Comparing the adverse clinical outcomes associated with fraction flow reserve-guided versus angiography-guided percutaneous coronary intervention: a systematic review and meta-analysis of randomized controlled trials

Clinical Outcomes Following Hemodynamic Parameter or Intravascular Imaging-Guided Percutaneous Coronary Intervention in the Era of Drug-Eluting Stents: An Updated Systematic Review and Bayesian Network Meta-Analysis of 28 Randomized Trials and 11,860 Patients

Background

Coronary angiography (CAG) is the standard imaging modality for guiding percutaneous coronary interventions (PCI). Intracoronary imaging techniques such as intravascular ultrasound (IVUS) and optical coherence tomography (OCT), and hemodynamic parameter like fractional flow reserve (FFR) can overcome some limitations of CAG.

Objective

We sought to explore the clinical outcomes of different PCI guidance modalities in the era of drug-eluting stent (DES).

Methods

A network meta-analysis of 28 randomized trials and 11,860 patients undergoing different modalities-guided PCI in the era of DES was performed. Odds ratio (OR) with 95% credible interval (CrI) were calculated.

Results

In comparison with CAG, IVUS was associated with a significant reduction in major adverse cardiovascular events (MACE, OR: 0.60; 95% CrI: 0.46–0.79), cardiovascular death (OR: 0.46; 95% CrI: 0.20–0.94), target vessel/lesion revascularization (TVR/TLR, OR: 0.55; 95% CrI: 0.41–0.74), and a trend toward decreased risk of stent thrombosis (OR: 0.44; 95% CrI: 0.17 to 1.00). FFR/quantitative flow ratio (QFR) could significantly reduce stroke compared with CAG, IVUS, and OCT/optical frequency domain imaging (OFDI). However, myocardial infarction (MI), all-cause death, stent thrombosis, and any revascularization presented similar risks for different PCI guidance modalities.

Conclusion

In the era of DES, IVUS led to lower risks of MACE than CAG, which was mainly due to lower risks of cardiovascular death and TVR/TLR. A trend toward decreased risk of stent thrombosis was also observed with IVUS. Hemodynamic parameter (FFR/QFR)-guided PCI could significantly reduce the stroke risk compared with CAG, IVUS, and OCT/OFDI.

Systematic Review Registration

[https://www.crd.york.ac.uk/PROSPERO/], identifier [CRD42021291442].

Short- and Long-Term Prognosis of Intravascular Ultrasound-Versus Angiography-Guided Percutaneous Coronary Intervention: A Meta-Analysis Involving 24,783 Patients

Background

Intravascular ultrasound (IVUS) guided percutaneous coronary intervention (PCI) has potential benefits. This meta-analysis aimed to explore whether IVUS-guided PCI had better short- and long-term prognoses than angiography-guided PCI.

Methods

We retrieved studies from PubMed, Embase, and Cochrane Library. Clinical trials including retrospective and randomized controlled trials (RCTs) that compared IVUS-guided PCI with angiography-guided PCI were included. The patients were followed up after operation at 30 days, 1 year, 2 years, and 3 years. The clinical outcomes were target lesion revascularization (TLR), target vessel revascularization (TVR), and MACEs, including stent thrombosis (ST), myocardial infarction (MI), cardiac death, and all-cause death. The study population included patients with MI, coronary bifurcation lesions, short or long lesions, and unprotected left main coronary artery stenosis (ULMCA). The quality of retrospective trials was evaluated using the Newcastle-Ottawa Scale, and the quality of randomized controlled trials was evaluated using the Jadad score. A total of 20 clinical trials met the criteria. Three trials were randomized controlled trials, while 17 were retrospective trials.

Results

A total of 24,783 patients were included. In observational trials, the OR of MACEs was 0.49 (95% CI: 0.38-0.62) in 30 days, 0.65 (95% CI: 0.58-0.73) in one year, 0.51 (95% CI: 0.36-0.71) in two years, and 0.45 (95% CI: 0.31-0.65) in three years. In patients with long coronary lesions, the OR of MACEs in 1 year was 0.64 (95% CI: 0.28-1.50). In patients with left main artery disease, the OR of MACEs in 3 years was 0.42 (95% CI: 0.26-0.67). Compared with angiography-guided PCI, IVUS-guided PCI was associated with a lower incidence of MACEs during the same following period.

Conclusion

Compared with angiography-guided PCI, IVUS-guided PCI has better performance in reducing the occurrence of MACEs.

Fractional flow reserve-guided complete revascularization versus culprit-only revascularization in acute ST-segment elevation myocardial infarction and multi-vessel disease patients: a meta-analysis and systematic review

Background

Approximately 30–50% patients with acute ST-segment elevation myocardial infarction (STMEI) were found to have non-infarct-related coronary artery (IRA) disease, which was significantly associated with worse prognosis. However, challenges still remain for these patients: which non-infarct-related lesion should be treated and when should the procedure be performed? The present study aims to investigate Fractional flow reserve (FFR)-guided complete revascularization (CR) in comparison to culprit-only revascularization (COR) in patients with ST-segment elevation myocardial infarction (STEMI) and multi-vessel disease (MVD).

Methods

Three appropriate randomized controlled trials (RCTs) were selected from the PubMed/Medline, EMBASE, and the Cochrane library /CENTRAL databases. 1631 patients (688 patients underwent FFR-guided CR and 943 patients underwent COR) following-up 12–44 months was evaluated.

