Clinical Outcomes of patients with coronary artery disease who underwent FFR evaluation of intermediate coronary lesionS- COFFRS study

Fractional flow reserve [FFR] guided stenting of Left Main Coronary Artery in Acute Coronary Syndrome: A Single centre experience

The present study assesses the clinical outcomes after left main coronary stenting, using clinical evaluation, angiography, and Fractional Flow Reserve (FFR). A prospective observational study was conducted on 72 patients undergoing left main coronary artery (LMCA) stenting, transthoracic echocardiography, coronary angiography, and percutaneous coronary intervention were done and FFR was recorded. At the end of 6 months, follow up check angiography, FFR study were performed. The stent was placed from LMCA to left anterior descending artery (LAD) artery among 45.83% of patients and 9.72% had from LMCA to Left circumflex artery. The mortality rate was 8.33%. The fractional flow reserve was 0.81 on an average ranging from 0.58 to 0.90. Relatively low incidence of major cardiac event was noted among patients with single vessel disease and ostial LMCA disease.

Coronary artery disease management and cost implications with fractional flow reserve guided coronary intervention in Indian patients with stable ischemic coronary artery disease

OBJECTIVES

To study the safety of stent avoidance, frequency of change in management decisions, and its cost implications while using a fractional flow reserve (FFR)-guided treatment strategy for intermediate-grade coronary artery stenosis.

BACKGROUND

The impact of FFR in guiding management decisions and its cost implications has not been studied after imposition of a ceiling on stent prices by the Government of India.

METHODS

In 400 patients with 477 intermediate-grade coronary lesions for whom coronary intervention was planned, functional assessment using FFR was done. Incidence of the primary composite endpoint (major adverse cardiac event [MACE], cardiac death, myocardial infarction, objective evidence of ischemia, and target vessel revascularization) in the stent avoided subset was compared with the stented group at follow-up. Micro-costing analysis was done using a computed model with current stent and FFR wire prices.

RESULTS

The overall incidence of MACE was 4.9%, 0.9% in the stent-avoided subset and 6.9% in stented group (p = 0.04, comparing the latter two) at a median follow-up of 21 months (interquartile range 12-31 months). Serious adverse events occurred only in 1% of patients receiving adenosine. The average cost saving was Indian rupees (INR) 51,847 [United States Dollar (USD) 746] per patient, resulting in total savings of INR 15,813,379 (USD 227,530). Cost savings persisted but were lower by 36% (INR 18,613/USD 268 per patient) after the ceiling of stent prices.

CONCLUSION

FFR-guided percutaneous coronary intervention (PCI) strategy is safe and cost-effective in countries where majority of patients self-finance their health care, resulting in stent and PCI avoidance in approximately one in three patients referred for coronary angioplasty.

Utility of Imaging Modalities in Coronary Lesions With Borderline Fractional Flow Reserve

BACKGROUND

Coronary intervention is routinely deferred in intermediate lesions with fractional flow reserve (FFR) ≥ 0.80. Patients with borderline FFR (0.80-0.85) who were initially deferred, have been shown to have higher risk of future interventions; however, the data is limited, and the long term prognosis in these patients remains unknown. We assessed the utility of adjunctive imaging modalities to determine the need for intervention in lesions with borderline FFR.

METHODS

We retrospectively evaluated consecutive patients who underwent coronary angiography at Einstein Medical Center from January 2013 to April 2016. All patients with borderline FFR (0.80-0.85) were included. Patients were divided into Defer or Perform intervention groups based on additional available or procured clinical data. The Perform group was further stratified into intervention With or Without adjunctive imaging guidance (including intravascular ultrasound, optical coherence tomography, echocardiography, and exercise or pharmacologic stress test). Follow-up data was collected for all patients, which included future target lesion revascularization (TLR) and major adverse cardiac events (MACE; all-cause and cardiovascular mortality and acute coronary syndromes).

RESULTS

A total of 196 patients were eligible. Median (IQR) FFR in Perform and Defer groups was 0.81 (0.8-0.83) and 0.84 (0.82-0.85) respectively. Median (IQR) follow up was 21 (13-29) and 25 (15-36) months respectively. Overall MACE rate in Perform group (n = 101) was 20.8% (n = 21) and Defer group (n = 95) was 15.8% (n = 15). The stratified MACE rate in Perform group With imaging guidance (n = 57) was 17.5% (n = 10) and Without imaging guidance (n = 44) was 25% (n = 11). Overall, the FFR only guided management (n = 196) led to MACE rate of 18.4% (n = 36); whereas, FFR With imaging guidance (n = 136) led to MACE rate of 16.2% (n = 22). The p values were non-significant in each of the above group comparisons due to relatively low numbers with trends as noted.

CONCLUSIONS

Our study suggests that intervention of coronary lesions with borderline FFR under imaging guidance, although not significant, trends towards improved cardiovascular outcomes compared with intervention in this group without adjunctive imaging. These findings are merely speculative without achieving statistical significance in a small subset and need to be further validated in a large scale prospective study.

Abnormal Fractional Flow Reserve in Nonobstructive Coronary Artery Disease

Background The basis of discordance between invasive coronary angiographic (ICA) anatomic stenosis and fractional flow reserve (FFR) is not fully understood. We analyzed coronary computed tomography angiography (CTA) characteristics of ICA-verified nonobstructive lesions in the proximal or midleft anterior descending artery with FFR ≤0.8, that is, anatomy-physiology mismatch. Methods and Results CTA and ICA were performed in 108 patients. FFR was measured during intravenous ATP (180 μg/[kg·min]) infusion. CTA-verified plaque characteristics between 53 consecutive ICA-FFR mismatch (ICA-quantitative coronary angiography <50%, FFR≤0.8) and 55 ICA-FFR match (ICA-quantitative coronary angiography<50%, FFR>0.8) vessels were compared. CTA-verified vessel area (20.7±6.7 versus 16.9±4.8 mm²; P=0.0007), positive area remodeling index (ARI; 1.38±0.23 versus 1.06±0.11; P<0.0001), %plaque area (64.7±12.7 versus 57.4±8.5%; P<0.0007), jeopardized myocardial mass (46.2±18.5 versus 37.1±14.3 g; P= 0.006), and the prevalence of low attenuation plaque (45.3% versus 9.1%; P<0.0001) at the minimum lumen area were significantly higher in the ICA-FFR mismatch than the match group. By receiver operation curve analysis, the areas under the curve for positive area remodeling index, %plaque area and jeopardized myocardial mass were 0.921, 0.681, and 0.641, respectively, for the diagnosis of mismatch (cutoff values 1.13, 66% and 58.7 g, respectively). The sensitivity and specificity of area remodeling index >1.13 for predicting ICA-FFR mismatch were 88.7% and 78.2%, respectively. Conclusions In the absence of anatomically significant stenosis, abnormal FFR is more frequently encountered in patients with CTA-derived positive remodeling, larger plaque burden, and low attenuation plaque. These findings contribute to a better understanding of how FFR-based decision-making might translate into demonstrated superior clinical outcomes.