Contemporary Patterns of Fractional Flow Reserve and Intravascular Ultrasound Use Among Patients Undergoing Percutaneous Coronary Intervention in the United States: Insights From the National Cardiovascular Data Registry

Study Questions:

What are the current patterns of use of both fractional flow reserve (FFR) and intravascular ultrasound (IVUS) associated with percutaneous coronary intervention (PCI) of intermediate lesions, and how might their use relate to procedural and patient-based outcomes?

Methods:

The investigators analyzed data for patients undergoing PCI of intermediate coronary stenoses (defined as a percent diameter stenosis ≥40% and ≤70%). Patients were excluded if PCI was performed for a nonintermediate stenosis (n = 373,320), if they underwent diagnostic angiography only (AO) (n = 1,977), or if they underwent both FFR and IVUS (n = 778). They examined data starting from April 2009 when version 4 of the CathPCI Registry data collection form began to be implemented, as IVUS and FFR use for PCI of intermediate stenoses were not collected in earlier versions. Logistic regression was used to compare in-hospital mortality and procedural success, adjusting for baseline patient characteristics in the CathPCI Registry mortality risk model.

Results:

Data for 61,874 attempted coronary interventions of intermediate coronary stenoses, performed between April 2009 and September 2010, were available for analysis. Among these, FFR was used in 3,763 (6.1%) patients, IVUS was used in 12,589 (20.3%) patients, and 45,522 (73.6%) patients had lesions assessed by AO. Compared with patients who underwent AO, patients undergoing FFR were more likely to be younger (p < 0.0001) and more frequently male (p < 0.0001), with slightly lower rates of diabetes (p = 0.017) and hypertension (p = 0.0003), and higher rates of dyslipidemia (p < 0.0001). Patients undergoing IVUS were younger (p < 0.0001) and less frequently male (p < 0.0001), with slightly lower rates of diabetes (p < 0.0001) and similar rates of hypertension (p = 0.75) and dyslipidemia (p = 0.31). After adjusting for comorbid conditions, the use of IVUS was associated with higher rates of major bleeding (odds ratio [OR], 1.23; interquartile range [IQR], 1.09-1.38; p < 0.001), lower rates of in-hospital death (OR, 0.66; IQR, 0.44-0.98; p = 0.04), and no difference in procedural success (OR, 1.10; IQR, 0.97-1.26; p = 0.14) compared with AO. No difference between the FFR and AO groups was seen in adjusted comparisons of mortality (OR, 1.07; IQR, 0.53-2.15; p = 0.857), major bleeding (OR, 0.95; IQR, 0.76-1.19; p = 0.683), or procedural success (OR, 0.97; IQR, 0.76-1.25; p = 0.836).

Conclusions:

The authors concluded that despite a wealth of data demonstrating the utility of these technologies in the evaluation of intermediate coronary stenoses, IVUS (20.3%) and FFR (6.1%) are used in only a small minority of such cases.

Perspective:

The study suggests that after adjustment for comorbidities, IVUS appears to be associated with lower rates of in-patient mortality, but was associated with higher rates of major bleeding, whereas FFR showed no such correlations. Neither technology was associated with differences in procedural success. However, since these data were analyzed retrospectively, outcomes associated with the use of IVUS and FFR are observational, and causality cannot be inferred. The 2012 American College of Cardiology Foundation (ACCF) Appropriate Use Criteria for Diagnostic Catheterization and the ACCF/American Heart Association 2011 PCI guidelines recommend FFR or IVUS as appropriate in angiographically indeterminate severity stenosis, and further dissemination of these guidelines will likely increase use of these adjunctive tests.

Clinical Topics: Diabetes and Cardiometabolic Disease, Dyslipidemia, Invasive Cardiovascular Angiography and Intervention, Prevention, Hypertension

Keywords: Odds Ratio, Hospital Mortality, Comorbidity, Constriction, Pathologic, Angioplasty, Balloon, Coronary, Percutaneous Coronary Intervention, Minority Groups, Registries, Dyslipidemias, Coronary Stenosis, Catheterization, Hypertension, United States, Diabetes Mellitus, Logistic Models


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