Long-Term Outcomes of Fractional Flow Reserve-Guided Percutaneous Coronary Intervention of Moderate Lesions in Patients with Chronic Coronary Syndrome
Abstract
Background: Fractional flow reserve (FFR) is crucial to evaluating coronary artery stenosis in patients diagnosed with chronic coronary syndrome (CCS). By assessing the severity of stenosis, FFR assists in determining whether percutaneous coronary intervention (PCI) is necessary.
Methods: Conducted at Tehran Heart Center from 2013 through 2017, this cohort study involved 52,248 CCS patients who underwent coronary angiography. Among them, 598 symptomatic individuals, despite receiving comprehensive medical treatment, underwent FFR assessment. Subsequently, 225 patients with positive FFR (≤0.80) underwent PCI, while 373 patients received solely medical treatment. The patients were monitored for 3 years to evaluate primary and secondary endpoints.
Results: After 3 years, the PCI group demonstrated a lower incidence of the primary composite endpoint, consisting of all-cause mortality, nonfatal myocardial infarction, repeat target vessel/lesion revascularization (TVR/TLR), and coronary artery bypass graft surgery, than the medical treatment group (HR, 0.85; 95% CI, 0.74 to 0.98; P=0.012). Additionally, urgent TVR/TLR significantly decreased in the PCI group (HR, 0.56; 95% CI, 0.42 to 0.74; P<0.001).
Conclusion: FFR-guided PCI demonstrated effectiveness in reducing long-term major adverse cardiac events, primarily by lowering the incidence of TVR/TLR. The results emphasize the significance of FFR-guided PCI in addressing stenosis rather than alleviating ischemia.
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2. Hassanzadeh-Makoui R, Jamei M, Hassanzadeh-Makoui M, Khederlou H. Effects of Vitamin D on Left Ventricular Ejection Fraction in Patients with Systolic Heart Failure: A Double-Blind Randomized Clinical Trial. Int J Endocrinol Metab 2020;18:e103528.
3. Makoui RH, Khederlou H, Rasouli A, Shojaei FS, Ramezanpour N. Relationship between the ABO Blood Groups and Acute Coronary Syndrome; Zanjan Mousavi Hospital 2017-2020. Clin Lab 2022;68.
4. Marzilli M, Crea F, Morrone D, Bonow RO, Brown DL, Camici PG, Chilian WM, DeMaria A, Guarini G, Huqi A, Merz CNB, Pepine C, Scali MC, Weintraub WS, Boden WE. Myocardial ischemia: From disease to syndrome. Int J Cardiol. 2020 Sep 1;314:32-35.
5. Pham V, Moroni A, Gall E, Benedetti A, Zivelonghi C, Picard F. Revascularization and Medical Therapy for Chronic Coronary Syndromes: Lessons Learnt from Recent Trials, a Literature Review. J Clin Med. 2023;12:2833.
6. Sels JW, Tonino PA, Siebert U, Fearon WF, Van't Veer M, De Bruyne B, Pijls NH. Fractional flow reserve in unstable angina and non-ST-segment elevation myocardial infarction experience from the FAME (Fractional flow reserve versus Angiography for Multivessel Evaluation) study. JACC Cardiovasc Interv 2011;4:1183-1189.
7. Bruno F, D'Ascenzo F, Marengo G, Manfredi R, Saglietto A, Gallone G, Franchin L, Piroli F, Angelini F, De Filippo O, Conrotto F, Omedè P, Montefusco A, Pennone M, Boffini M, Pocar M, Rinaldi M, De Ferrari GM. Fractional flow reserve guided versus angiographic guided surgical revascularization: A meta-analysis. Catheter Cardiovasc Interv 2021;98:E18-E23.
8. Scoccia A, Tomaniak M, Neleman T, Groenland FTW, Plantes ACZD, Daemen J. Angiography-Based Fractional Flow Reserve: State of the Art. Curr Cardiol Rep 2022;24:667-678.
