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Instantaneous Wave Free Ratio vs. Fractional Flow Reserve
Quick Takes
- 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.
- Based on the current data, FFR-guided strategy should be the preferred option in proximal lesions in large coronary arteries with a large perfusion territory.
- Pending additional data, it is prudent to use nonhyperemic pressure indices judiciously and consider FFR-guided revascularization the gold standard strategy for intracoronary pressure measurement.
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 the iFR-SWEDEHEART and DEFINE-FLAIR trials. The 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).
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 was 188 (8.3%), 484 (21.5%), 235 (10.4%), and 123 (5.5%) vs. 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 (1.04; 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 of iFR-SWEDEHEART and DEFINE-FLAIR of 5-year outcome data 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. Based on the current data, an FFR-guided strategy should be the preferred option in proximal lesions in large coronary arteries with a large perfusion territory. At this time, pending additional data, it is prudent to use nonhyperemic pressure indices judiciously and consider FFR-guided revascularization the gold standard strategy for intracoronary pressure measurement.
Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention
Keywords: Fractional Flow Reserve, Myocardial, Myocardial Revascularization
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