Does Routine Pressure Wire Assessment Influence Management Strategy at Coronary Angiography for Diagnosis of Chest Pain? - RIPCORD 2

Sep 27, 2022
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Author/Summarized by Author:
Dharam J. Kumbhani, MD, SM, FACC
Summary Reviewer:
Deepak L. Bhatt, MD, MPH, MBA, FACC
Trial Sponsor:
Boston Scientific Corporation
Date Published:
08/10/2022
Original Posted Date:
09/27/2022
References

Contribution To Literature:

The RIPCORD 2 trial showed that a strategy of systematic FFR of all major arteries amenable to revascularization was not superior to angiography-guided management among patients undergoing coronary angiography for stable ischemic heart disease or NSTEMI.

Description:

The goal of the trial was to demonstrate the safety and efficacy of routine systematic measurement of FFR in all vessels of sufficient caliber to be potential targets for revascularization.

Study Design

Eligible patients were randomized in a 1:1 open-label fashion to either fractional flow reserve (FFR)-guided revascularization (n = 548) or angiography-guided management (n = 552). In the FFR arm, FFR measurement was performed in all coronary arteries of sufficient caliber for percutaneous coronary intervention (PCI) or placement of a bypass graft conduit, examining all major vessels and branches regardless of the presence or absence of atheroma. An FFR of ≤0.80 was considered to be positive.

  • Total number of enrollees: 1,100
  • Duration of follow-up: 1 year
  • Mean patient age: 64.3 years
  • Percentage female: 25%
  • Percentage with diabetes: 19%
  • Race: White, 95%

Inclusion criteria:

  • Stable angina or non–ST-segment elevation myocardial infarction (NSTEMI) presentation scheduled to undergo coronary angiography
  • ≥1 stenosis of ≥30% narrowing in a coronary vessel of a caliber suitable for either PCI or a bypass graft

Other salient features/characteristics:

  • Acute coronary syndrome presentation: 52%
  • Ejection fraction ≤44%: 7%
  • Angiographic disease: zero: 26%, one-vessel disease: 43%, two-vessel disease: 20%, three-vessel disease: 8%, left main >50%: 8%

Principal Findings:

Co-primary endpoints for FFR vs. angiography alone:

  • Total hospital cost: £4510 vs. £4136 (p = 0.14)
  • Median EuroQol EQ-5D visual analog scale score: 75 vs. 75 (p = 0.88)

Secondary outcomes for FFR vs. angiography alone:

  • Additional testing before declaration of management: 1.8% vs. 14.7% (p < 0.0001)
  • PCI: 56.2% vs. 60.9% (p = 0.20)
  • Procedure time: 69.0 vs. 42.2 minutes (p < 0.001)
  • Any complication related to pressure wire: 1.8% vs. 0%
  • Hierarchical major adverse cardiac events: 9.5% vs. 8.7% (p = 0.64)

Interpretation:

The results of this trial indicate that a strategy of systematic FFR of all major arteries amenable to revascularization was not superior to angiography-guided management among patients undergoing coronary angiography for stable ischemic heart disease or NSTEMI in terms of cost or patient quality of life at 1 year. Clinical events at 1 year were low and similar between the two arms. A systematic FFR strategy resulted in longer procedure times and higher contrast use.

This trial was designed differently from FAME 1 and FAME 2, in which FFR was pursued for lesions with >50% epicardial stenosis by angiographic assessment, but showed a benefit in favor of FFR. In addition, PCI use has traditionally been lower in the FFR arm than in the angiographic arm of prior trials, but this was not noted in the current trial.

References:

Stables RH, Mullen LJ, Elguindy M, et al. Routine Pressure Wire Assessment Versus Conventional Angiography in the Management of Patients With Coronary Artery Disease: The RIPCORD 2 Trial. Circulation 2022;146:687-98.

Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Cardiovascular Care Team, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Stable Ischemic Heart Disease, Vascular Medicine, Atherosclerotic Disease (CAD/PAD), Aortic Surgery, Cardiac Surgery and SIHD, Interventions and ACS, Interventions and Coronary Artery Disease, Interventions and Imaging, Interventions and Vascular Medicine, Angiography, Nuclear Imaging, Chronic Angina

Keywords: Acute Coronary Syndrome, Angina, Stable, Angiography, Coronary Angiography, Coronary Artery Disease, Coronary Stenosis, Costs and Cost Analysis, Fractional Flow Reserve, Myocardial, Myocardial Ischemia, Myocardial Revascularization, Non-ST Elevated Myocardial Infarction, Percutaneous Coronary Intervention, Plaque, Atherosclerotic, Quality of Life, Stroke Volume


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