Clinical Events After Deferral of LAD Revascularization Following Physiological Coronary Assessment.

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.

• Authors: Sayan Sen, Yousif Ahmad, Hakim-Moulay Dehbi, James P Howard, Juan F Iglesias, Rasha Al-Lamee, Ricardo Petraco, Sukhjinder Nijjer, Ravinay Bhindi, Sam Lehman, Darren Walters, James Sapontis, Luc Janssens, Christiaan J Vrints, Ahmed Khashaba, Mika Laine, Eric Van Belle, Florian Krackhardt, Waldemar Bojara, Olaf Going, Tobias Härle, Ciro Indolfi, Giampaolo Niccoli, Flavio Ribichini, Nobuhiro Tanaka, Hiroyoshi Yokoi, Hiroaki Takashima, Yuetsu Kikuta, Andrejs Erglis, Hugo Vinhas, Pedro Canas Silva, Sérgio B Baptista, Ali Alghamdi, Farrel Hellig, Bon-Kwon Koo, Chang-Wook Nam, Eun-Seok Shin, Joon-Hyung Doh, Salvatore Brugaletta, Eduardo Alegria-Barrero, Martijin Meuwissen, Jan J Piek, Niels van Royen, Murat Sezer, Carlo Di Mario, Robert T Gerber, Iqbal S Malik, Andrew S P Sharp, Suneel Talwar, Kare Tang, Habib Samady, John Altman, Arnold H Seto, Jasvindar Singh, Allen Jeremias, Hitoshi Matsuo, Rajesh K Kharbanda, Manesh R Patel, Patrick Serruys, Javier Escaned, Justin E Davies
• Journal: Journal of the American College of Cardiology (J Am Coll Cardiol) Vol. 73 Issue 4 Pg. 444-453 (02 05 2019) ISSN: 1558-3597 [Electronic] United States
• PMID: 30704577 (Publication Type: Comparative Study, Journal Article, Randomized Controlled Trial, Research Support, Non-U.S. Gov't)
• Copyright: Copyright © 2019 The Authors. Published by Elsevier Inc. All rights reserved.

Topics

• Aged
• Coronary Angiography
• Coronary Stenosis (complications, diagnostic imaging)
• Coronary Vessels (diagnostic imaging)
• Female
• Fractional Flow Reserve, Myocardial
• Humans
• Male
• Middle Aged
• Myocardial Revascularization