Relation between fractional flow reserve value of coronary lesions with deferred revascularization and cardiovascular outcomes in non-diabetic and diabetic patients

Why percutaneous revascularisation might not reduce the risk of myocardial infarction and mortality in patients with stable CAD?

Percutaneous coronary intervention (PCI) is widely adopted to treat chronic coronary artery disease. Numerous randomised trials have been conducted to test whether PCI may provide any prognostic advantage over oral medical therapy (OMT) alone, without definitive results. This has maintained the paradigm of OMT as the first-line standard of care for patients, reserving PCI for symptom control. In this review, we discuss the current evidence in favour and against PCI in stable coronary syndromes and highlight the pitfalls of the available studies. We offer a critical appraisal of the possible reasons why the existing data does not provide evidence supporting the role of PCI in improving clinical outcomes in patients with stable coronary syndromes.

Outcomes of deferred revascularisation following negative fractional flow reserve in diabetic and non-diabetic patients: a meta-analysis

BACKGROUND

Fractional Flow Reserve (FFR) is a widely applied invasive physiological assessment, endorsed by major guidelines to aid in the decision to perform or defer revascularisation. While a threshold of  > 0.8 has been applied universally, clinical outcomes may be affected by numerous factors, including the presence of diabetes. This meta-analysis aims to investigate the outcomes of diabetic versus non-diabetic patients in whom revascularisation was deferred based on negative FFR.

METHODS

We performed a meta-analysis investigating the outcomes of diabetic and non-diabetic patients in whom revascularisation was deferred based on negative FFR. A search was performed on MEDLINE, PubMed and EMBASE, and peer-reviewed studies that reported MACE for diabetic and non-diabetic patients with deferred revascularisation based on FFR  > 0.8 were included. The primary end point was MACE.

RESULTS

The meta-analysis included 7 studies in which 4275 patients had revascularisation deferred based on FFR > 0.8 (1250 diabetic). Follow up occurred over a mean of 3.2 years. Diabetes was associated with a higher odds of MACE (OR = 1.66, 95% CI 1.35-2.04, p =  < 0.001), unplanned revascularisation (OR = 1.48, 95% CI 1.06-2.06, p = 0.02), all-cause mortality (OR = 1.74, 95% CI 1.20-2.52, p = 0.004) and cardiovascular mortality (OR = 2.08, 95% CI 1.07-4.05, p = 0.03).

CONCLUSIONS

For patients with stable coronary syndromes and deferred revascularisation based on FFR > 0.8, the presence of diabetes portends an increased long-term risk of MACE compared to non-diabetic patients. Trail registration URL:  https://www.crd.york.ac.uk/PROSPERO/ ; Unique identifier: CRD42022367312.

Anatomical and Functional Discrepancy in Diabetic Patients With Intermediate Coronary Lesions - An Intravascular Ultrasound and Quantitative Flow Ratio Study

BACKGROUND

Data regarding the performance of computational fractional flow reserve in patients with diabetes mellitus (DM) remain scarce. This study sought to explore the impact of DM on quantitative flow ratio (QFR) and its association with intravascular ultrasound (IVUS)-derived anatomical references.Methods and Results: IVUS and QFR were retrospectively analyzed in 237 non-diabetic and 93 diabetic patients with 250 and 102 intermediate lesions, respectively. Diabetics were further categorized based on adequate (HbA1c <7.0%: 47 patients with 53 lesions) or poor (HbA1c ≥7.0%: 46 patients with 49 lesions) glycemic control. Lesions with QFR ≤0.8 or minimum lumen area (MLA) ≤4.0 mm²and plaque burden (PB, %) ≥70 were considered functionally or anatomically significant, respectively. PB increased, and MLA decreased stepwise across non-diabetics, diabetics with adequate glycemic control and those with poor glycemic control. In contrast, QFR was similar among the 3 groups. PB correlated significantly with the QFR for lesions in non-diabetics, but not for lesions in diabetics. DM was independently correlated with the functionally non-significant lesions (QFR >0.8) with high-risk IVUS features (MLA ≤4.0 mm²and PB ≥70; OR 2.053, 95% CI: 1.137-3.707, P=0.017). When considering the effect of glycemic control, HbA1c was an independent predictor of anatomical-functional discordance (OR 1.347, 95% CI: 1.089-1.667, P=0.006).

