Clinical Events After Deferral of LAD Revascularization Following Physiological Coronary Assessment

• Type of Material: Article
• Authors: Sayan Sen, Hammersmith Hospital; Yousif Ahmad, Hammersmith Hospital; Hakim-Moulay Dehbi, University College London; James P. Howard, Hammersmith Hospital; Juan F. Iglesias, Lausanne University Hospital; Rasha Al-Lamee, Hammersmith Hospital; Ricardo Petraco, Hammersmith Hospital; Sukhjinder Nijjer, Hammersmith Hospital; Ravinay Bhindi, Royal North Shore Hospital; Sam Lehman, Flinders University South Australia; Darren Walters, Prince Charles Hospital; James Sapontis, MonashHeart; Luc Janssens, Imelda Hospital; Christiaan J. Vrints, Antwerp University Hospital; Ahmed Khashaba, Ain Shams University; Mika Laine, Helsinki University Hospital; Eric Van Belle, INSERM; Florian Krackhardt, Lille University; Waldemar Bojara, Gemeinschaftsklinikum Mittelrhein; Olaf Going, Sana Klinikum Lichtenberg; Tobias Haerle, Carl von Ossietzky Universitat Oldenburg; Ciro Indolfi, Magna Graecia University of Catanzaro; Giampaolo Niccoli, University of Cattolica Sacro Cuore; Flavio Ribichini, University Hospital of Verona; Nobuhiro Tanaka, Tokyo Medical University; Hiroyoshi Yokoi, Fukuoka Sannou Hospital; Hiroaki Takashima, Aichi Medical University; Yuetsu Kikuta, Fukuyama Cardiovasc Hospital; Andrejs Erglis, Pauls Stradins Clinical University Hospital; Hugo Vinhas, Hospital Garcia Horta; Pedro Canas Silva, Hospital Santa Maria; Sergio B. Baptista, Hospital Prof Doutor Fernando Fonseca; Ali Alghamdi, King Abdulaziz Medical; Farrel Hellig, Sunninghill Hospital; Bon-Kwon Koo, Seoul National University Hospital; Chang-Wook Nam, Keimyung University; Eun-Seok Shin, University of Ulsan; Joon-Hyung Doh, Inje University; Salvatore Brugaletta, Hospital Clinic of Barcelona; Eduardo Alegria-Barrero, Hospital University of Torrejon; Martijin Meuwissen, Amphia Hospital; Jan J. Piek, Academy Medical Center; Niels van Royen, Vrije Universiteit Amsterdam; Murat Sezer, Istanbul University; Carlo Di Mario, Royal Brompton Hospital; Robert T. Gerber, Conquest Hospital; Iqbal S. Malik, Hammersmith Hospital; Andrew S.P. Sharp, Royal Devon & Exeter Hospital; Suneel Talwar, Royal Bournemouth General Hospital; Kare Tang, Essex Cardiothoracic Center; Habib Samady, Emory University; John Altman, Colorado Heart & Vascular; Arnold H. Seto, Veteran Affairs Long Beach Healthcare System; Jasvindar Singh, Washington University; Allen Jeremias, SUNY Stony Brook; Hitoshi Matsuo, Gifu Heart Center; Rajesh K. Kharbanda, Oxford University; Manesh R. Patel, Duke University; Patrick Serruys, Hammersmith Hospital; Javier Escaned, Hammersmith Hospital; Justin E. Davies, Hospital Clinico San Carlos
• Language: English
• Date: 2019-02-05
• Publisher: Elsevier: 12 months
• Publication Version: Final Published Version
• Copyright Statement: © 2019 The Authors
• License: Creative Commons Attribution 4.0 International
• Final Published Version (URL): http://dx.doi.org/10.1016/j.jacc.2018.10.070
• Title of Journal or Parent Work: Journal of the American College of Cardiology
• ISSN: 0735-1097
• Volume: 73
• Issue: 4
• Start Page: 444
• End Page: 453
• Keywords: DISCORDANCE; Cardiac & Cardiovascular Systems; Science & Technology; WAVE-FREE RATIO; FRACTIONAL FLOW RESERVE; PRESSURE; VELOCITY; SEVERITY; coronary stenosis; instantaneous wave-free ratio; Life Sciences & Biomedicine; fractional flow reserve; ANGIOPLASTY; STENOSES; Cardiovascular System & Cardiology
• Research Categories: Health Sciences, Medicine and Surgery

Abstract

Background: Physicians are not always comfortable deferring treatment of a stenosis in the left anterior descending (LAD) artery because of the perception that there is a high risk of major adverse cardiac events (MACE). The authors describe, using the DEFINE-FLAIR (Functional Lesion Assessment of Intermediate Stenosis to Guide Revascularisation) trial, MACE rates when LAD lesions are deferred, guided by physiological assessment using fractional flow reserve (FFR) or the instantaneous wave-free ratio (iFR). Objectives: The purpose of this study was to establish the safety of deferring treatment in the LAD using FFR or iFR within the DEFINE-FLAIR trial. Methods: MACE rates at 1 year were compared between groups (iFR and FFR) in patients whose physiological assessment led to LAD lesions being deferred. MACE was defined as a composite of cardiovascular death, myocardial infarction (MI), and unplanned revascularization at 1 year. Patients, and staff performing follow-up, were blinded to whether the decision was made with FFR or iFR. Outcomes were adjusted for age and sex. Results: A total of 872 patients had lesions deferred in the LAD (421 guided by FFR, 451 guided by iFR). The event rate with iFR was significantly lower than with FFR (2.44% vs. 5.26%; adjusted HR: 0.46; 95% confidence interval [CI]: 0.22 to 0.95; p = 0.04). This was driven by significantly lower unplanned revascularization with iFR and numerically lower MI (unplanned revascularization: 2.22% iFR vs. 4.99% FFR; adjusted HR: 0.44; 95% CI: 0.21 to 0.93; p = 0.03; MI: 0.44% iFR vs. 2.14% FFR; adjusted HR: 0.23; 95% CI: 0.05 to 1.07; p = 0.06). Conclusions: iFR-guided deferral appears to be 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.