Coronary Revascularization Guided by iFR Compared to FFR

Sep 06, 2023
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Authors:
Eftekhari A, Holck EN, Westra J, et al.
Citation:
Five-Year Major Cardiovascular Events Are Increased When Coronary Revascularization Is Guided by Instantaneous Wave-Free Ratio Compared to Fractional Flow Reserve: A Pooled Analysis of iFR-SWEDEHEART and DEFINE-FLAIR Trials. Eur Heart J 2023:Aug 27:[Epub ahead of print].
Summary By:
Debabrata Mukherjee, MD, FACC

Quick Takes

  • iFR-guided revascularization is associated with an increase in all-cause mortality alone compared to FFR-guided revascularization, while the rates of MI and unplanned revascularization did not differ.
  • These data suggest caution with the use of nonhyperemic pressure indexes in guiding revascularization, pending further studies.
  • At this time, FFR-guided revascularization should be the preferred strategy when intracoronary pressure measurement is indicated.

Study Questions:

What are the long-term outcomes between instantaneous wave-free ratio (iFR) and fractional flow reserve (FFR)-guided percutaneous coronary intervention (PCI)?

Methods:

The investigators conducted a study-level meta-analysis of the 5-year outcome data in iFR-SWEDEHEART and DEFINE-FLAIR trials. A composite of major adverse cardiovascular events (MACE) and its individual components (all-cause death, myocardial infarction [MI], and unplanned revascularization) were analyzed. Raw Kaplan-Meier estimates, numbers at risk, and number of events were extracted at 5-year follow-up and analyzed using the ipdfc package (Stata version 18, StataCorp College Station, TX USA).

Results:

In total, iFR and FFR-guided revascularization was performed in 2,254 and 2,257 patients, respectively. Revascularization was more often deferred in the iFR-group (n = 1,128 [50.0%]) versus the FFR-group (n = 1,021 [45.2 %]; p = 0.001). In the iFR-guided group, the number of deaths, MACE, unplanned revascularization, and MI were 188 (8.3%), 484 (21.5%), 235 (10.4%), and 123 (5.5%) versus 143 (6.3%), 420 (18.6%), 241 (10.7%), and 123 (5.4%) in the FFR-group. Hazard ratio (95% confidence interval) estimates for MACE were 1.18 (1.035; 1.34), all-cause mortality 1.34 (1.08; 1.67), unplanned revascularization 0.99 (0.83; 1.19), and MI 1.02 (0.80; 1.32).

Conclusions:

The authors report that 5-year all-cause mortality and MACE rates were increased with revascularization guided by iFR compared to FFR.

Perspective:

This study-level meta-analysis reports that iFR-guided revascularization is associated with an increase in the composite of MACE (all-cause mortality, MI, or unplanned revascularization) and all-cause mortality alone compared to FFR-guided revascularization, while the rates of MI and unplanned revascularization did not differ. These data suggest caution with the use of nonhyperemic pressure indexes in guiding revascularization, pending further studies. At this time, FFR-guided revascularization should be the preferred strategy when intracoronary pressure measurement is indicated.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Prevention, Aortic Surgery, Cardiac Surgery and Arrhythmias

Keywords: Cardiac Surgical Procedures, Fractional Flow Reserve, Myocardial, Myocardial Infarction, Myocardial Ischemia, Myocardial Revascularization, Percutaneous Coronary Intervention, Secondary Prevention


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