9. Zimmermann FM, Ferrara A, Johnson NP, van Nunen LX, Escaned J, Albertsson P, Erbel R, Legrand V, Gwon HC, Remkes WS, Stella PR, van Schaardenburgh P, Bech GJ, De Bruyne B, Pijls NH. Deferral vs. performance of percutaneous coronary intervention of functionally non-significant coronary stenosis: 15-year follow-up of the DEFER trial. Eur Heart J 2015;36:3182-3188.
10. Koo BK, Hu X, Kang J, Zhang J, Jiang J, Hahn JY, Nam CW, Doh JH, Lee BK, Kim W, Huang J, Jiang F, Zhou H, Chen P, Tang L, Jiang W, Chen X, He W, Ahn SG, Yoon MH, Kim U, Lee JM, Hwang D, Ki YJ, Shin ES, Kim HS, Tahk SJ, Wang J; FLAVOUR Investigators. Fractional Flow Reserve or Intravascular Ultrasonography to Guide PCI. N Engl J Med 2022;387:779-789.
11. Cavallari LH, Lee CR, Duarte JD, Nutescu EA, Weitzel KW, Stouffer GA, Johnson JA. Implementation of inpatient models of pharmacogenetics programs. Am J Health Syst Pharm 2016;73:1944-1954.
12. Pijls NH, van Son JA, Kirkeeide RL, De Bruyne B, Gould KL. Experimental basis of determining maximum coronary, myocardial, and collateral blood flow by pressure measurements for assessing functional stenosis severity before and after percutaneous transluminal coronary angioplasty. Circulation 1993;87:1354-1367.
13. Pijls NH, De Bruyne B, Peels K, Van Der Voort PH, Bonnier HJ, Bartunek J Koolen JJ, Koolen JJ. Measurement of fractional flow reserve to assess the functional severity of coronary-artery stenoses. N Engl J Med 1996;334:1703-1708.
14. Murai T, Lee T, Yonetsu T, Isobe M, Kakuta T. Influence of microvascular resistance on fractional flow reserve after successful percutaneous coronary intervention. Catheter Cardiovasc Interv 2015;85:585-592.
15. Melikian N, De Bondt P, Tonino P, De Winter O, Wyffels E, Bartunek J, Heyndrickx GR, Fearon WF, Pijls NH, Wijns W, De Bruyne B. Fractional flow reserve and myocardial perfusion imaging in patients with angiographic multivessel coronary artery disease. JACC Cardiovasc Interv 2010;3:307-314.
16. Jenei C, Tar B, Ágoston A, Sánta P, Sánta J, Csippa B, Wéber R, Gyürki D, Halász G, Szabó GT, Czuriga D, Kőszegi Z. Novel Method to Detect Pitfalls of Intracoronary Pressure Measurements by Pressure Waveform Analysis. J Pers Med 2022;12:2035.
17. De Bruyne B, Pijls NH, Kalesan B, Barbato E, Tonino PA, Piroth Z, Jagic N, Möbius-Winkler S, Rioufol G, Witt N, Kala P, MacCarthy P, Engström T, Oldroyd KG, Mavromatis K, Manoharan G, Verlee P, Frobert O, Curzen N, Johnson JB, Jüni P, Fearon WF; FAME 2 Trial Investigators. Fractional flow reserve-guided PCI versus medical therapy in stable coronary disease. N Engl J Med 2012;367:991-1001.
18. Boden WE, O'Rourke RA, Teo KK, Hartigan PM, Maron DJ, Kostuk WJ, Knudtson M, Dada M, Casperson P, Harris CL, Chaitman BR, Shaw L, Gosselin G, Nawaz S, Title LM, Gau G, Blaustein AS, Booth DC, Bates ER, Spertus JA, Berman DS, Mancini GB, Weintraub WS; COURAGE Trial Research Group. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med 2007;356:1503-1516.
19. Koo BK, Hu X, Kang J, Zhang J, Jiang J, Hahn JY, Nam CW, Doh JH, Lee BK, Kim W, Huang J, Jiang F, Zhou H, Chen P, Tang L, Jiang W, Chen X, He W, Ahn SG, Yoon MH, Kim U, Lee JM, Hwang D, Ki YJ, Shin ES, Kim HS, Tahk SJ, Wang J; FLAVOUR Investigators. Fractional Flow Reserve or Intravascular Ultrasonography to Guide PCI. N Engl J Med 2022;387:779-789.
