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Long-Term Survival in Patients Undergoing Percutaneous Interventions With or Without Intracoronary Pressure Wire Guidance or Intracoronary Ultrasonographic Imaging: A Large Cohort Study
Study Questions:
What is the effect on long-term survival of using fractional flow reserve (FFR) and intravascular ultrasound (IVUS) during percutaneous coronary intervention (PCI)?
Methods:
This was a cohort study based on the pan-London (United Kingdom) PCI registry. In total, 64,232 patients are included in this registry covering the London, England, area. All patients (n = 41,688) who underwent elective or urgent PCI in National Health Service hospitals in London between January 1, 2004, and July 31, 2011, were included. Patients with ST-segment elevation myocardial infarction (n = 11,370) were excluded. Patients underwent PCI guided by angiography (visual lesion assessment) alone, PCI guided by FFR, or IVUS-guided PCI. The primary endpoint was all-cause mortality at a median of 3.3 years. Time-to-event analyses were performed with a multivariate Cox proportional hazards model.
Results:
FFR was used in 2,767 patients (6.6%) and IVUS was used in 1,831 patients (4.4%). No difference in mortality was observed between patients who underwent angiography-guided PCI compared with patients who underwent FFR-guided PCI (hazard ratio [HR], 0.88; 95% confidence interval [CI], 0.67-1.16; p = 0.37). Patients who underwent IVUS had a slightly higher adjusted mortality (HR, 1.39; 95% CI, 1.09-1.78; p = 0.009) compared with patients who underwent angiography-guided PCI. However, this difference was no longer statistically significant in a propensity score–based analysis (HR, 1.33; 95% CI, 0.85-2.09; p = 0.25). The mean (standard deviation) number of implanted stents was lower in the FFR group (1.1 [1.2] stents) compared with the IVUS group (1.6 [1.3]) and the angiography-guided group (1.7 [1.1]) (p < 0.001).
Conclusions:
The authors concluded that FFR-guided PCI and IVUS-guided PCI were not associated with improved long-term survival compared with standard angiography-guided PCI.
Perspective:
This large cohort study with a median follow-up period of 3.3 years showed no mortality benefit for FFR-guided or IVUS-guided PCI compared with angiography alone. The use of FFR was associated with fewer implanted stents, which represented a secondary endpoint. These data are in line with results from previous randomized trials suggesting that FFR-guided PCI may have a stent-sparing effect, but this did not translate into a survival benefit. A recently published FAME 2 substudy revealed an incremental cost-effectiveness ratio of $36,000 per quality-adjusted life-year for FFR-guided PCI related to lower stent costs, and may have health policy implications.
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