Clinical Events After Deferral of LAD Revascularization Following Physiological Coronary Assessment.
coronary stenosis
fractional flow reserve
instantaneous wave-free ratio
Journal
Journal of the American College of Cardiology
ISSN: 1558-3597
Titre abrégé: J Am Coll Cardiol
Pays: United States
ID NLM: 8301365
Informations de publication
Date de publication:
05 02 2019
05 02 2019
Historique:
received:
24
07
2018
revised:
04
10
2018
accepted:
22
10
2018
entrez:
2
2
2019
pubmed:
2
2
2019
medline:
22
11
2019
Statut:
ppublish
Résumé
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). 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. 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. 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). 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.
Sections du résumé
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.
Identifiants
pubmed: 30704577
pii: S0735-1097(18)39304-5
doi: 10.1016/j.jacc.2018.10.070
pmc: PMC6354033
pii:
doi:
Types de publication
Comparative Study
Journal Article
Randomized Controlled Trial
Research Support, Non-U.S. Gov't
Langues
eng
Sous-ensembles de citation
IM
Pagination
444-453Subventions
Organisme : Medical Research Council
ID : G1100443
Pays : United Kingdom
Organisme : British Heart Foundation
ID : FS/11/46/28861
Pays : United Kingdom
Organisme : Medical Research Council
ID : G1000357
Pays : United Kingdom
Organisme : British Heart Foundation
ID : FS/05/006
Pays : United Kingdom
Organisme : Wellcome Trust
ID : 212183/Z/18/Z
Pays : United Kingdom
Commentaires et corrections
Type : CommentIn
Informations de copyright
Copyright © 2019 The Authors. Published by Elsevier Inc. All rights reserved.
Références
Am J Cardiol. 2000 Dec 15;86(12):1322-6
pubmed: 11113406
Circ Cardiovasc Interv. 2014 Jun;7(3):301-11
pubmed: 24782198
N Engl J Med. 2009 Jan 15;360(3):213-24
pubmed: 19144937
Eur Heart J. 2014 Oct 1;35(37):2541-619
pubmed: 25173339
JACC Cardiovasc Interv. 2017 Dec 26;10(24):2525-2527
pubmed: 29268882
Circulation. 2001 Jun 19;103(24):2928-34
pubmed: 11413082
JACC Cardiovasc Interv. 2016 Dec 12;9(23):2390-2399
pubmed: 27838269
Circulation. 1994 May;89(5):2150-60
pubmed: 8181140
Circ Cardiovasc Interv. 2014 Aug;7(4):492-502
pubmed: 24987048
JACC Cardiovasc Interv. 2017 Dec 26;10(24):2514-2524
pubmed: 29268881
N Engl J Med. 2017 May 11;376(19):1824-1834
pubmed: 28317458
J Am Coll Cardiol. 2012 Apr 10;59(15):1392-402
pubmed: 22154731
J Am Coll Cardiol. 2012 Feb 28;59(9):857-81
pubmed: 22296741
JACC Cardiovasc Interv. 2018 Aug 13;11(15):1423-1433
pubmed: 30093048
J Am Coll Cardiol. 2002 Mar 6;39(5):852-8
pubmed: 11869852
N Engl J Med. 2017 May 11;376(19):1813-1823
pubmed: 28317438