CONCLUSIONS

Anatomical-functional discordance of intermediate coronary lesions assessed by IVUS and QFR is exacerbated in patients with diabetes, especially when glycemia is poorly controlled.

The Role of Coronary Physiology in Contemporary Percutaneous Coronary Interventions

Invasive assessment of coronary physiology has radically changed the paradigm of myocardial revascularization in patients with coronary artery disease. Despite the prognostic improvement associated with ischemia-driven revascularization strategy, functional assessment of angiographic intermediate epicardial stenosis remains largely underused in clinical practice. Multiple tools have been developed or are under development in order to reduce the invasiveness, cost, and extra procedural time associated with the invasive assessment of coronary physiology. Besides epicardial stenosis, a growing body of evidence highlights the role of coronary microcirculation in regulating coronary flow with consequent pathophysiological and clinical and prognostic implications. Adequate assessment of coronary microcirculation function and integrity has then become another component of the decision-making algorithm for optimal diagnosis and treatment of coronary syndromes. This review aims at providing a comprehensive description of tools and techniques currently available in the catheterization laboratory to obtain a thorough and complete functional assessment of the entire coronary tree (both for the epicardial and microvascular compartments).

Usefulness of Routine Fractional Flow Reserve for Clinical Management of Coronary Artery Disease in Patients With Diabetes

Importance

Approximately one-third of patients considered for coronary revascularization have diabetes, which is a major determinant of clinical outcomes, often influencing the choice of the revascularization strategy. The usefulness of fractional flow reserve (FFR) to guide treatment in this population is understudied and has been questioned.

Objective

To evaluate the usefulness and rate of major adverse cardiovascular events (MACE) of integrating FFR in management decisions for patients with diabetes who undergo coronary angiography.

Design, Setting, and Participants

This cross-sectional study used data from the PRIME-FFR study derived from the merger of the POST-IT study (Portuguese Study on the Evaluation of FFR-Guided Treatment of Coronary Disease [March 2012-November 2013]) and R3F study (French Study of FFR Integrated Multicenter Registries Implementation of FFR in Routine Practice [October 2008-June 2010]), 2 prospective multicenter registries that shared a common design. A population of all-comers for whom angiography disclosed ambiguous lesions was analyzed for rates, patterns, and outcomes associated with management reclassification, including revascularization deferral, in patients with vs without diabetes. Data analysis was performed from June to August 2018.

Main Outcomes and Measures

Death from any cause, myocardial infarction, or unplanned revascularization (MACE) at 1 year.

Results

Among 1983 patients (1503 [77%] male; mean [SD] age, 65 [10] years), 701 had diabetes, and FFR was performed for 1.4 lesions per patient (58.2% of lesions in the left anterior descending artery; mean [SD] stenosis, 56% [11%]; mean [SD] FFR, 0.81 [0.01]). Reclassification by FFR was high and similar in patients with and without diabetes (41.2% vs 37.5%, P = .13), but reclassification from medical treatment to revascularization was more frequent in the former (142 of 342 [41.5%] vs 230 of 730 [31.5%], P = .001). There was no statistical difference between the 1-year rates of MACE in reclassified (9.7%) and nonreclassified patients (12.0%) (P = .37). Among patients with diabetes, FFR-based deferral identified patients with a lower risk of MACE at 12 months (25 of 296 [8.4%]) compared with those undergoing revascularization (47 of 257 [13.1%]) (P = .04), and the rate was of the same magnitude of the observed rate among deferred patients without diabetes (7.9%, P = .87). Status of insulin treatment had no association with outcomes. Patients (6.6% of the population) in whom FFR was disregarded had the highest MACE rates regardless of diabetes status.

