Long-Term Outcomes of Fractional Flow Reserve-Guided vs. Angiography-Guided Percutaneous Coronary Intervention in Contemporary Practice

Study Questions:

What are the long-term outcomes of fractional flow reserve (FFR)-guided percutaneous coronary intervention (PCI) in general clinical practice?

Methods:

The authors compared the outcome of consecutive patients (n = 7,358) referred for PCI at the Mayo Clinic between October 2002 and December 2009. Patients were divided into two groups: those who underwent angiography-only–guided PCI (n = 6268), or those who underwent FFR measurements (FFR-guided, n = 1,090). These patients were further classified as the FFR-Perform group (n = 369) if FFR was followed by PCI, and the FFR-Defer group (n = 721) if PCI was deferred. The median follow-up was 51 months.

Results:

The rate of major adverse cardiac events at 7 years was 57.0% in the PCI-only versus 50.0% in the FFR-guided group (p = 0.016). Patients with FFR-guided interventions had a trend towards a lower rate of death or myocardial infarction compared with those with angiography-guided interventions (hazard ratio [HR], 0.85; 95% confidence interval [CI], 0.71-1.01; p = 0.06). Patients who underwent FFR but in whom PCI was deferred were at a reduced hazard of myocardial infarction (HR, 0.46; 95% CI, 0.26-0.82; p = 0.008).

Conclusions:

The authors concluded that an FFR-guided therapy is associated with better long-term outcome.

Perspective:

The benefits of FFR-guided PCI have been established in randomized controlled trials (e.g., FAME 2, N Engl J Med 2012; 367:991-1001). The current study, however, does not establish the superiority of FFR-guided PCI over angiography-guided PCI. Patients undergoing FFR had less advanced coronary artery disease, and were less likely to present with acute coronary syndrome. The better outcome in those undergoing FFR was mainly driven by the large number of patients who were in the FFR-defer group (who by definition did not have severe coronary artery disease). Nonetheless, there is strong evidence to support functional assessment of coronary stenosis prior to revascularization, and FFR guidance should be routinely utilized in the appropriate clinical setting.

Clinical Topics: Acute Coronary Syndromes, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Interventions and ACS, Interventions and Coronary Artery Disease, Interventions and Imaging, Angiography, Nuclear Imaging

Keywords: Coronary Artery Disease, Myocardial Infarction, Acute Coronary Syndrome, Follow-Up Studies, Coronary Stenosis, Coronary Angiography, Cardiovascular Diseases, Coronary Circulation, Confidence Intervals, Angioplasty, Percutaneous Coronary Intervention


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