20. Xaplanteris P, Fournier S, Pijls NHJ, Fearon WF, Barbato E, Tonino PAL, Engstrøm T, Kääb S, Dambrink JH, Rioufol G, Toth GG, Piroth Z, Witt N, Fröbert O, Kala P, Linke A, Jagic N, Mates M, Mavromatis K, Samady H, Irimpen A, Oldroyd K, Campo G, Rothenbühler M, Jüni P, De Bruyne B; FAME 2 Investigators. Five-Year Outcomes with PCI Guided by Fractional Flow Reserve. N Engl J Med 2018;379:250-259.
21. Hamaya R, Kanaji Y, Usui E, Hoshino M, Murai T, Yonetsu T, Kakuta T. Improvement of Fractional Flow Reserve after Percutaneous Coronary Intervention Does Not Necessarily Indicate Increased Coronary Flow. Eur Cardiol 2019;14:10-12.
22. Smits PC, Abdel-Wahab M, Neumann FJ, Boxma-de Klerk BM, Lunde K, Schotborgh CE, Piroth Z, Horak D, Wlodarczak A, Ong PJ, Hambrecht R, Angerås O, Richardt G, Omerovic E; Compare-Acute Investigators. Fractional Flow Reserve-Guided Multivessel Angioplasty in Myocardial Infarction. N Engl J Med 2017;376:1234-1244.
23. Engstrøm T, Kelbæk H, Helqvist S, Høfsten DE, Kløvgaard L, Holmvang L, Jørgensen E, Pedersen F, Saunamäki K, Clemmensen P, De Backer O, Ravkilde J, Tilsted HH, Villadsen AB, Aarøe J, Jensen SE, Raungaard B, Køber L; DANAMI-3—PRIMULTI Investigators. Complete revascularisation versus treatment of the culprit lesion only in patients with ST-segment elevation myocardial infarction and multivessel disease (DANAMI-3—PRIMULTI): an open-label, randomised controlled trial. Lancet 2015;386:665-671.
24. Frøbert O, van't Veer M, Aarnoudse W, Simonsen U, Koolen JJ, Pijls NH. Acute myocardial infarction and underlying stenosis severity. Catheter Cardiovasc Interv 2007;70:958-965.
2. Hassanzadeh-Makoui R, Jamei M, Hassanzadeh-Makoui M, Khederlou H. Effects of Vitamin D on Left Ventricular Ejection Fraction in Patients with Systolic Heart Failure: A Double-Blind Randomized Clinical Trial. Int J Endocrinol Metab 2020;18:e103528.
3. Makoui RH, Khederlou H, Rasouli A, Shojaei FS, Ramezanpour N. Relationship between the ABO Blood Groups and Acute Coronary Syndrome; Zanjan Mousavi Hospital 2017-2020. Clin Lab 2022;68.
4. Marzilli M, Crea F, Morrone D, Bonow RO, Brown DL, Camici PG, Chilian WM, DeMaria A, Guarini G, Huqi A, Merz CNB, Pepine C, Scali MC, Weintraub WS, Boden WE. Myocardial ischemia: From disease to syndrome. Int J Cardiol. 2020 Sep 1;314:32-35.
5. Pham V, Moroni A, Gall E, Benedetti A, Zivelonghi C, Picard F. Revascularization and Medical Therapy for Chronic Coronary Syndromes: Lessons Learnt from Recent Trials, a Literature Review. J Clin Med. 2023;12:2833.
6. Sels JW, Tonino PA, Siebert U, Fearon WF, Van't Veer M, De Bruyne B, Pijls NH. Fractional flow reserve in unstable angina and non-ST-segment elevation myocardial infarction experience from the FAME (Fractional flow reserve versus Angiography for Multivessel Evaluation) study. JACC Cardiovasc Interv 2011;4:1183-1189.
