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Implications of Fractional Flow Reserve After Coronary Stenting
Quick Takes
- Low post-PCI FFR is common and demonstrated a significant inverse association with target vessel failure.
- The cumulative incidence of target vessel failure at 2 years was significantly higher in patients with post-PCI FFR of ≤0.86 than with post-PCI FFR >0.86 (9.1% vs. 6.1%; adjusted HR, 1.58; 95% CI, 1.24-2.00; p < 0.001).
- Optimal management of residual ischemia measured by post-PCI FFR remains to be determined.
Study Questions:
What is the clinical relevance of post–percutaneous coronary intervention (PCI) fractional flow reserve (FFR) measurement after drug-eluting stent (DES) implantation?
Methods:
Patient-level data were collected from 17 cohorts using a standardized spreadsheet. Meta-estimates for primary and secondary outcomes were analyzed per patient and using mixed-effects Cox proportional hazard regression with registry identifiers included as a random effect. The primary outcome was target vessel failure (TVF) at 2 years, a composite of cardiac death, target vessel myocardial infarction (TVMI), and target vessel revascularization (TVR). The secondary outcome was a composite of cardiac death or TVMI at 2 years.
Results:
Of 2,268 articles identified, 29 studies met selection criteria. Of these, 28 articles from 17 cohorts provided data, including a total of 5,277 patients with 5,869 vessels who underwent FFR measurement after DES implantation. Mean (SD) age was 64.4 (10.1) years and 4,141 patients (78.5%) were men. Median (interquartile range) post-PCI FFR was 0.89 (0.84-0.94) and 690 vessels (11.8%) had a post-PCI FFR of ≤0.80. The cumulative incidence of TVF was 340 patients (7.2%), with cardiac death or TVMI occurring in 111 patients (2.4%) at 2 years. Lower post-PCI FFR significantly increased the risk of TVF (adjusted hazard ratio [HR] per 0.01 FFR decrease, 1.04; 95% confidence interval [CI], 1.02-1.05; p < 0.001). The risk of cardiac death or MI also increased inversely with post-PCI FFR (adjusted HR, 1.03; 95% CI, 1.00-1.07; p = 0.049). These associations were consistent regardless of age, sex, the presence of hypertension or diabetes, and clinical diagnosis.
Conclusions:
Reduced FFR after DES implantation was common and associated with the risks of TVF and of cardiac death or TVMI. These results indicate the prognostic value of post-PCI physiologic assessment after DES implantation.
Perspective:
Findings from this large, predominantly male patient-level meta-analysis suggest that low FFR post-DES PCI is common and associated with increased risk of TVF and cardiac death over 2 years. FFR <0.86 was associated with a 3% absolute increase in TVF (adjusted HR, 1.58; 95% CI, 1.24-2.00; p < 0.001). Ongoing studies should help provide additional understanding of mechanisms and optimal management of residual ischemia post-PCI.
Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Prevention, Aortic Surgery, Cardiac Surgery and Arrhythmias, Hypertension
Keywords: Diabetes Mellitus, Drug-Eluting Stents, Fractional Flow Reserve, Myocardial, Hypertension, Myocardial Infarction, Myocardial Ischemia, Myocardial Revascularization, Percutaneous Coronary Intervention, Risk, Secondary Prevention
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