A 63-year-old male with hypertension, hyperlipidemia and previous smoking history presented to his cardiologist's office with a 3-month history of exertional chest pain. Exercise nuclear stress test revealed diffuse >1mm ST depressions without drop in ejection fraction, transient ischemic dilation, or distinct areas of infarction on images concerning for balanced ischemia. He subsequently underwent cardiac catheterization which revealed triple vessel coronary artery disease with 90% stenosis of the mid left anterior descending coronary artery, 75% stenosis of the proximal right coronary artery, and 80% stenosis of the mid left circumflex coronary artery. The left main was free of disease. Syntax score was 26. Despite the symptoms, he has been able to continue his work at his own landscaping business and would like to would like return to work as soon as possible after any indicated intervention.
Which revascularization approach offers improved QOL within the first year post-procedure?
The correct answer is: A. Fractional Flow Reserve (FFR) guided - Percutaneous Coronary Intervention (PCI)
A recent analysis of the Fractional Flow Reserve versus Angiography for Multivessel Evaluation (FAME) 3 trial assessed quality-of-life (QOL) after FFR guided PCI with current generation zotarolimus drug eluting stent compared with CABG.1 The study originally enrolled 1,500 patients with triple vessel disease without left main artery involvement and randomized them 1:1 to either treatment arm. The main measure of QOL was the European QOL–5 Dimensions (EQ-5D) that assessed QOL across the areas of mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. At 12 months, no difference between groups was seen with regards to QOL, angina, or percentage of patients working full-time or part-time. However, trajectory of QOL improvement was greater in the PCI group (< 0.001). For patients under the age of 65, at 1 year, 68% in the PCI group returned to work in the first year versus 57% in the CABG group (p< 0.05). Derived QOL benefits will need to be weighed against possible PCI risks given that this approach did not meet the criterion set for noninferiority regarding major adverse cardiac and cerebrovascular events at 1 year. Previous post procedural comparisons favor CABG as early as 6 months post operatively with regards to angina frequency and QOL benefits.2 Restenosis post PCI was previously pinpointed as a cause of decreased QOL yet none of these studies employed FFR guidance. PCI performed on lower abnormal FFR groups has been previously correlated with greater improvement in QOL and may account for the QOL trends seen in the FAME 3 trial.3
Fearon WF, Zimmermann FM, Ding VY, et al. Quality of life after fractional flow reserve-guided PCI compared with coronary bypass surgery. Circulation 2022;145:1655-62.
Fatima K, Yousuf-Ul-Islam M, Ansari M, et al. Comparison of the postprocedural quality of life between coronary artery bypass graft surgery and percutaneous coronary intervention: a systematic review. Cardiol Res Pract 2016;2016:7842514.
Nishi T, Piroth Z, De Bruyne B, et al. Fractional flow reserve and quality-of-life improvement after percutaneous coronary intervention in patients with stable coronary artery disease. Circulation 2018;138:1797-1804.