Abstract Introduction Studies of both invasive fractional flow reserve (FFR) and fractional flow reserve derived from CT (FFR-CT), have indicated that medically managed patients with chronic coronary syndrome (CCS) with a positive FFR have worse outcomes compared to those that undergo revascularisation. However, these studies have not taken patient symptoms into account. NICE guidance in the UK limits the use of revascularisation only for patients who are symptomatic on medical management unless they have left main stem or 3 vessel disease. The effect of deferring revascularisation in patients who have FFR-CT positive stenoses but asymptomatic on medical therapy is unknown. Methods All patients with CCS who completed FFR-CT analysis at our centre between November 2018 and February 2024 were retrospectively included. Patients with unavailable FFR-CT, minimal stenoses or those who had FFR-CT performed for other indications were excluded. FFR-CT was measured at the furthest point along a vessel distal to a stenosis. Based on the symptoms, location and severity of stenoses and FFR-CT results, patients were recommended medical therapy alone, medical therapy and invasive angiography only for ongoing symptoms or medical therapy and proceed to invasive coronary angiography (ICA) and revascularisation. Patients were categorized into 4 groups – 1. FFR-CT negative, 2. FFR-CT positive, asymptomatic on review, 3. FFR-CT positive, symptomatic on review and 4. FFR-CT positive and recommended ICA. Patients in groups 1 and 2 were managed medically while those in groups 3 and 4 were recommended revascularisation. The primary outcome was a composite of unstable angina admissions, non-fatal myocardial infarction (MIs) or all-cause mortality (ACM). The secondary outcome was a composite of MIs or ACM. Both were assessed in a time-to-event analysis. Results 801 patients underwent CTCA with FFR-CT analysis of which 555 patients (mean age: 61.8 +/- 7.6 years) met the inclusion criteria. Patients were followed up for a median length of 43.3 months (IQR 26.2-58.9 months). Primary outcome events were observed in 8 patients in group 1 (8/145; 5%), 7 patients in group 2 (7/ 174; (4.0%); (p=0.71); 17 patients in group 3 (17/74; 23.0%) (p0.001); and 31 patients in group 4 (31/162 patient 19.1%) (p0.001). Secondary event outcomes were observed in 3 patients in group 1( 3/145, 2.1%); 6 patients in group 2 (6/174, 3.4%), 6 patients in group 3 ( 6/74, 8.1%) and 11 patients in group 4 (11/162, 6.8%) (p=0.095). Conclusion Guideline driven management limiting revascularisation to symptomatic patients with FFR-CT positive coronary stenoses is safe. The primary outcome in patients with FFR-CT positive disease who are asymptomatic on medical treatment is comparable to those with FFR-CT negative stenoses. There was no significant difference in the secondary outcome between groups, suggesting any difference in the primary outcome was driven by unstable angina admissions.
Chotalia et al. (Sat,) studied this question.