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Fractional Flow Reserve in Stable Ischemic Heart Disease Patients
Study Questions:
What are trends in use of fractional flow reserve (FFR) and its effects on clinical outcomes among patients with stable ischemic heart disease (SIHD) and intermediate stenoses?
Methods:
Data were analyzed from the Veterans Affairs (VA) Clinical Assessment, Reporting, and Tracking (CART) Program to analyze patients who underwent coronary angiography between January 1, 2009, and September 30, 2017, and had SIHD with angiographically intermediate disease (40-69% diameter stenosis on visual inspection). The authors documented trends in FFR utilization and evaluated predictors using generalized mixed models. They applied Cox proportional hazards models to determine the association between an FFR-guided revascularization strategy and all-cause mortality at 1 year.
Results:
A total of 17,989 patients at 66 sites were included. The rate of FFR use gradually increased from 14.8% to 18.5% among all patients with intermediate lesions, and from 44% to 75% among patients who underwent percutaneous coronary intervention (PCI). One-year mortality was 2.8% in the FFR group and 5.9% in the angiography-only group (p < 0.0001). After adjustment for patient, site-level, and procedural factors, FFR-guided revascularization was associated with a 43% lower risk of mortality at 1 year compared with angiography-only revascularization (hazard ratio, 0.57; 95% confidence interval, 0.45-0.71; p < 0.0001).
Conclusions:
In patients with SIHD and angiographically intermediate stenoses, use of FFR has slowly risen, and was associated with significantly lower 1-year mortality.
Perspective:
This analysis from the VA database shows increasing use of FFR over time, albeit a small increase in all-comers and a more substantial increase among those undergoing PCI. The FFR-guided group had a 43% relative reduction in all-cause 1-year mortality; however, there was no difference in rates of myocardial infarction, stroke, or repeat revascularization between the groups. Keeping the limitations of a retrospective analysis in mind and that this was an almost completely male-only cohort, findings further bolster the benefits of using FFR to assess all stable intermediate coronary lesions prior to PCI.
Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Aortic Surgery, Interventions and Imaging, Angiography, Nuclear Imaging
Keywords: Constriction, Pathologic, Coronary Angiography, Fractional Flow Reserve, Myocardial, Myocardial Infarction, Myocardial Ischemia, Myocardial Revascularization, Percutaneous Coronary Intervention, Stroke, Veterans
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