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Borderline lesions may pose higher risk than previously thought
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Borderline lesions determined by fractional flow reserve to be between 0.81 and 0.85 were at greater risk for deferred lesion intervention than non-borderline lesions greater than 0.86.
As a result, researchers who presented the study at the Society for Cardiovascular Angiography and Interventions Scientific Sessions suggest further evaluation is needed to refine the management of coronary lesions with borderline FFR values.
In the study, researchers from the Washington University School of Medicine in St. Louis retrospectively identified 674 patients at one center with 816 intermediate severity coronary lesions who underwent assessment with FFR and had PCI deferral based on FFR. Patients were classified as having borderline (0.81-0.85; n=275) or non-borderline (>0.86; n=541) lesions. Researchers classified deferred lesion intervention (DLI) as subsequent PCI or CABG to treat the lesion during long-term follow-up.
Mean FFR values for deferred lesions were significantly higher in the non-borderline group (0.91 ± 0.03 vs. 0.83 ± 0.01; P<.001).
During follow-up (mean, 4.6 ± 2.1 years), 144 deferred lesions (17.6%) underwent DLI by PCI (n=107) or CABG (n=37). DLI was performed more frequently for lesions with borderline compared with non-borderline FFR values (24% vs. 14.4%; P=.004), and there also was a significantly higher risk of DLI in the borderline arm (HR=1.72; 95% CI, 1.24-2.39).
Jeremiah P. Depta
Despite these results, it would be premature to conclude that the FFR cutoff must be revised or that borderline lesions need stenting or CABG, study researcher Jeremiah P. Depta, MD, a cardiology fellow at Washington University, said in a press release.
“Our study is a first step,” Depta said. “We are currently investigating other patient and lesion characteristics that may alter the risk for revascularization and adverse events after treatment is deferred on the basis of FFR.”
For more information:
Patel J. Poster B-053. Presented at: the Society for Cardiovascular Angiography and Interventions Scientific Sessions; May 8-11, 2013; Orlando, Fla.
Perspective
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Barry M. Cohen, MD
This test often helps guide the interventional cardiologist as to who should be revascularized (PCI or CABG) and who should be treated with medical therapy alone (when symptoms are adequately controlled). Classically, a FFR value of 0.8 or less was necessary for recommended intervention on intermediate lesions. Dr. Patel and colleagues’ data found that patients with FFR between 0.81 to 0.85 had a higher event risk (deferred PCI or CABG) than patients whose FFR was more than 0.86.
At a time when interventional cardiologists are being careful not to treat intermediate lesions above the 0.80 level, this can have profound implications on revascularization strategies. These data are preliminary and need to be further corroborated and examined in a prospective randomized trial before practice patterns will substantially change.
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