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Angiography-Derived Fractional Flow Reserve in the SYNTAX II Trial
Study Questions:
What is the applicability of quantitative flow ratio (QFR) in patients with three-vessel disease (3VD), and what is the impact of functional SYNTAX score derived from QFR (fSSQFR) on clinical outcomes?
Methods:
The investigators retrospectively screened all the lesions interrogated with instantaneous wave-free ratio (iFR) and/or fractional flow reserve (FFR) in the SYNTAX II trial and analyzed for QFR. The diagnostic performance of QFR was investigated with hybrid wire-derived pressure assessment (iFR/FFR) utilized in the trial as a reference. Patients with analyzable QFR in three vessels were stratified according to fSSQFR to evaluate its clinical prognostic value based on 2-year patient-oriented composite endpoint (POCE).
Results:
QFRs were analyzable in 71.0% of the lesions (836 lesions). The diagnostic performance of QFR to predict binary wire-based ischemia was substantial (area under a curve [AUC] 0.81, accuracy 73.8%) with a positive predictive value of 85.9%. Independent predictors for diagnostic discordance were lesions in side branches, involvement of bifurcation/trifurcation, and small vessel. According to 2-year POCE, fSSQFR reclassified 26.1% (36/138) of the patients in the high-/intermediate-risk group into low-risk group appropriately (net reclassification improvement 0.32, p < 0.001). AUC of fSSQFR predicting 2-year POCE was higher than that of classic anatomical SYNTAX score (0.68 vs. 0.56, p = 0.002).
Conclusions:
The authors concluded that QFR demonstrated substantial applicability in patients with 3VD.
Perspective:
This post hoc substudy of the SYNTAX II trial reports that the feasibility of QFR was achieved in 71% of lesions, and in 28.2% of these patients, it was feasible in the entire coronary circulation. Furthermore, QFR demonstrated substantial diagnostic performance with high positive predictive value, but low negative predictive value was observed, especially for lesions in small vessels (vessel diameter ≤2.25 mm) and bifurcation or trifurcation lesions. It appears that the fSSQFR has the potential to further refine prognostic risk estimation in a less invasive fashion. Additional studies are indicated to assess the impact of the fSSQFR on the treatment decision of a heart team for patients with multivessel disease.
Clinical Topics: Invasive Cardiovascular Angiography and Intervention, Prevention, Interventions and Imaging, Angiography, Nuclear Imaging
Keywords: Angiography, Cardiology Interventions, Coronary Circulation, Fractional Flow Reserve, Myocardial, Myocardial Ischemia, Primary Prevention, Risk Assessment, Vascular Diseases
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