Conclusions and Relevance

Routine integration of FFR for the management of coronary artery disease in patients with diabetes may be associated with a high rate of treatment reclassification. Management strategies guided by FFR, including revascularization deferral, may be useful for patients with diabetes.

Coronary Artery Bypass Grafting or Fractional Flow Reserve–Guided Percutaneous Coronary Intervention in Diabetic Patients With Multivessel Disease

Background:

In diabetic patients with multivessel coronary artery disease, coronary artery bypass grafting (CABG) has shown long-term benefits over percutaneous coronary intervention (PCI). Physiology-guided PCI has shown to improve clinical outcomes in multivessel coronary artery disease, though its impact in diabetic patients has never been investigated. We evaluated long-term clinical outcomes of diabetic patients with multivessel coronary artery disease treated with fractional flow reserve (FFR)–guided PCI compared with CABG.

Methods:

From 2010 to 2018, 4622 diabetic patients undergoing coronary angiography were screened for inclusion. The inclusion criterion was the presence of at least 2-vessel disease defined as with diameter stenosis ≥50%, in which at least 1 intermediate stenosis (diameter stenosis, 30%–70%) was treated or deferred according to FFR. Inverse probability of treatment weighting analysis was used to account for baseline differences with a contemporary cohort of patients treated with CABG. The primary end point was major adverse cardiovascular and cerebrovascular events, defined as all-cause death, myocardial infarction, revascularization, or stroke.

Results:

A total of 418 patients were included in the analysis. Among them, 209 patients underwent CABG and 209 FFR-guided PCI. At 5 years, the incidence of major adverse cardiovascular and cerebrovascular events was higher in the FFR-guided PCI versus the CABG group (44.5% versus 31.9%; hazard ratio, 1.60 [95% CI, 1.15–2.22]; P =0.005). No difference was found in the composite of all-cause death, myocardial infarction, or stroke (28.8% versus 27.5%; hazard ratio, 1.05 [95% CI, 0.72–1.53]; P =0.81). Repeat revascularization was more frequent with FFR-guided PCI (24.9% versus 8.2%; hazard ratio, 3.51 [95% CI, 1.93–6.40]; P <0.001).

Conclusions:

In diabetic patients with multivessel coronary artery disease, CABG was associated with a lower rate of major adverse cardiovascular and cerebrovascular events compared with FFR-guided PCI, driven by a higher rate of repeat revascularization. At 5-year follow-up, no difference was observed in the composite of all-cause death, myocardial infarction, or stroke between CABG and FFR-guided PCI.

Graphic Abstract:

A graphic abstract is available for this article.

Clinical practice patterns in revascularization of diabetic patients with coronary heart disease: nationwide register study

Aims: To compare diabetic patients with coronary heart disease (CHD) needing revascularization to corresponding non-diabetic patients in terms of revascularization methods, comorbidities and urgency of procedure. We also examined the impact of patient characteristics and comorbidities on the revascularization method.Methods: We identified all diabetic (n = 33,018) and non-diabetic (n = 106,224) patients with first-ever, percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) from electronic health records in Finland between 2000 and 2015.Results: Overall, PCI was the most common revascularization method. PCI outnumbered CABG in women and men both in diabetic and non-diabetic patients. However, diabetic patients were more likely to undergo CABG than PCI (OR 1.30; 95% CI 1.27-1.34, adjusted for age, gender, region of residence and procedure year). Moreover, 26.9% of diabetic patients' urgent procedures were CABG compared to 21.6% in non-diabetic patients (p<.001). Among diabetic patients, prior myocardial infarction was associated with increased odds of CABG, whereas female gender, atrial fibrillation, congestive heart failure, hypertension and later procedure year were associated with lower odds of CABG.Conclusions: CABG has been performed more frequently in diabetic than in non-diabetic CHD patients. Nevertheless, PCI was the dominant revascularization method over CABG both in diabetic and non-diabetic patients. KEY MESSAGESPCI was the dominant revascularization method in both diabetic and non-diabetic patients. Diabetic patients were more likely to undergo CABG than PCI when compared to non-diabetic patients (OR: 1.30; CI 1.27-1.34).Diabetic patients underwent urgent CABG procedures more often than non-diabetic patients and had more comorbidities compared to non-diabetic patients.

