Trial of Angiography versus pressure-Ratio Guided Enhancement Techniques - Fractional Flow Reserve - TARGET FFR

Dec 13, 2021
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Author/Summarized by Author:
Anthony A. Bavry, MD, MPH, FACC
Summary Reviewer:
Deepak L. Bhatt, MD, MPH, MBA, FACC
Trial Sponsor:
NHS National Waiting Times Centre Board endowment funds
Date Presented:
10/16/2020
Date Published:
09/04/2021
Date Updated:
12/13/2021
Original Posted Date:
10/16/2020
References

Contribution To Literature:

Highlighted text has been updated as of December 13, 2021.

The TARGET FFR trial failed to show that a physiology-guided incremental optimization strategy was beneficial at improving the proportion of physiologically optimal PCI.

Description:

The goal of the trial was to evaluate a physiology-guided incremental optimization strategy compared with usual care among patients who underwent angiographically successful percutaneous coronary intervention (PCI).

Study Design

  • Randomized
  • Parallel
  • Blinded

After successful PCI, subjects underwent FFR of the target lesion. Subjects were randomized to a physiology-guided incremental optimization strategy (n = 131) versus a blinded control group (n = 129). In the physiology-guided incremental optimization arm, PCI could be further optimized (post-dilatation or an additional stent) according to suboptimal FFR values.

  • Total number of enrollees: 260
  • Duration of follow-up: 1 year
  • Mean patient age: 59 years
  • Percentage female: 13%
  • Percentage with diabetes: 19%

Inclusion criteria:

  • Subjects ≥18 years of age who underwent angiographically successful PCI
  • Stable angina, medically stabilized non–ST-segment elevation myocardial infarction (NSTEMI), or staged completion of nonculprit vessel revascularization for NSTEMI or STEMI

Exclusion criteria:

  • PCI of a coronary bypass graft
  • PCI for in-stent restenosis
  • PCI to a vessel that is providing collateral blood flow to another territory
  • Inability to receive adenosine
  • Marked hypotension
  • Advanced AV block
  • Severe cardiomyopathy (left ventricular ejection fraction <30%)
  • Renal insufficiency

Other salient features/characteristics:

  • Post-PCI (pre-randomization), the FFR value was ≥0.9 in 32%, 0.81-0.89 in 39%, and ≤0.8 in 29%.
  • Among those with FFR <0.9 in the physiology-guided incremental optimization group, 25% had diffuse disease in which further optimization was not felt to be feasible, the operator declined optimization in 15%, and optimization was attempted in 31%.

Principal Findings:

The primary outcome, proportion of patients with FFR ≥0.9, was 38.1% in the physiology-guided incremental optimization group compared with 28.1% in the blinded control group (p = 0.099).

Secondary outcomes: The proportion of patients with FFR ≤0.8 was 18.6% in the physiology-guided incremental optimization group compared with 29.8% in the blinded control group (p = 0.045).

Interpretation:

Among patients who underwent angiographically successful PCI, a physiology-guided incremental optimization strategy failed to improve the proportion of patients with an optimal result (i.e., FFR ≥0.9). A possible explanation for the lack of benefit from physiology-guided incremental optimization is that optimization was only attempted in 31%. A physiology-guided incremental optimization strategy was associated with a decrease in suboptimal result (i.e., FFR ≤0.8). Appropriately powered randomized trials would be required to evaluate if physiology-guided optimization of PCI can improve patient outcomes.

References:

Collison D, Didagelos M, Aetesam-ur-Rahman M, et al. Post-stenting fractional flow reserve vs coronary angiography for optimization of percutaneous coronary intervention (TARGET-FFR). Eur Heart J 2021;42:4656-68.

Editorial: Erlinge D, Götberg M. We need intracoronary physiology guidance before percutaneous coronary intervention, but do we need it post-stenting? Eur Heart J 2021;42:4669-70.

Presented by Dr. Damien Collison at the Transcatheter Cardiovascular Therapeutics Virtual Meeting (TCT Connect), October 16, 2020.

Clinical Topics: Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Interventions and Imaging, Angiography, Nuclear Imaging

Keywords: Angiography, Coronary Angiography, Dilatation, Fractional Flow Reserve, Myocardial, Myocardial Ischemia, Percutaneous Coronary Intervention, Physiology, Stents, TCT20, Transcatheter Cardiovascular Therapeutics


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