Results

FFR-guided CR significantly reduced major adverse cardiac event (MACE) (OR 0.47, 95% CI: 0.35–0.62, P < 0.00001) and ischemia-driven repeat revascularization (OR 0.36, 0.26–0.51, P < 0.00001), as compared to COR. However, there is no difference in all-cause mortality (OR 1.24, 0.65–2.35, P = 0.51).

Conclusions

In patients with STEMI and MVD, FFR-guided CR is better than COR in terms of MACE and ischemia-driven repeat revascularization, while there are almost similar in all-cause mortality.

Trial registration

All analyses were based on previous published studies, thus no ethical approval and patient consent are required COMPARE-ACUTE trial number NCT01399736; DANAMI-3–PRIMULTI trial number NCT01960933.

Electronic supplementary material

The online version of this article (10.1186/s12872-019-1022-6) contains supplementary material, which is available to authorized users.

One-year clinical outcome of angiography, fractional flow reserve and instantaneous wave-free ratio guided percutaneous coronary intervention: A PRISMA-compliant meta-analysis

The present study aimed to compare the clinical outcome of patients with coronary artery disease (CAD) who underwent a revascularization using conventional coronary angiography or a physiologically guided revascularization with Fractional Flow Reserve (FFR). Furthermore, outcomes in FFR guided percutaneous coronary intervention (PCI) and instantaneous wave-free ratio (iFR) guided PCI were compared. The analysis was performed for reported outcomes at a 1-year follow-up. After searching PubMed, EMBASE, and Web of Science for suitable publications, a total of 15,880 subjects were included. Comparing angiography guided and FFR guided PCI showed no significant difference in major adverse cardiac events [odds ratio (OR), 0.78; 95% confidence interval (CI), 0.59-1.04; P=0.09; I²=73%], death from any cause (OR, 0.74; 95% CI, 0.46-1.18; P=0.20; I²=74%), myocardial infarction (OR, 0.93; 95% CI, 0.81-1.07; P=0.31; I²=0%) or unplanned revascularization (OR, 0.71; 95% CI, 0.41-1.23; P=0.22; I²=79%). In addition, no significant difference could be found between iFR and FFR guided PCI for major adverse cardiac events (OR, 0.97; 95% CI; 0.76-1.23; P=0.81; I²=0%), death from any cause (OR, 0.66; 95% CI, 0.40-1.11; P=0.12; I²=0%), myocardial infarction (OR, 0.83; 95% CI, 0.56-1.24; P=0.37) or unplanned revascularization (OR, 1.16; 95% CI, 0.85-1.58; P=0.34; I²=16%). Overall, there was a tendency towards better outcomes of FFR in all four clinical endpoints compared with angiography guiding of PCI, and furthermore iFR showed no significant inferiority when compared to FFR in said clinical endpoints. When conducting a network meta-analysis, the results confirmed a non-inferiority of iFR compared to angiography guided revascularization.

Is there a role for fractional flow reserve in coronary artery bypass graft (CABG) planning?

The concept of significant lesions has substantially evolved over the last decade. With growing evidence for use of fractional flow reserve (FFR) as a determinant of lesion-specific ischemia and its superiority to angiography-guided revascularization and medical therapy, the field of percutaneous revascularization has shifted to rely exclusively on FFR instead of luminal stenosis alone in guiding revascularization. This transition to physiological assessment has not yet made it to the realm of surgical revascularization. FFR-guided therapy has been shown to be superior to angiography-guided therapy mainly by safe deferral of about 1/3rd of lesions, leading to less periprocedural events and better outcomes. Is it possible that utilization of FFR-guided CABG would lead to less complicated procedures, shorter operating times, more frequent off pump CABG procedures and more hybrid procedures? Can FFR-guided CABG improve the cardiovascular outcomes as compared to current standard of practice? In the following paragraphs we review the concept of FFR, the evidence behind FFR-guided therapy, the emerging data regarding use FFR-guided CABG and discuss where the revascularization field is headed.

Should fraction flow reserve be considered an important decision-making tool to stratify patients with stable coronary artery disease for percutaneous coronary intervention?: A meta-analysis

BACKGROUND

Nowadays, fraction flow reserve (FFR) is being discussed in every percutaneous coronary intervention (PCI) capable hospitals. Owing to recent development in the medical field, FFR-guided PCI should be able to find a place in Interventional Cardiology. At present, the importance of FFR to stratify patients who require PCI has seldom systematically been investigated. In this analysis, we aimed to compare the major adverse cardiac events (MACEs) mainly in patients with stable coronary artery disease (CAD) to whom PCI was recommended and deferred respectively based on the FFR value.

METHODS

Electronic databases were searched for studies comparing FFR-recommended versus FFR-deferred coronary stenting. Long-term MACEs, mortality, and myocardial infarction (MI) were considered as the clinical endpoints in this analysis. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated and the analyses were carried out by the latest version of the RevMan software.

RESULTS

A total number of 1753 patients (670 patients were revascularized, whereas 1083 patients were deferred from revascularization based on the FFR value) were analyzed. Current results showed MACEs and MI were significantly higher in the FFR-recommended PCI group with OR 1.34 (95% CI: 1.05-1.72; P = .02) and OR 1.73 (95% CI: 1.19-2.51; P = .004, I = 0%), respectively. However, mortality was similarly manifested with OR 1.23 (95% CI: 0.92-1.63; P = .16, I = 0%).

CONCLUSION

Significantly higher MACEs were observed in patients to whom PCI was recommended compared to those patients who were deferred from undergoing PCI based on the FFR values. Therefore, FFR might indeed be an important decision-making procedural tool, which should be used to stratify stable CAD patients with an advanced disease and who are qualified candidates for PCI. Further research should confirm this hypothesis.