Clinical Outcomes of Deferred Revascularisation Using Fractional Flow Reserve in Diabetic Patients

BACKGROUND

Fractional flow reserve (FFR) is used to assess the functional significance of coronary artery lesions. Diabetic patients are associated with high burden of atherosclerosis and microvascular dysfunction. We studied the clinical outcomes of diabetic patients who underwent FFR-guided deferred revascularisation.

METHODS

Consecutive patients from a single large volume centre who underwent FFR assessment were included. Clinical endpoints were prospectively collected using the national electronic care records system. The primary endpoint was defined as the four-year risk of the vessel-oriented composite outcome of cardiac death, vessel-related myocardial infarction (VMI), and vessel-related urgent revascularisation (VUR). Absolute FFR values groups (0.81 to 0.85; 0.86 to 0.90; and >0.90) were used to further stratify patient outcomes.

RESULTS

FFR-guided deferred revascularisation occurred in 860 patients (63%), of whom 159 were diabetic. The primary endpoint was significantly higher in the diabetic compared to the non-diabetic group [HR 1.76 (95%CI 1.08 to 2.88), P = 0.024]. The difference was driven from cardiac death (6.3% vs. 3.0%, P = 0.044) and VMI (5.0% vs. 1.7%, P = 0.012) but not VUR (8.8% vs. 5.1%, P = 0.07). There was a significant decrease in the incidence of the primary endpoint in the diabetic group according to FFR groups (23.6%, 12.3%, 2.4%, P = 0.001) with comparable clinical outcomes in the non-diabetic group (11.8%, 6.4%, 7.4%, P = 0.085).

CONCLUSIONS

Our study demonstrated an increased risk of death and target vessel MI in diabetic patients undergoing FFR-guided deferred revascularisation compared to non-diabetic group. Nonetheless, FFR remained a useful tool to identify those at future risk, mainly in diabetic patients.

Comparison of the Diagnostic Performance of Coronary Computed Tomography Angiography-Derived Fractional Flow Reserve in Patients With Versus Without Diabetes Mellitus (from the MACHINE Consortium)

Coronary computed tomography angiography-derived fractional flow reserve (CT-FFR) is a noninvasive application to evaluate the hemodynamic impact of coronary artery disease by simulating invasively measured FFR based on CT data. CT-FFR is based on the assumption of a normal coronary microvascular response. We assessed the diagnostic performance of a machine-learning based application for on-site computation of CT-FFR in patients with and without diabetes mellitus with suspected coronary artery disease. The study population included 75 diabetic and 276 nondiabetic patients who were enrolled in the MACHINE consortium. The overall diagnostic performance of coronary CT angiography alone and in combination with CT-FFR were analyzed with direct invasive FFR comparison in 110 coronary vessels of the diabetic group and in 415 coronary vessels of the nondiabetic group. Per-vessel discrimination of lesion-specific ischemia by CT-FFR was assessed by the area under the receiver operating characteristic curves. The overall diagnostic accuracy of CT-FFR in diabetic patients was 83% and in nondiabetic patients 75% (p = 0.088), showing improvement over the diagnostic accuracy of coronary CT angiography, which was 58% and 65% (p = 0.223), respectively. In addition, the diagnostic accuracy of CT-FFR was similar between diabetic and nondiabetic patients per stratified CT-FFR group (CT-FFR < 0.6, 0.6 to 0.69, 0.7 to 0.79, 0.8 to 0.89, ≥0.9). The area under the curves for diabetic and nondiabetic patients were also comparable, 0.88 and 0.82 (p = 0.113), respectively. In conclusion, on-site machine-learning CT-FFR analysis improved the diagnostic performance of coronary CT angiography and accurately discriminated lesion-specific ischemia in both diabetic and nondiabetic patients suspected of coronary artery disease.

