Instantaneous wave-free ratio (iFR®) to determine hemodynamically significant coronary stenosis: A comprehensive review

Q: What is the clinical evidence from this study?

Study design: Review. Population: Coronary artery stenosis / coronary heart disease. Intervention: Instantaneous wave-free ratio (iFR) vs. Fractional flow reserve (FFR).

Q: What does this research mean for the field?

Instantaneous wave-free ratio (iFR) is non-inferior to fractional flow reserve (FFR) for 1-year major adverse cardiac events while significantly reducing procedural adverse events and avoiding vasodilator use. Novelty: ClaimNovelty.SYNTHESIS. Consensus alignment: ConsensusAlignment.SUPPORTS_CONSENSUS.

Stefan Baumann; Leonard Chandra; Elizaveta Skarga; Matthias Renker; Martin Borggrefe; İbrahim Akın; Dirk Loßnitzer

doi:10.4330/wjc.v10.i12.267

December 24, 2018World Journal of CardiologyOpen Access

Instantaneous wave-free ratio (iFR®) to determine hemodynamically significant coronary stenosis: A comprehensive review

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Key result

Instantaneous wave-free ratio (iFR) demonstrated non-inferiority to fractional flow reserve (FFR) in 1-year MACE (6.8% vs 7.0% in DEFINE-FLAIR; 6.7% vs 6.1% in SWEDEHEART) with fewer adverse events.

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Why the study?

Invasive fractional flow reserve is the current standard for estimating the hemodynamic significance of coronary artery stenosis, but its clinical use remains limited due to the need for adenosine administration and prolonged procedure length. Instantaneous wave-free ratio offers a resting assessment without vasodilators.

Does instantaneous wave-free ratio (iFR) provide non-inferior hemodynamic assessment and clinical outcomes compared to fractional flow reserve (FFR) in patients with coronary artery stenosis?

Key Points

To review the clinical evidence, diagnostic accuracy, and utility of the instantaneous wave-free ratio compared to fractional flow reserve for determining the hemodynamic significance of coronary artery stenosis.
Synthesized diagnostic performance data and clinical outcomes across prospective cohort and randomized trials comparing instantaneous wave-free ratio with fractional flow reserve.
Evaluated multicenter randomized clinical trials, including DEFINE-FLAIR (N=2492) and iFR-SWEDEHEART (N=2037), assessing 1-year major adverse cardiac events and procedural adverse events.
In the DEFINE-FLAIR trial, 1-year major adverse cardiac event rates were 6.8% with instantaneous wave-free ratio versus 7.0% with fractional flow reserve (P = 0.003), while adverse events occurred in 3.1% versus 30.8% of patients (P < 0.001).
In the iFR-SWEDEHEART trial, 1-year major adverse cardiac event rates were 6.7% with instantaneous wave-free ratio versus 6.1% with fractional flow reserve (P = 0.007), with adverse event rates of 3.0% versus 68.3% (P < 0.0001).
Diagnostic accuracy of resting instantaneous wave-free ratio compared with fractional flow reserve ranged from 68% to 93% across evaluated cohort studies, eliminating the need for hyperemic agents such as adenosine.

Structured PICO

Does instantaneous wave-free ratio (iFR) provide non-inferior hemodynamic assessment and clinical outcomes compared to fractional flow reserve (FFR) in patients with coronary artery stenosis?

P

Population

Patients with coronary artery stenosis undergoing invasive hemodynamic evaluation reviewed across clinical trials.

I

Intervention

Instantaneous wave-free ratio (iFR) and iFR-pullback obtained at rest during the diastolic wave-free period without vasodilator administration

C

Comparator

Fractional flow reserve (FFR) measurement obtained during adenosine-induced hyperemia

Limitations

Advancing the coronary-pressure guide wire is potentially accompanied by complications such as perforation or dissection.
Uncertain how to proceed in cases where iFR and FFR results differ or whether an adenosine stress test is indicated.
Residual pressure gradient across the implanted stent can lead to failed prediction of post-PCI iFR values.
It is not completely clarified how to proceed in uncertain cases where iFR and FFR differ and whether a stress test with adenosine is indicated.
Residual pressure gradient across an implanted stent is an independent risk factor for failed prediction of post-PCI iFR.

Implication

This comprehensive review highlights that instantaneous wave-free ratio (iFR) is a Class IA guideline-recommended, vasodilator-free alternative that is non-inferior to fractional flow reserve (FFR) for guiding coronary revascularization while reducing procedural time, patient discomfort, and costs.

Abstract

Coronary angiography is considered to be the gold standard in the morphological evaluation of coronary artery stenosis. The morphological assessment of the severity of a coronary lesion is very subjective. Thus, the invasive fractional flow reserve (FFR) measurement represents the current standard for estimation of the hemodynamic significance of coronary artery stenosis. The FFR-guided revascularization strategy was initially classified as a Class-IA-recommendation in the 2014 European Society of Cardiology/European Association for Cardio-Thoracic Surgery guidelines on myocardial revascularization. Both the Deferral vs Performance of Percutaneous Coronary Intervention of Functionally Non-Significant Coronary Stenosis and Flow Reserve vs Angiography for Multivessel Evaluation studies showed no treatment advantage for hemodynamically insignificant stenoses. With the help of FFR (and targeted interventions), clinical results could be improved; however, the use in clinical practice is still limited due to the need of adenosine administration and a significant prolongation of the length of the procedure. Instantaneous wave-free ratio (iFR®) is a new innovative approach for the determination of the hemodynamic significance of coronary stenosis, which can be obtained at rest without the use of vasodilators. Regarding the periprocedural complications as well as prognosis, iFR® showed non-inferiority to FFR in the SWEDEHEART and DEFINE-FLAIR trials. Furthermore, iFR®, enhanced by iFR®-pullback, provides the possibility to display the iFR®-change over the course of the vessel to create a hemodynamic map.

Discussion

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Cite This Study

Baumann et al. (2018) conducted a review in Coronary artery stenosis / coronary heart disease. Instantaneous wave-free ratio (iFR) vs. Fractional flow reserve (FFR) was evaluated. Instantaneous wave-free ratio (iFR) demonstrated non-inferiority to fractional flow reserve (FFR) in 1-year MACE (6.8% vs 7.0% in DEFINE-FLAIR; 6.7% vs 6.1% in SWEDEHEART) with fewer adverse events.

synapsesocial.com/papers/6a7652a63bd31deb7eb1c295 https://doi.org/10.4330/wjc.v10.i12.267

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Instantaneous wave-free ratio (iFR®) to determine hemodynamically significant coronary stenosis: A comprehensive review

Figures

Key Points

Structured PICO

Limitations

Implication

Abstract

Discussion

Cite This Study

Instantaneous wave-free ratio (iFR®) to determine hemodynamically significant coronary stenosis: A comprehensive review

Figures

Key Points

Structured PICO

Limitations

Implication

Abstract

Discussion

Cite This Study

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