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Revascularization Deferral of Nonculprit Stenoses Based on FFR
Quick Takes
- FFR-based revascularization deferral in ACS patients was associated with higher 1-year MACE rates as compared to patients with stable angina pectoris.
- The difference in MACE rate was predominantly driven by a higher rate of early unplanned revascularization in patients with ACS.
- Additional prospective studies are indicated to determine the safety of physiology-based revascularization deferral of nonculprit lesions in ACS patients.
Study Questions:
What is the safety of revascularization deferral based on fractional flow reserve (FFR) interrogation of nonculprit lesions (NCLs) in patients with acute coronary syndromes (ACS)?
Methods:
The investigators performed a pooled analysis of individual patient data included in five large international published studies on physiology-guided revascularization. The primary endpoint was major adverse cardiac events (MACE: composite of death, nonfatal myocardial infarction, or unplanned revascularization) at 1-year follow-up. Clinical outcomes of ACS and stable angina pectoris (SAP) patients were compared, both in the deferred and in the revascularized groups. For MACE and its components, time-to-event analyses were performed.
Results:
A total of 8,579 patients were included in the analysis: 6,461 presented with SAP and 2,118 with ACS and NCLs. Using FFR, revascularization was deferred in 5,129 (59.8%) and performed in 3,450 patients (40.2%). In the deferred-ACS group, a higher MACE rate was observed compared to the deferred-SAP group (4.46% vs. 2.83%, adjusted hazard ratio [HR], 1.72; 95% confidence interval [CI], 1.17-2.53; p < 0.01). Both early unplanned revascularization (3.34% vs. 2.04% in ACS and SAP, adjusted HR, 1.81; 95% CI, 1.09-3.00; p = 0.02), and mortality (0.86% vs. 0.56% in ACS and SAP, adjusted HR, 1.60; 95% CI, 0.68-3.79; p = 0.28) contributed to this excess in MACE. On the contrary, no differences in outcome linked to clinical presentation were found in treated patients (MACE rate 6.51% vs. 6.20%, adjusted HR, 1.21; 95% CI, 0.88-1.26; p = 0.24).
Conclusions:
The authors concluded that patients with ACS in whom revascularization of NCL was deferred based on FFR have more MACE at 1 year, compared to SAP patients with deferred revascularization.
Perspective:
This pooled analysis reports that FFR-based revascularization deferral in ACS patients was associated with higher 1-year MACE rates as compared to patients with SAP. The difference in MACE rate was predominantly driven by a higher rate of early unplanned revascularization in patients with ACS. One possible explanation is that FFR measurements in the acute setting of ACS may lead to misclassification of the severity of nonculprit stenoses, compared to subacute FFR measurements. An important limitation of the current analysis is that it did not distinguish among unplanned revascularization occurring on a previously FFR-deferred lesion versus another de novo stenosis. Additional prospective studies are indicated to determine the safety of physiology-based revascularization deferral of NCLs in ACS patients.
Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Cardiovascular Care Team, Invasive Cardiovascular Angiography and Intervention, Prevention, Stable Ischemic Heart Disease, Cardiac Surgery and Arrhythmias, Cardiac Surgery and SIHD, Interventions and ACS, Chronic Angina
Keywords: Acute Coronary Syndrome, Angina Pectoris, Angina, Stable, Constriction, Pathologic, Fractional Flow Reserve, Myocardial, Myocardial Infarction, Myocardial Ischemia, Myocardial Revascularization, Secondary Prevention
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