018 ESC/EACTS Guidelines on myocardial revascularization

Neumann¹,

Ahlsson²,

Alfonso³

et al. 2018

European Heart Journal

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Section: Use Of Intravascular Imaging For the Diagnostic Assessment Omentioning

confidence: 99%

2018 ESC/EACTS Guidelines on myocardial revascularization

Neumann¹,

Ahlsson²,

Alfonso³

et al. 2018

European Heart Journal

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2,078

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“…18 were treated either by revascularisation or medical therapy. 20 Rates of major adverse cardiac events (death, MI and any revascularisation) up to 5 years were comparable between medical therapy and revascularisation groups (13.9 and 11.2%, respectively; p=0.30), whereas a trend towards a higher rate of death or MI was observed in the medical therapy group (9.4 versus 4.8 %, respectively; p=0.06).…”

Section: Famous-nstemi Trialmentioning

confidence: 80%

The FAME Trials: Impact on Clinical Decision Making

Heyndrickx

Tóth

2016

Interventional Cardiology Review

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Careful and stepwise evaluation of the fractional flow reserve (FFR) index has been performed over the years, culminating in the landmark Fractional Flow Reserve Versus Angiography for Multivessel Evaluation (FAME) and Fractional Flow Reserve-Guided Percutaneous Coronary Intervention Plus Optimal Medical Treatment Versus Optimal Medical Treatment Alone in Patients with Stable Coronary Artery Disease (FAME II) trials. Findings from these studies demonstrated unequivocally the overall inadequacy of angiography versus FFR to correctly assess stenosis severity. Thus, proof of concept and clinical applicability was established beyond debate and will be discussed here. KeywordsCoronary artery disease, ischaemia, angiography, fractional flow reserve, FAME Disclosure: The authors have no disclosures to make that are relevant to the present article. The presence as well as the extent of myocardial ischaemia are key to determining cardiovascular outcome, 1-3 thus its identification is important. An endeavour to improve diagnostic accuracy in deciding which angiographic lesions are haemodynamically significant led to the development of the concept of fractional flow reserve (FFR). Based on pressure-flow analysis of a stenosis during maximum flow, the FFR indicates the impact of a coronary stenosis on the maximum inducible coronary flow and whether it would be susceptible to induce ischaemia during stress. In a landmark report, Pijls and co-workers validated the FFR index in a group of patients with single moderate coronary artery stenosis using three different non-invasive stress tests (exercise test, thallium scan and stress echocardiogram). 4 Based on the findings of this study, the authors proposed a cut-off FFR value of 0.75 as a threshold for discrimination between ischaemia-inducible and ischaemia-noninducible lesions (see for example Figure 1). In the DEFER (Deferral versus Performance of PercutaneousTransluminal Coronary Angioplasty in Patients Without Documented Ischaemia) trial, the predictive value of this novel invasive index was tested for the first time in patients. 5 The DEFER study was designed to investigate the safety and outcomes of deferring stenting in angiographic (FFR >0.75) stenoses. A total of 325 patients who were referred for percutaneous coronary intervention (PCI) due to an angiographic significant stenosis of >50 % were randomised to either the PCI group or PCI-deferral group. PCI was performed regardless of the FFR value in the PCI group. In the PCI-deferral group, PCI was undertaken only when the FFR was ≤0.75, and was deferred when the FFR was >0.75. At 12 months, event-free survival rates were similar in the deferral and PCI groups (89 versus 83 %, respectively; p=0.27).The results of this study indicate that a large number of patients referred for PCI on the basis of a coronary stenosis without objective proof of ischaemia had nonsignificant lesions as indicated by the FFR value. Stenting these patients did not reduce the rates of adverse cardiac events neither did it result in an...

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“…Several studies investigated the prognostic impact of the extent of anatomical nonobstructive disease evaluated by coronary angiography9, 20 or coronary computed tomography angiography 8, 21, 22. In the CONFIRM (coronary CT angiography evaluation for clinical outcomes: an international multicenter registry) registry,22 patients with 2‐ or 3‐vessel involvement of nonobstructive (1–49% diameter stenosis) CAD on coronary computed tomography angiography had a 3‐fold higher risk of all‐cause mortality than normal subjects.…”

Section: Discussionmentioning

confidence: 99%

Clinical Relevance of Functionally Insignificant Moderate Coronary Artery Stenosis Assessed by 3‐Vessel Fractional Flow Reserve Measurement

Park

Lee

Koo

et al. 2018

JAHA

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BackgroundUnderstanding of the risk conferred by functionally insignificant lesions in multiple coronary vessels is limited. We investigated the prognostic implications of coronary artery disease (CAD) based on 3‐vessel fractional flow reserve (FFR).Methods and ResultsA total of 1,136 patients underwent FFR measurement in the 3 major epicardial arteries. We defined vessels with “Moderate CAD” as vessels with FFR, 0.81 to 0.87. Patients were classified into Group 1: No apparent CAD (FFR>0.87 in all 3‐vessels); Group 2: Single‐vessel moderate CAD; Group 3: Multivessel moderate CAD; and Group 4: Functionally significant CAD (FFR≤0.80) in any vessel. The primary end point was 2‐year major adverse cardiac events, a composite of cardiac death, myocardial infarction, and ischemia‐driven revascularization. Forty‐three percent of patients had moderate CAD (Group 2: 403/1136, 35.5%; Group 3: 84/1136, 7.4%). The 2‐year risk of major adverse cardiac events was not significantly different between patients with single‐vessel moderate CAD and no apparent CAD (2.6 versus 2.6%; HR, 1.1; 95% confidence interval, 0.4%–2.8%; P=0.89). However, patients with multivessel moderate CAD were at significantly higher risk than Group 1 (7.4 versus 2.6%; hazard ratio, 3.3; 95% confidence interval, 1.1%–9.8%; P=0.03). The risk of major adverse cardiac events in patients with multivessel moderate CAD was comparable to that of patients with functionally significant CAD (hazard ratio, 1.2; 95% confidence interval, 0.5%–3.0%; P=0.67). In a multivariable regression model, multivessel moderate CAD was an independent predictor of greater risk of 2‐year major adverse cardiac events.ConclusionsGlobal physiologic assessment with FFR measurement of 3 vessels can identify multivessel moderate CAD. The prognostic implication of multivessel moderate CAD appears comparable to that of functionally significant CAD.Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT01621438.

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Significance of Intermediate Values of Fractional Flow Reserve in Patients With Coronary Artery Disease

Cited by 125 publications

References 34 publications

2018 ESC/EACTS Guidelines on myocardial revascularization

2018 ESC/EACTS Guidelines on myocardial revascularization

The FAME Trials: Impact on Clinical Decision Making

Clinical Relevance of Functionally Insignificant Moderate Coronary Artery Stenosis Assessed by 3‐Vessel Fractional Flow Reserve Measurement

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