This article is more than 5 years old. Information may no longer be current.
ERIS: Coronary physiology assessment may be underused in CAD
Click Here to Manage Email Alerts
The current guidelines were met in approximately half of patients who underwent a coronary physiology assessment in daily practice, according to data presented at EuroPCR.
“Educational programs focused on the advantages of invasive coronary physiology assessment should be implemented to fill the gap between guideline indications and daily practice,” Matteo Tebaldi, MD, of the Cardiovascular Institute at Azienda Ospedaliero-Universitaria di Ferrara in Cona, Italy, and colleagues wrote in a simultaneous publication in JACC: Cardiovascular Interventions.
Italian catherization labs
Researchers analyzed data from 76 Italian catheterization laboratories that performed at least 20 functional assessments in 2015. These laboratories completed surveys on the management of intermediate coronary lesions from October 2016 to January 2017. Information was collected on operators, the center itself and four clinical cases. Participants were also asked to identify relevant stenosis and how they would manage in their clinical practice.
After the surveys were returned, each participating laboratory had 60 days to include consecutive cases in the study (n = 1,858). Patients were older than 18 years, underwent coronary artery angiography to diagnose ischemic heart disease and were assessed by fractional flow reserve and/or instantaneous wave-free ratio in at least one coronary lesion with at least 50% diameter stenosis.
Patients were then categorized by physiology assessment (n = 1,177), in which invasive physiology-based assessment was performed before deciding on whether coronary intervention should be completed, or visual estimation (n = 681), when operators did not perform FFR or iFR even though patients met protocol eligibility criteria for invasive functional assessment.
Indications for FFR or iFR included the European Society of Cardiology guidelines, American College of Cardiology/American Heart Association guidelines and the consensus of the committee.
Other data that were collected included baseline demographics, coronary anatomy and lesions, information on cardiac procedures, route of adenosine administration, functional assessment type, result of a coronary physiology examination subsequent revascularization decision and procedures.
Physiology-guided procedures accounted for 7% of the total volume of coronary angiography and 13% of PCIs. The use of FFR or iFR was in line with the American and European guidelines in 48% of cases. Physiology guidance was also used in 45% of patients with ACS.
Confidence in data
Among operators who relied on visual estimation, 39% of them cited that they were confident that the angiographic and clinical data were sufficient to make the correct decision for a patient.
“Obviously, physiology assessment does not substitute for clinical judgment and should always be interpreted in the clinical context of each patient,” Tebaldi and colleagues wrote. “However, a merely angiography-based approach results in a higher rate of discordant decisions with respect to the true functional importance of the stenosis and thus in unnecessary stenting or inappropriate deferral in approximately 30% to 50% of all cases.”
In a related editorial, Nils P. Johnson, MD, MS, associate professor of cardiovascular medicine at University of Texas McGovern Medical School in Houston, and Bon-Kwon Koo, MD, PhD, of the department of internal medicine and cardiovascular center at Seoul National University Hospital in Korea, wrote: “As demonstrated by both virtual and real-world studies, and large temporal increases in its uptake, factors such as cost, reimbursement, need for hyperemic drugs or pressure sensor design and delivery play minor roles. Although operators can be reluctant to admit it, the fundamental reason has received different labels: attitude, belief, local practice, ‘experience’ and culture. Put simply, we as a profession do not yet emotionally accept coronary physiology to guide treatment.” – by Darlene Dobkowski
References:
Tebaldi M, et al. FFR-iFR Pressure-Derived Physiology in Practice. Outcomes and New Approaches. Presented at: EuroPCR; May 22-25, 2018; Paris.
Johnson NP, et al. JACC Cardiovasc Interv. 2018;doi:10.1016/j.jcin.2018.05.021.
Tebaldi M, et al. JACC Cardiovasc Interv. 2018;doi:10.1016/j.jcin.2018.04.037.
Disclosures: The authors report no relevant financial disclosures. Johnson reports he received internal funding from the Weatherhead PET Center for Preventing and Reversing Atherosclerosis, had an institutional licensing and consulting agreement with Boston Scientific for the smart minimum FFR algorithm, received significant institutional research support from Philips/Volcano and St. Jude Medical and has a patent pending on diagnostic methods for quantifying TAVR physiology and aortic stenosis. Koo reports he received institutional research support from St. Jude Medical/Abbott and Philips/Volcano.
Perspective
Back to Top
Roxana Mehran, MD, MSCAI, FACC, FAHA, FESC
Even though this was a nationwide pool of patients, it is still a small cohort and it is a registry, not a randomized study. Of large number of cases performed, approximately 1,800 patients were included in this registry. A majority of patients had physiology-guided PCI, but one-third had angiographic visual assessment only to guide PCI. The truth is that physiology studies are used in a small number of patients, even though there are great outcomes data associated with them. They are used in about 10% of cases, and in this study, their use ranged from 7% to 13%. Many cases in this study were performed in accordance with U.S. and European guidelines, but many physicians don’t want to use physiology because they are very confident in their visual estimate and the patient’s presentation and symptomatology.
These results reflect what is going on in the real world and are thus important. We have to incorporate physiology whenever we have any small doubt. Now that FFR and iFR are available and there is increased awareness of them, there should be more physiologic assessments performed to inform our treatments. In many ways, we can curtail how we do PCI, performing it in a much more guideline-driven way if we incorporate physiology more. Angiography is two-dimensional imaging and doesn’t tell us anything about functional status of the coronary stenosis or ischemic burden. This study tells us we should incorporate physiology whenever possible.
Click Here to Manage Email Alerts