7. Bruno F, D'Ascenzo F, Marengo G, Manfredi R, Saglietto A, Gallone G, Franchin L, Piroli F, Angelini F, De Filippo O, Conrotto F, Omedè P, Montefusco A, Pennone M, Boffini M, Pocar M, Rinaldi M, De Ferrari GM. Fractional flow reserve guided versus angiographic guided surgical revascularization: A meta-analysis. Catheter Cardiovasc Interv 2021;98:E18-E23.
8. Scoccia A, Tomaniak M, Neleman T, Groenland FTW, Plantes ACZD, Daemen J. Angiography-Based Fractional Flow Reserve: State of the Art. Curr Cardiol Rep 2022;24:667-678.
9. Zimmermann FM, Ferrara A, Johnson NP, van Nunen LX, Escaned J, Albertsson P, Erbel R, Legrand V, Gwon HC, Remkes WS, Stella PR, van Schaardenburgh P, Bech GJ, De Bruyne B, Pijls NH. Deferral vs. performance of percutaneous coronary intervention of functionally non-significant coronary stenosis: 15-year follow-up of the DEFER trial. Eur Heart J 2015;36:3182-3188.
10. Koo BK, Hu X, Kang J, Zhang J, Jiang J, Hahn JY, Nam CW, Doh JH, Lee BK, Kim W, Huang J, Jiang F, Zhou H, Chen P, Tang L, Jiang W, Chen X, He W, Ahn SG, Yoon MH, Kim U, Lee JM, Hwang D, Ki YJ, Shin ES, Kim HS, Tahk SJ, Wang J; FLAVOUR Investigators. Fractional Flow Reserve or Intravascular Ultrasonography to Guide PCI. N Engl J Med 2022;387:779-789.
11. Cavallari LH, Lee CR, Duarte JD, Nutescu EA, Weitzel KW, Stouffer GA, Johnson JA. Implementation of inpatient models of pharmacogenetics programs. Am J Health Syst Pharm 2016;73:1944-1954.
12. Pijls NH, van Son JA, Kirkeeide RL, De Bruyne B, Gould KL. Experimental basis of determining maximum coronary, myocardial, and collateral blood flow by pressure measurements for assessing functional stenosis severity before and after percutaneous transluminal coronary angioplasty. Circulation 1993;87:1354-1367.
13. Pijls NH, De Bruyne B, Peels K, Van Der Voort PH, Bonnier HJ, Bartunek J Koolen JJ, Koolen JJ. Measurement of fractional flow reserve to assess the functional severity of coronary-artery stenoses. N Engl J Med 1996;334:1703-1708.
14. Murai T, Lee T, Yonetsu T, Isobe M, Kakuta T. Influence of microvascular resistance on fractional flow reserve after successful percutaneous coronary intervention. Catheter Cardiovasc Interv 2015;85:585-592.
15. Melikian N, De Bondt P, Tonino P, De Winter O, Wyffels E, Bartunek J, Heyndrickx GR, Fearon WF, Pijls NH, Wijns W, De Bruyne B. Fractional flow reserve and myocardial perfusion imaging in patients with angiographic multivessel coronary artery disease. JACC Cardiovasc Interv 2010;3:307-314.
16. Jenei C, Tar B, Ágoston A, Sánta P, Sánta J, Csippa B, Wéber R, Gyürki D, Halász G, Szabó GT, Czuriga D, Kőszegi Z. Novel Method to Detect Pitfalls of Intracoronary Pressure Measurements by Pressure Waveform Analysis. J Pers Med 2022;12:2035.
17. De Bruyne B, Pijls NH, Kalesan B, Barbato E, Tonino PA, Piroth Z, Jagic N, Möbius-Winkler S, Rioufol G, Witt N, Kala P, MacCarthy P, Engström T, Oldroyd KG, Mavromatis K, Manoharan G, Verlee P, Frobert O, Curzen N, Johnson JB, Jüni P, Fearon WF; FAME 2 Trial Investigators. Fractional flow reserve-guided PCI versus medical therapy in stable coronary disease. N Engl J Med 2012;367:991-1001.