Relationship between FFR, CFR and coronary microvascular resistance - Practical implications for FFR-guided percutaneous coronary intervention

Objective

The aim was threefold: 1) expound the independent physiological parameters that drive FFR, 2) elucidate contradictory conclusions between fractional flow reserve (FFR) and coronary flow reserve (CFR), and 3) highlight the need of both FFR and CFR in clinical decision making. Simple explicit theoretical models were supported by coronary data analyzed retrospectively.

Methodology

FFR was expressed as a function of pressure loss coefficient, aortic pressure and hyperemic coronary microvascular resistance. The FFR-CFR relationship was also demonstrated mathematically and was shown to be exclusively dependent upon the coronary microvascular resistances. The equations were validated in a first series of 199 lesions whose pressures and distal velocities were monitored. A second dataset of 75 lesions with pre- and post-PCI measures of FFR and CFR was also analyzed to investigate the clinical impact of our hemodynamic reasoning.

Results

Hyperemic coronary microvascular resistance and pressure loss coefficient had comparable impacts (45% and 49%) on FFR. There was a good concordance (y = 0.96 x − 0.02, r² = 0.97) between measured CFR and CFR predicted by FFR and coronary resistances. In patients with CFR < 2 and CFR/FFR ≥ 2, post-PCI CFR was significantly >2 (p < 0.001), whereas it was not (p = 0.94) in patients with CFR < 2 and CFR/FFR < 2.

Conclusion

The FFR behavior and FFR-CFR relationship are predictable from basic hemodynamics. Conflicting conclusions between FFR and CFR are explained from coronary vascular resistances. As confirmed by our results, FFR and CFR are complementary; they could jointly contribute to better PCI guidance through the CFR-to-FFR ratio in patients with coronary artery disease.

Revascularization for patients with diabetes mellitus and stable ischemic heart disease: an update

PURPOSE OF REVIEW

To provide an update on the management of patients with diabetes mellitus and requiring coronary revascularization.

RECENT FINDINGS

Evidence continues to show that patients with diabetes mellitus and ischemic heart disease represent a very high-risk group of patients. Choice of stent appears important for minimizing target lesion and target vessel adverse events with everolimus eluting stents having the best performance, particularly in patients being treated with insulin. The higher risk of adverse angioplasty results in patients with diabetes appears most related to the disease state per se and not necessarily to anatomical complexities. Interestingly, physiologic documentation of nonischemia producing lesions with use of fractional flow reserve appears less reassuring in this setting of aggressive and rapid atherosclerosis progression, particularly if myocardial infarction has occurred previously, than in patients without diabetes. Coronary artery bypass surgery in patients with appropriate anatomy and diabetes continues to emerge in many analyzes as the optimal, long-term therapy.

IMPLICATIONS

The treatment of diabetes per se, advances in stent technology and optimization of coronary artery bypass techniques are all occurring in parallel making it very critical for the design of modern era trials that keep pace with these advances. Currently, in patients with appropriate anatomy who are willing candidates, bypass surgery remains the optimal, long-term therapeutic option.

Is ischemia the only factor predicting cardiovascular outcomes in all diabetes mellitus patients?

Diabetes mellitus (DM) is associated with an excess in cardiovascular morbidity and mortality, and is characterized by increased rates of coronary artery disease. Furthermore, once atherosclerosis is established, this is associated with an increased extent, complexity and a more rapid progression than seen in non-DM patients. Ischemia is the single most important predictor of future hard cardiac events and ischemia correction remains the cornerstone of current revascularization strategies. However recent data suggests that, in DM patients, coronary atherosclerosis despite the absence of ischemia, detected by either invasive or non-invasive methods, may not be associated with the same low risk of future cardiac events as seen in non-DM patients. This review seeks to examine the current evidence supporting an ischemia driven revascularization strategy, and to challenge the notion that ischemia is the only clinically relevant factor in the prediction of cardiovascular outcomes in all-comer DM patients. Specifically, we examine whether in DM patients certain characteristics beyond ischemia, such as microvascular disease, coronary atherosclerosis burden, progression and plaque composition, may need to be considered for a more refined risk stratification in these high-risk patients.

