FFR during angiography led to high rate of treatment reclassification

DALLAS — Use of fractional flow reserve during diagnostic coronary angiography was linked with reclassification of the revascularization decision in approximately half of the patients and was shown to be safe in a study presented at AHA 2013.

Eric Van Belle, MD, PhD, with the Centre Hospitalier Regional in Lille Cedex, France, presented the results from the The Registre Français de la FFR and explained that the study “provides important information on the use of FFR in patients referred for diagnostic coronary angiography.”

The registry study examined 1,075 consecutive patients (age, 65 ± 10 years; 75% men) undergoing diagnostic angiography that included an FFR investigation at 20 French centers. Patients had a mean FFR of 0.82 ± 0.10 and most of the investigated lesions were found in the left anterior descending artery (58%).

Reclassification with FFR frequent, safe

The prospective results showed that the strategy a priori based on angiography was medical therapy in 55% of patients and revascularization in 45% (PCI, 38%; CABG, 7%). FFR lead to treatment decisions in 95.7% of patients.

After FFR, the applied strategy was medical therapy in 58% of patients and revascularization in 42% (PCI, 32%; CABG, 10%). The final strategy differed from the strategy a priori in 43% of cases — 33% of a priori medical therapy patients, 56% of a priori PCI patients and 62% of a priori CABG patients.

Among patients who were reclassified based on FFR that was in disagreement with the angiography-based a priori decision (n=464), the 1-year outcome of survival free of MACE (11.2%) was as good as in patients in whom final applied strategy corresponded with the angiography-based a priori decision (n=611; MACE,11.9%; P log-rank =.78).

Eric Van Belle

At 1 year, more than 93% of patients were asymptomatic, without a significant difference observed between reclassified and nonreclassified patients (Generalized Linear Mixed Model, P=.75). Van Belle also reported that reclassification safety was preserved in high-risk patients.

“[This study] demonstrates that the use of FFR is associated with small changes in the proportion of patients referred to each treatment modality, while it is associated with reclassification of the revascularization decision in about half of the patients,” Van Belle said during a presentation. “It further demonstrates that it is safe to pursue a revascularization strategy divergent to that suggested by angiography alone but guided by FFR measurements. The present data further support and [extend] the concept of a ‘physiology-guided’ decision of coronary revascularization.”

Further research necessary

In a discussant following the presentation, Young-Hak Kim, MD, PhD, of Asan Medical Center in Seoul, said that the comparably excellent rates of 1-year MACE in both groups indicate the safety and efficacy of FFR-guided treatment for stable CAD, but explained that patients with complex disease and lesion subsets such as patients who have multivessel disease, diabetes and long complex lesions, may have a greater likelihood of being treated with revascularization.

In addition, “This is a single arm cohort. Therefore it is still not clear whether global utilization of function-guided treatment improves CAD prognosis compared with anatomy-guided treatment,” Kim said. “Further research is still required to assess the changes of doctors’ behavior, patient outcomes and medical cost after globally implementing function-guided treatment for patients with CAD.” – by Brian Ellis

For more information:

Van Belle E. CS. 02. Biomarkers in populations. Presented at: the American Heart Association Scientific Sessions; Nov. 16-20, 2013; Dallas.

Van Belle E. Circulation. 2014;doi:10.1161/circulationaha.113.006646.

Disclosure: Van Belle reports serving as a consultant for St. Jude Medical and receiving speaker’s fees from Volcano.