Johnson, Nils P2; Tóth, Gábor G2; Lai, Dejian2; Zhu, Hongjian2; Açar, Göksel2; Agostoni, Pierfrancesco2; Appelman, Yolande2; Arslan, Fatih2; Barbato, Emanuele2; Chen, Shao-Liang2; Di Serafino, Luigi2; Domínguez-Franco, Antonio J2; Dupouy, Patrick2; Esen, Ali M2; Esen, Ozlem B2; Hamilos, Michalis2; Iwasaki, Kohichiro2; Jensen, Lisette O3; Jiménez-Navarro, Manuel F2; Katritsis, Demosthenes G2; Kocaman, Sinan A2; Koo, Bon-Kwon2; López-Palop, Ramón2; Lorin, Jeffrey D2; Miller, Louis H2; Muller, Olivier2; Nam, Chang-Wook2; Oud, Niels2; Puymirat, Etienne2; Rieber, Johannes2; Rioufol, Gilles2; Rodés-Cabau, Josep2; Sedlis, Steven P2; Takeishi, Yasuchika2; Tonino, Pim A L2; Van Belle, Eric2; Verna, Edoardo2; Werner, Gerald S2; Fearon, William F2; Pijls, Nico H J2; De Bruyne, Bernard2; Gould, K Lance2
1 Cardiology, Department of Clinical Research, Det Sundhedsvidenskabelige Fakultet, SDU2 unknown3 Cardiology, Department of Clinical Research, Det Sundhedsvidenskabelige Fakultet, SDU
linking physiologic severity to clinical outcomes
BACKGROUND: Fractional flow reserve (FFR) has become an established tool for guiding treatment, but its graded relationship to clinical outcomes as modulated by medical therapy versus revascularization remains unclear. OBJECTIVES: The study hypothesized that FFR displays a continuous relationship between its numeric value and prognosis, such that lower FFR values confer a higher risk and therefore receive larger absolute benefits from revascularization. METHODS: Meta-analysis of study- and patient-level data investigated prognosis after FFR measurement. An interaction term between FFR and revascularization status allowed for an outcomes-based threshold. RESULTS: A total of 9,173 (study-level) and 6,961 (patient-level) lesions were included with a median follow-up of 16 and 14 months, respectively. Clinical events increased as FFR decreased, and revascularization showed larger net benefit for lower baseline FFR values. Outcomes-derived FFR thresholds generally occurred around the range 0.75 to 0.80, although limited due to confounding by indication. FFR measured immediately after stenting also showed an inverse relationship with prognosis (hazard ratio: 0.86, 95% confidence interval: 0.80 to 0.93; p < 0.001). An FFR-assisted strategy led to revascularization roughly half as often as an anatomy-based strategy, but with 20% fewer adverse events and 10% better angina relief. CONCLUSIONS: FFR demonstrates a continuous and independent relationship with subsequent outcomes, modulated by medical therapy versus revascularization. Lesions with lower FFR values receive larger absolute benefits from revascularization. Measurement of FFR immediately after stenting also shows an inverse gradient of risk, likely from residual diffuse disease. An FFR-guided revascularization strategy significantly reduces events and increases freedom from angina with fewer procedures than an anatomy-based strategy.
Journal of the American College of Cardiology, 2014, Vol 64, Issue 16, p. 1641-54