Factors associated with deferred lesion failure following fractional flow reserve assessment in patients with diabetes mellitus

OBJECTIVE

To explore the predictors of deferred lesion failure (DLF) in patients with diabetes mellitus (DM) and lesions with a fractional flow reserve (FFR) >0.80 and to examine whether a predictive relationship between negative FFR values (>0.80-1.00) and DLF exists.

BACKGROUND

DM is associated with rapidly progressive atherosclerosis and predictors of DLF in FFR negative lesions in this high-risk group are unknown.

METHODS

All DM patients who underwent FFR-assessment between 1/01/2010 and 31/12/2013 were included, and followed until 1/7/2015. Patients carrying ≥1 FFR negative lesion(s) were assessed for DLF, and multivariate models used to identify independent factors associated with DLF.

RESULTS

A total of 205 patients with 252 FFR >0.80 lesions were identified. At a mean follow-up of 3.1 ± 1.4 years, DLF occurred in 29/205 (14.1%) patients, 31/252 (12.3%) lesions. Using marginal Cox regression multivariate analysis, insulin requiring DM [HR 2.24 (95%CI; 1.01-4.95), P = 0.046] and prior revascularization [HR 2.70 (95%CI 1.21-6.01), P = 0.015] were identified as being associated with a higher incidence of DLF. Absolute FFR values in FFR negative lesions in DM patients are not predictive of DLF (receiver operating characteristics curve analysis: area under the curve: 0.57 ± 0.06, 95%CI 0.46-0.69).

CONCLUSIONS

In DM patients with FFR negative lesions, insulin requiring DM and prior revascularization are predictors for DLF. In contrast to non-DM patients, no predictive relationship between absolute negative FFR values (ranging >0.80-1.00) and the risk of DLF exists in DM patients. © 2017 Wiley Periodicals, Inc.

Diabetes does not impact the diagnostic performance of contrast-based fractional flow reserve: insights from the CONTRAST study

BACKGROUND

Adenosine-free coronary pressure wire metrics have been proposed to test the functional significance of coronary artery lesions, but it is unexplored whether their diagnostic performance might be altered in patients with diabetes.

METHODS

We performed a post-hoc analysis of the CONTRAST study, which prospectively enrolled an international cohort of patients undergoing routine fractional flow reserve (FFR) assessment for standard indications. Paired, repeated measurements of all physiology metrics (Pd/Pa, iFR, contrast-based FFR, and FFR) were made. A central core laboratory analyzed blinded pressure tracings in a standardized fashion.

RESULTS

Of 763 subjects enrolled at 12 international centers, 219 (29%) had diabetes. The two groups were well-balanced for age, clinical presentation (stable or unstable), coronary vessel studied, volume and type of intracoronary contrast, and volume of intracoronary adenosine. A binary threshold of cFFR ≤ 0.83 produced an accuracy superior to both Pd/Pa and iFR when compared with FFR ≤ 0.80 in the absence of significant interaction with diabetes status; indeed, accuracy in subgroups of patients with or without diabetes was similar for cFFR (86.7 vs 85.4% respectively; p = 0.76), iFR (84.2 vs 80.0%, p = 0.29) and Pd/Pa (81.3 vs 78.9%, p = 0.55). There was no significant heterogeneity between patients with or without diabetes in terms of sensitivity and specificity of all metrics. The area under the receiver operating characteristic (ROC) curve was largest for cFFR compared with Pd/Pa and iFR which were equivalent (cFFR 0.961 and 0.928; Pd/Pa 0.916 and 0.870; iFR 0.911 and 0.861 in diabetic and non-diabetic patients respectively).