18. Boden WE, O'Rourke RA, Teo KK, Hartigan PM, Maron DJ, Kostuk WJ, Knudtson M, Dada M, Casperson P, Harris CL, Chaitman BR, Shaw L, Gosselin G, Nawaz S, Title LM, Gau G, Blaustein AS, Booth DC, Bates ER, Spertus JA, Berman DS, Mancini GB, Weintraub WS; COURAGE Trial Research Group. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med 2007;356:1503-1516.
19. Koo BK, Hu X, Kang J, Zhang J, Jiang J, Hahn JY, Nam CW, Doh JH, Lee BK, Kim W, Huang J, Jiang F, Zhou H, Chen P, Tang L, Jiang W, Chen X, He W, Ahn SG, Yoon MH, Kim U, Lee JM, Hwang D, Ki YJ, Shin ES, Kim HS, Tahk SJ, Wang J; FLAVOUR Investigators. Fractional Flow Reserve or Intravascular Ultrasonography to Guide PCI. N Engl J Med 2022;387:779-789.
20. Xaplanteris P, Fournier S, Pijls NHJ, Fearon WF, Barbato E, Tonino PAL, Engstrøm T, Kääb S, Dambrink JH, Rioufol G, Toth GG, Piroth Z, Witt N, Fröbert O, Kala P, Linke A, Jagic N, Mates M, Mavromatis K, Samady H, Irimpen A, Oldroyd K, Campo G, Rothenbühler M, Jüni P, De Bruyne B; FAME 2 Investigators. Five-Year Outcomes with PCI Guided by Fractional Flow Reserve. N Engl J Med 2018;379:250-259.
21. Hamaya R, Kanaji Y, Usui E, Hoshino M, Murai T, Yonetsu T, Kakuta T. Improvement of Fractional Flow Reserve after Percutaneous Coronary Intervention Does Not Necessarily Indicate Increased Coronary Flow. Eur Cardiol 2019;14:10-12.
22. Smits PC, Abdel-Wahab M, Neumann FJ, Boxma-de Klerk BM, Lunde K, Schotborgh CE, Piroth Z, Horak D, Wlodarczak A, Ong PJ, Hambrecht R, Angerås O, Richardt G, Omerovic E; Compare-Acute Investigators. Fractional Flow Reserve-Guided Multivessel Angioplasty in Myocardial Infarction. N Engl J Med 2017;376:1234-1244.
23. Engstrøm T, Kelbæk H, Helqvist S, Høfsten DE, Kløvgaard L, Holmvang L, Jørgensen E, Pedersen F, Saunamäki K, Clemmensen P, De Backer O, Ravkilde J, Tilsted HH, Villadsen AB, Aarøe J, Jensen SE, Raungaard B, Køber L; DANAMI-3—PRIMULTI Investigators. Complete revascularisation versus treatment of the culprit lesion only in patients with ST-segment elevation myocardial infarction and multivessel disease (DANAMI-3—PRIMULTI): an open-label, randomised controlled trial. Lancet 2015;386:665-671.
24. Frøbert O, van't Veer M, Aarnoudse W, Simonsen U, Koolen JJ, Pijls NH. Acute myocardial infarction and underlying stenosis severity. Catheter Cardiovasc Interv 2007;70:958-965.
| Files | ||
| Issue | Vol 19 No 1 (2024): J Teh Univ Heart Ctr | |
| Section | Original Article(s) | |
| DOI | https://doi.org/10.18502/jthc.v19i1.15538 | |
| Keywords | ||
| Coronary artery disease Major adverse cardiac events Fractional flow reserve Percutaneous coronary intervention | ||
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How to Cite
1.
Khederlou H, Mohajeri M, Bavandpour Karvane H, Jalali A, Salarifar M. Long-Term Outcomes of Fractional Flow Reserve-Guided Percutaneous Coronary Intervention of Moderate Lesions in Patients with Chronic Coronary Syndrome. J Tehran Heart Cent. 2024;19(1):54-59.
