The physiological severity and distribution of coronary artery disease are key decision factors in stable coronary artery disease: results of the COMMIT-LAD retrospective registry

Background Intracoronary pressure measurements, including fractional flow reserve (FFR) and resting full-cycle ratio (RFR), are valuable for assessing lesion severity and guiding treatment decisions. However, the impact of pullback measurements on treatment decision-making remains unclear in clinical practice. Purpose This study assessed the influence of pullback measurements on the allocation of pharmacological, percutaneous, and surgical interventions for stable coronary artery disease (CAD). Methods This single-centre, retrospective cohort study identified patients with stable CAD and a positive FFR (≤0.80) or RFR (≤0.90) in the Left Anterior Descending (LAD) artery in 2022 and 2023. Patients were stratified and compared based on whether a pullback measurement was performed. Focal CAD was defined by a >75% pressure drop at ≤2 locations on pullback measurement. All other cases were classified as diffuse CAD. An additional analysis was conducted to identify patient differences across treatment strategies (conservative management (OMT), percutaneous coronary intervention (PCI), and coronary artery bypass grafting (CABG)). Finally, multinomial logistic regression was performed to identify independent predictors of treatment decisions, incorporating clinically relevant variables and those selected based on baseline characteristics (BMI, hypercholesterolemia, smoking, triple vessel disease, symptom burden, pullback measurements and FFR value). Results Among 422 patients, 303 (72%) underwent a pullback measurement. Patients in the non-pullback group were older, while other baseline characteristics were similar (Table 1). OMT patients had higher FFR values compared to those treated with PCI or CABG (0.78 [IQR 0.74-0.79] vs 0.72 [IQR 0.68-0.76], p<0.001). Using receiver operating characteristic (ROC) analysis, an FFR threshold of 0.75 was identified as the optimal cut-off for differentiating between conservative management and revascularization (AUC: 0.766, sensitivity: 0.729, specificity: 0.665), matching older guidelines. In the subset of patients with an FFR ≤0.75, OMT was significantly more prevalent among those with diffuse disease (52%) compared to those with focal disease (14%) (p<0.001). PCI was more frequently performed in cases of focal disease (55% for focal vs 24% for diffuse disease, p<0.001). Pullback measurements, FFR >0.75, age and symptom burden were all independent predictors of treatment choice (Table 2). Conclusions Despite current guidelines, conservative treatment is common for borderline significant CAD (FFR 0.75-0.80). In significant CAD (FFR ≤0.75), pullback measurements guide treatment decisions: PCI for focal, OMT for diffuse disease. Physiological and clinical factors, rather than solely anatomical severity, appear to be the primary determinants of treatment selection.