Revascularization Deferral of Nonculprit Stenoses Based on FFR

Aug 19, 2020
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Authors:
Cerrato E, Mejía-Rentería H, Dehbi HM, et al.
Citation:
Revascularization Deferral of Nonculprit Stenoses on the Basis of Fractional Flow Reserve: 1-Year Outcomes of 8,579 Patients. JACC Cardiovasc Interv 2020;13:1894-1903.
Summary By:
Bina Ahmed, MD, FACC

Quick Takes

  • Deferral of nonculprit lesions based on FFR is associated with higher rates of unplanned revascularization at 1 year among patients with ACS compared to patients with stable angina.
  • Reliability of FFR in the setting of ACS remains to be determined.
  • The role and clinical application of physiological indexes in ACS needs further examination.

Study Questions:

Is it safe to defer nonculprit lesions based on fractional flow reserve (FFR) in patients with acute coronary syndromes (ACS)?

Methods:

This was a pooled analysis of individual patient data from five large international published studies on physiology-guided revascularization. The primary endpoint was major adverse cardiac events (MACE) (a composite of death, nonfatal myocardial infarction, or unplanned revascularization) at 1-year follow-up. Clinical outcomes of patients with ACS and stable angina pectoris (SAP) were compared in both the deferred and the revascularized groups.

Results:

A total of 8,579 patients were included in the analysis, 6,461 with SAP and 2,118 with ACS and nonculprit stenoses. Using FFR, revascularization was deferred in 5,129 patients (59.8%) and performed in 3,450 patients (40.2%). In the deferred ACS group, a higher MACE rate was observed compared with 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). In particular, early unplanned revascularization (3.34% and 2.04% in ACS and SAP; adjusted hazard ratio [HR], 1.81; 95% confidence interval [CI], 1.09-3.00; p = 0.02) contributed to this excess in MACE, but the difference between the ACS and SAP groups did not reach statistical significance. On the contrary, no differences in outcomes 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:

Patients with ACS in whom revascularization of nonculprit lesions was deferred on the basis of FFR have more MACE at 1 year compared with patients with SAP with deferred revascularization. Unplanned revascularization mainly contributed to this excess of MACE.

Perspective:

When comparing nonculprit lesions among patients with ACS versus those with SAP, deferral of lesions based on FFR is associated with a higher rate of unplanned revascularization in the ACS group. Findings were not able to clarify which lesions required subsequent revascularization (deferred, original culprit, or new lesion) or what the clinical implications of these findings are. There was no difference in rates of nonfatal myocardial infarction or death. This study adds important data to a complex question about the reliability and applicability of FFR across the spectrum of ACS. But it remains to be determined what the role of FFR should be in ACS.

Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Cardiovascular Care Team, Invasive Cardiovascular Angiography and Intervention, Stable Ischemic Heart Disease, Cardiac Surgery and SIHD, Interventions and ACS, Chronic Angina

Keywords: Acute Coronary Syndrome, Angina, Stable, Constriction, Pathologic, Fractional Flow Reserve, Myocardial, Myocardial Infarction, Myocardial Revascularization, Physiology


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