Key result
iFR guidance linked to ~18% higher 5-year MACE rates compared with FFR.
Why the study?
Individual 5-year results of two major randomized trials suggested increased all-cause mortality following iFR-guided revascularization compared to FFR, motivating a combined analysis.
Does iFR-guided revascularization compared to FFR-guided revascularization improve outcomes in patients with intermediate epicardial artery stenosis?
Meta-Analysis (n=4,511)
Yes
Does iFR-guided revascularization compared to FFR-guided revascularization improve outcomes in patients with intermediate epicardial artery stenosis?
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“These findings reinforce the clinical importance of mapping the resistance distribution rather than treating angiographic severity alone. PPG may identify high-risk patterns even in lesions that are ischemia negative by traditional thresholds, raising the possibility that disease patterns, independently from absolute FFR values, may carry prognostic implications.”
A study-level meta-analysis of two major trials shows that iFR-guided revascularization is associated with significantly higher 5-year all-cause mortality and MACE compared to FFR-guided revascularization, potentially challenging guidelines that recommend them equally.
Background and Aims Guidelines recommend revascularization of intermediate epicardial artery stenosis to be guided by evidence of ischaemia. Fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) are equally recommended. Individual 5-year results of two major randomized trials comparing FFR with iFR-guided revascularization suggested increased all-cause mortality following iFR-guided revascularization. The aim of this study was a study-level meta-analysis of the 5-year outcome data in iFR-SWEDEHEART (NCT02166736) and DEFINE-FLAIR (NCT02053038). Methods Composite of major adverse cardiovascular events (MACE) and its individual components [all-cause death, myocardial infarction (MI), and unplanned revascularisation] were analysed. Raw Kaplan–Meier estimates, numbers at risk, and number of events were extracted at 5-year follow-up and analysed using the ipdfc package (Stata version 18, StataCorp, College Station, TX, USA). Results In total, iFR and FFR-guided revascularization was performed in 2254 and 2257 patients, respectively. Revascularization was more often deferred in the iFR group [n = 1128 (50.0%)] vs. the FFR group [n = 1021 (45.2%); P = .001]. In the iFR-guided group, the number of deaths, MACE, unplanned revascularization, and MI was 188 (8.3%), 484 (21.5%), 235 (10.4%), and 123 (5.5%) vs. 143 (6.3%), 420 (18.6%), 241 (10.7%), and 123 (5.4%) in the FFR group. Hazard ratio [95% confidence interval (CI)] estimates for MACE were 1.18 [1.04; 1.34], all-cause mortality 1.34 [1.08; 1.67], unplanned revascularization 0.99 [0.83; 1.19], and MI 1.02 [0.80; 1.32]. Conclusions Five-year all-cause mortality and MACE rates were increased with revascularization guided by iFR compared to FFR. Rates of unplanned revascularization and MI were equal in the two groups.
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Eftekhari et al. (2023) conducted a meta-analysis in intermediate epicardial artery stenosis (n=4,511). iFR-guided revascularization vs. FFR-guided revascularization was evaluated on Composite of major adverse cardiovascular events (MACE) including all-cause death, myocardial infarction, and unplanned revascularisation (HR 1.18, 95% CI 1.04-1.34). iFR-guided revascularization was associated with higher 5-year rates of MACE compared to FFR guidance (21.5% vs 18.6%; HR 1.18; 95% CI 1.04-1.34).
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