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Safety of the Deferral of Coronary Revascularization on the Basis of Instantaneous Wave-Free Ratio and Fractional Flow Reserve Measurements in Stable Coronary Artery Disease and Acute Coronary Syndromes
Hospital Clínico San Carlos, IDISSC, Madrid, Spain; Universidad Complutense de Madrid, Madrid, Spain.
Department of Cardiology, Faculty of Health, Örebro University, Örebro, Sweden.ORCID iD: 0000-0002-9821-0510
Örebro University, School of Medical Sciences.
Hammersmith Hospital, Imperial College London, London, United Kingdom.
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Number of Authors: 882018 (English)In: JACC: Cardiovascular Interventions, ISSN 1936-8798, E-ISSN 1876-7605, Vol. 11, no 15, p. 1437-1449Article in journal (Refereed) Published
Abstract [en]

OBJECTIVES: The aim of this study was to investigate the clinical outcomes of patients deferred from coronary revascularization on the basis of instantaneous wave-free ratio (iFR) or fractional flow reserve (FFR) measurements in stable angina pectoris (SAP) and acute coronary syndromes (ACS).

BACKGROUND: Assessment of coronary stenosis severity with pressure guidewires is recommended to determine the need for myocardial revascularization.

METHODS: The safety of deferral of coronary revascularization in the pooled per-protocol population (n = 4,486) of the DEFINE-FLAIR (Functional Lesion Assessment of Intermediate Stenosis to Guide Revascularisation) and iFR-SWEDEHEART (Instantaneous Wave-Free Ratio Versus Fractional Flow Reserve in Patients With Stable Angina Pectoris or Acute Coronary Syndrome) randomized clinical trials was investigated. Patients were stratified according to revascularization decision making on the basis of iFR or FFR and to clinical presentation (SAP or ACS). The primary endpoint was major adverse cardiac events (MACE), defined as the composite of all-cause death, nonfatal myocardial infarction, or unplanned revascularization at 1 year.

RESULTS: Coronary revascularization was deferred in 2,130 patients. Deferral was performed in 1,117 patients (50%) in the iFR group and 1,013 patients (45%) in the FFR group (p < 0.01). At 1 year, the MACE rate in the deferred population was similar between the iFR and FFR groups (4.12% vs. 4.05%; fully adjusted hazard ratio: 1.13; 95% confidence interval: 0.72 to 1.79; p = 0.60). A clinical presentation with ACS was associated with a higher MACE rate compared with SAP in deferred patients (5.91% vs. 3.64% in ACS and SAP, respectively; fully adjusted hazard ratio: 0.61 in favor of SAP; 95% confidence interval: 0.38 to 0.99; p = 0.04).

CONCLUSIONS: Overall, deferral of revascularization is equally safe with both iFR and FFR, with a low MACE rate of about 4%. Lesions were more frequently deferred when iFR was used to assess physiological significance. In deferred patients presenting with ACS, the event rate was significantly increased compared with SAP at 1 year.

Place, publisher, year, edition, pages
Elsevier, 2018. Vol. 11, no 15, p. 1437-1449
Keywords [en]
ACS, FFR, SAP, coronary physiology, deferral of revascularization, iFR
National Category
Cardiac and Cardiovascular Systems
Identifiers
URN: urn:nbn:se:oru:diva-68506DOI: 10.1016/j.jcin.2018.05.029ISI: 000440859800006PubMedID: 30093050Scopus ID: 2-s2.0-85050687646OAI: oai:DiVA.org:oru-68506DiVA, id: diva2:1239690
Note

Funding Agencies:

Philips  

Upsala Clinical Research Centre  

Volcano  

Imperial College  

Philips Volcano  

Imperial College London  

Medical Research Council 

Available from: 2018-08-17 Created: 2018-08-17 Last updated: 2018-09-04Bibliographically approved

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Calais, FredrikFröbert, Ole

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