LAD Revascularization Deferral Substudy of DEFINE-FLAIR

Feb 01, 2019
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Authors:
Sen S, Ahmad Y, Dehbi HM, et al.
Citation:
Clinical Events After Deferral of LAD Revascularization Following Physiological Coronary Assessment. J Am Coll Cardiol 2019;73:444-453.
Summary By:
Vikas Aggarwal, MBBS, MPH, FACC

Study Questions:

Is it safe to defer treatment in the left anterior descending artery (LAD) using fractional flow reserve (FFR) or instantaneous wave-free ratio (iFR) within the DEFINE-FLAIR (Functional Lesion Assessment of Intermediate Stenosis to Guide Revascularisation) trial?

Methods:

One-year major adverse cardiac event (MACE) rates in the DEFINE-FLAIR trial patients who had a negative FFR (>0.80) or iFR (>0.89) and did not receive LAD percutaneous coronary intervention (PCI) were compared. Outcomes were adjusted for age and sex.

Results:

A total of 872 patients had LAD PCI deferred in the LAD (421 guided by FFR, 451 guided by iFR). Overall, MACE rate at 1 year was 3.9% (34/872). Patients in the iFR subset were younger and more likely to be male. After adjusting for age and sex, risk of MACE with iFR-based PCI deferral was significantly lower compared to FFR-based PCI deferral (2.44% vs. 5.26%; hazard ratio [HR], 0.46; 95% confidence interval [CI], 0.22-0.95). This was driven by significantly lower unplanned revascularization in the iFR subset (2.22% iFR vs. 4.99% FFR; HR, 0.44; 95% CI, 0.21-0.93).

Conclusions:

iFR-guided deferral is safe for patients with LAD lesions. Patients in whom iFR-guided deferral was performed had statistically significantly lower event rates than those with FFR-guided deferral.

Perspective:

LAD lesions are often perceived as higher risk given its myocardial territory supplied. These results are re-assuring and continue to build on existing evidence for using functional indices over anatomical features to guide PCI in stable coronary artery disease patients. Compared to FFR, iFR has a superior negative predictive value for future MACE in this subset of patients. Dedicated randomized data comparing iFR-based deferral to FFR-based deferral would be ideal, but larger observational data sets with longitudinal follow-up will also help inform future practice in real-world settings.

Keywords: Angina Pectoris, Constriction, Pathologic, Coronary Artery Disease, Coronary Stenosis, Fractional Flow Reserve, Myocardial, Myocardial Ischemia, Myocardial Revascularization, Percutaneous Coronary Intervention, Secondary Prevention


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