CONCLUSIONS

cFFR provides superior diagnostic performance compared with Pd/Pa or iFR for predicting FFR irrespective of diabetes (clinicaltrials.gov identifier NCT02184117).

Combined optical coherence tomography morphologic and fractional flow reserve hemodynamic assessment of non- culprit lesions to better predict adverse event outcomes in diabetes mellitus patients: COMBINE (OCT-FFR) prospective study. Rationale and design

BACKGROUND

Fractional flow reserve (FFR) is a widely used tool for the identification of ischaemia-generating stenoses and to guide decisions on coronary revascularisation. However, the safety of FFR-based decisions in high-risk subsets, such as patients with Diabetes Mellitus (DM) or vulnerable stenoses presenting thin-cap fibro-atheroma (TCFA), is unknown. This study will examine the impact of optical coherence tomography (OCT) plaque morphological assessment and the identification of TCFA, in combination with FFR to better predict clinical outcomes in DM patients.

METHODS

COMBINE (OCT-FFR) is a prospective, multi-centre study investigating the natural history of DM patients with ≥1 angiographically intermediate target lesion in three subgroups of patients; patients with FFR negative lesions without TCFA (group A) and patients with FFR negative lesions with TCFA (group B) as detected by OCT and to compare these two groups with each other, as well as to a third group with FFR-positive, PCI-treated intermediate lesions (group C). The study hypothesis is that DM patients with TCFA (group B) have a worse outcome than those without TCFA (group A) and also when compared to those patients with lesions FFR ≤0.80 who underwent complete revascularisation. The primary endpoint is the incidence of target lesion major adverse cardiac events (MACE); a composite of cardiac death, myocardial infarction or rehospitalisation for unstable/progressive angina in group B vs. group A.

CONCLUSION

COMBINE (OCT-FFR) is the first prospective study to examine whether the addition of OCT plaque morphological evaluation to FFR haemodynamic assessment of intermediate lesions in DM patients will better predict MACE and possibly lead to new revascularisation strategies. Trial Registration Netherlands Trial Register: NTR5376.

Clinical outcomes of deferred revascularisation using fractional flow reserve in patients with and without diabetes mellitus

Objective

Deferred revascularisation based upon fractional flow reserve (FFR >0.80) is associated with a low incidence of target lesion failure (TLF). Whether deferred revascularisation is also as safe in diabetes mellitus (DM) patients is unknown.

Methods

All DM patients and the next consecutive Non-DM patients who underwent a FFR-assessment between 1/01/2010 and 31/12/2013 were included, and followed until 1/07/2015. Patients with lesions FFR >0.80 were analysed according to the presence vs. absence of DM, while patients who underwent index revascularisation in FFR-assessed or other lesions were excluded. The primary endpoint was the incidence of TLF; a composite of target lesion revascularisation (TLR) and target vessel myocardial infarction (TVMI).

Results

A total of 250 patients (122 DM, 128 non-DM) who underwent deferred revascularisation of all lesions (FFR >0.80) were compared. At a mean follow up of 39.8 ± 16.3 months, DM patients compared to non-DM had a higher TLF rate, 18.1 vs 7.5 %, logrank p ≤ 0.01, Cox regression-adjusted HR 3.65 (95 % CI 1.40–9.53, p < 0.01), which was largely driven by a higher incidence of TLR (17.2 vs. 7.5 %, HR 3.52, 95 % CI 1.34–9.30, p = 0.01), whilst a non-significant but numerically higher incidence of TVMI (6.1 vs. 2.0 %, HR 3.34, 95 % CI 0.64–17.30, p = 0.15) was observed.

Conclusions

This study, the largest to directly compare the clinical outcomes of FFR-guided deferred revascularisation in patients with and without DM, shows that DM patients are associated with a significantly higher TLF rate. Whether intravascular imaging, additional invasive haemodynamics or stringent risk factor modification may impact on this higher TLF rate remains unknown.