Fractional Flow Reserve Versus Angiography for Guiding PCI
Objectives The purpose of this study was to investigate whether fractional flow reserve (FFR) should be performed for patients with coronary artery disease (CAD) to guide the percutaneous coronary intervention (PCI) strategy.
Background PCI is the most effective method to improve the outcomes of CAD. However, the proper usage of PCI has not been achieved in clinical practice.
Methods A meta-analysis was performed on angiography-guided PCI and FFR-guided PCI strategies. Prospective and retrospective studies were included when research subjects were patients with CAD undergoing PCI. The primary endpoint was the rate of major adverse cardiac events (MACE) or major adverse cardiac and cerebrovascular events (MACCE). Secondary endpoints included death, myocardial infarction (MI), repeat revascularisation and death or MI.
Results Four prospective and three retrospective studies involving 49 517 patients were included. Absolute risks of MACE/MACCE, death, MI, revascularisation and death or MI for angiography-guided PCI and FFR-guided PCI were 34.8% vs 22.5%, 15.3% vs 7.6%, 8.1% vs 4.2%, 20.4% vs 14.8%, and 21.9% vs 11.8%, respectively. The meta-analysis demonstrated that FFR-guided PCI was associated with lower MACE/MACCE (OR: 1.71, 95% CI 1.31 to 2.23), death (OR: 1.64, 95% CI 1.37 to 1.96), MI (OR: 2.05, 95% CI 1.61 to 2.60), repeat revascularisation (OR: 1.25, 95% CI 1.09 to 1.44), and death or MI (OR: 1.84, 95% CI 1.58 to 2.15) than angiography-guided PCI strategy.
Conclusions This meta-analysis supports current guidelines advising the FFR-guided PCI strategy for CAD. PCI should only be performed when haemodynamic significance is found.
To date, coronary artery disease (CAD) remains the leading cause of death worldwide. The standard technique for the diagnosis and treatment of anatomic CAD has been coronary angiography. However, the most important prognostic factor in patients with CAD is the presence and extent of inducible ischaemia. Performing percutaneous coronary intervention (PCI) for stenoses that are anatomically worrisome but not functionally significant will diminish the benefit of relieving ischaemia by exposing the patients to an increased stent-related risk.
Fractional Flow Reserve (FFR), defined as the ratio of pressure distal to the stenosis and aortic pressure after induced maximal hyperaemia, can identify the haemodynamically significant lesions. In patients with multivessel CAD, the FAME (Fractional Flow Reserve vs Angiography for Multivessel Evaluation) study indicates that FFR-guided revascularisation relates lower rates of adverse events with lower healthcare costs than angiography-guided revascularisation. FFR is now considered the gold standard for guiding percutaneous coronary revascularisation with class IA European Society of Cardiology and class IIA American Heart Association practice guideline recommendations. The normal value of FFR is 1.0, regardless of the patient or the specific vessel studied. Coronary lesions with FFR <0.75 are almost always functionally significant, whereas stenoses with FFR >0.80 are rarely associated with inducible ischaemia.
Despite the apparent benefits, the adoption of FFR into daily clinical practice has been limited due to the invasive nature of the procedure, the need for pharmacologic vasodilation, and risks related to instrumentation of the coronary arteries.
Almost all studies comparing an angiography-guided PCI strategy with an FFR-guided one in patients with CAD are of a small scale, and most of them are retrospective studies which do not have a high evidence level. We performed this meta-analysis of contemporary clinical trials that compared the two strategies in patients with CAD to identify the advantages of FFR for guiding PCI strategy.
Abstract and Introduction
Abstract
Objectives The purpose of this study was to investigate whether fractional flow reserve (FFR) should be performed for patients with coronary artery disease (CAD) to guide the percutaneous coronary intervention (PCI) strategy.
Background PCI is the most effective method to improve the outcomes of CAD. However, the proper usage of PCI has not been achieved in clinical practice.
Methods A meta-analysis was performed on angiography-guided PCI and FFR-guided PCI strategies. Prospective and retrospective studies were included when research subjects were patients with CAD undergoing PCI. The primary endpoint was the rate of major adverse cardiac events (MACE) or major adverse cardiac and cerebrovascular events (MACCE). Secondary endpoints included death, myocardial infarction (MI), repeat revascularisation and death or MI.
Results Four prospective and three retrospective studies involving 49 517 patients were included. Absolute risks of MACE/MACCE, death, MI, revascularisation and death or MI for angiography-guided PCI and FFR-guided PCI were 34.8% vs 22.5%, 15.3% vs 7.6%, 8.1% vs 4.2%, 20.4% vs 14.8%, and 21.9% vs 11.8%, respectively. The meta-analysis demonstrated that FFR-guided PCI was associated with lower MACE/MACCE (OR: 1.71, 95% CI 1.31 to 2.23), death (OR: 1.64, 95% CI 1.37 to 1.96), MI (OR: 2.05, 95% CI 1.61 to 2.60), repeat revascularisation (OR: 1.25, 95% CI 1.09 to 1.44), and death or MI (OR: 1.84, 95% CI 1.58 to 2.15) than angiography-guided PCI strategy.
Conclusions This meta-analysis supports current guidelines advising the FFR-guided PCI strategy for CAD. PCI should only be performed when haemodynamic significance is found.
Introduction
To date, coronary artery disease (CAD) remains the leading cause of death worldwide. The standard technique for the diagnosis and treatment of anatomic CAD has been coronary angiography. However, the most important prognostic factor in patients with CAD is the presence and extent of inducible ischaemia. Performing percutaneous coronary intervention (PCI) for stenoses that are anatomically worrisome but not functionally significant will diminish the benefit of relieving ischaemia by exposing the patients to an increased stent-related risk.
Fractional Flow Reserve (FFR), defined as the ratio of pressure distal to the stenosis and aortic pressure after induced maximal hyperaemia, can identify the haemodynamically significant lesions. In patients with multivessel CAD, the FAME (Fractional Flow Reserve vs Angiography for Multivessel Evaluation) study indicates that FFR-guided revascularisation relates lower rates of adverse events with lower healthcare costs than angiography-guided revascularisation. FFR is now considered the gold standard for guiding percutaneous coronary revascularisation with class IA European Society of Cardiology and class IIA American Heart Association practice guideline recommendations. The normal value of FFR is 1.0, regardless of the patient or the specific vessel studied. Coronary lesions with FFR <0.75 are almost always functionally significant, whereas stenoses with FFR >0.80 are rarely associated with inducible ischaemia.
Despite the apparent benefits, the adoption of FFR into daily clinical practice has been limited due to the invasive nature of the procedure, the need for pharmacologic vasodilation, and risks related to instrumentation of the coronary arteries.
Almost all studies comparing an angiography-guided PCI strategy with an FFR-guided one in patients with CAD are of a small scale, and most of them are retrospective studies which do not have a high evidence level. We performed this meta-analysis of contemporary clinical trials that compared the two strategies in patients with CAD to identify the advantages of FFR for guiding PCI strategy.