Key result
FFR/iFR guidance during PCI is linked to ~21% lower long-term mortality versus no guidance.
Why the study?
Limited data existed on the impact of FFR/iFR guidance on long-term clinical outcomes in patients undergoing PCI for stable angina, UA/NSTEMI, or STEMI.
Does intracoronary pressure wire guidance (FFR/iFR) reduce all-cause mortality in patients undergoing PCI for stable angina, UA/NSTEMI, or STEMI?
Observational (n=151,001)
Yes
Does intracoronary pressure wire guidance (FFR/iFR) reduce all-cause mortality in patients undergoing PCI for stable angina, UA/NSTEMI, or STEMI?
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“These observational, real-world data are important because they corroborate the significant reduction in death and myocardial infarction with FFR-guided PCI compared with angiography-guided PCI that was seen in the randomized, controlled FAME trial and the reduction in spontaneous MI at 5 years after FFR-guided PCI compared with medical therapy alone in patients with stable CAD enrolled in the FAME 2 trial.”
“We have evidence [from the FAME trials] that FFR-led revascularization decreases the incidence of myocardial infarction. Myocardial infarction is the single most important cause of death in Western societies, so one could argue that any intervention that decreases the incidence of myocardial infarction would eventually translate into a decrease in all-cause mortality.”
The use of FFR or iFR guidance during PCI is associated with significantly lower long-term all-cause mortality and stent thrombosis/restenosis across both stable and acute coronary syndromes.
Background Intracoronary pressure wire measurements of fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) provide decision-making guidance during percutaneous coronary intervention (PCI). However, limited data exist on the impact of FFR/iFR on long-term clinical outcomes in patients with stable angina, unstable angina (UA)/non-ST-segment elevation myocardial infarction (NSTEMI), or STEMI. Methods We used data from the Swedish Coronary Angiography and Angioplasty Registry (SCAAR) on all patients in Sweden undergoing PCI (with or without FFR/iFR guidance) for stable angina, UA/NSTEMI, or STEMI between January 2005 and March 2018. The primary endpoint was all-cause mortality and the secondary endpoints were stent thrombosis or restenosis and periprocedural complications. The primary model was multilevel Cox proportional-hazards regression using an instrumental variable (IV) to adjust for known and unknown confounders with treating hospital as a treatment-preference instrument. The following variables were entered into Cox proportional-hazards regression in addition to the IV: age, sex, diabetes, indication for PCI, severity of coronary disease, smoking status, hypertension, hyperlipidemia, previous myocardial infarction, previous PCI, previous coronary artery bypass graft, type of stent. Results In total, 151,001 patients underwent PCI: 31,514 (20.9%) for stable angina, 74,982 (49.6%) for UA/NSTEMI, and 44,505 (29.5%) for STEMI. Of these, FFR/iFR guidance was used in 11,433 patients (7.6%): 5029 (44.0%) with stable angina, 5989 (52.4%) with UA/NSTEMI, and 415 (3.6%) with STEMI; iFR was used in 1156 (10.1%) of these patients. After a median follow-up of 1784 (range 1–4824) days, the FFR/iFR group had lower adjusted risk estimates for all-cause mortality [hazard ratio (HR) 0.79; 95% confidence interval (CI) 0.69–0.91; P=0.001] and stent thrombosis and restenosis (HR 0.13; 95% CI 0.09–0.19; P<0.001). The number of periprocedural complications did not differ significantly between the groups (odds ratio 0.69; 95% CI 0.30–1.55; P=0.368). There was no interaction between FFR/iFR and indication for PCI. We found no difference between FFR and iFR (HR 1.12; 95% CI 0.90–1.59; P=0.216). Conclusions In this observational study, the use of FFR/IFR was associated with a lower risk of long-term mortality in patients undergoing PCI for stable angina, UA/NSTEMI, or STEMI. Our study supports the current European and American guidelines for the use of FFR/iFR during PCI and shows that intracoronary pressure wire guidance has prognostic benefit in patients with stable angina as well as in patients with the acute coronary syndrome. Funding Acknowledgement Type of funding source: Foundation. Main funding source(s): Heart and Lung Foundation, ALF Västra Götaland, Swedish Scientific Council
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Völz et al. (2020) conducted an observational in Stable angina, UA/NSTEMI, or STEMI undergoing PCI (n=151,001). Intracoronary pressure wire guidance (FFR/iFR) vs. PCI without FFR/iFR guidance was evaluated on All-cause mortality (HR 0.79, 95% CI 0.69-0.91, p=0.001). Intracoronary pressure wire guidance (FFR/iFR) during PCI was associated with a lower risk of long-term all-cause mortality compared to no guidance (HR 0.79; 95% CI 0.69-0.91; P=0.001).
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