Clinical events after deferral of LAD revascularization following physiological coronary assessment
File(s)
Published version
Author(s)
Type
Journal Article
Abstract
BACKGROUND: Physicians are not always comfortable deferring treatment of a stenosis in the left anterior descending (LAD) artery because of the perception that there is a high risk of major adverse cardiac events (MACE). The authors describe, using the DEFINE-FLAIR (Functional Lesion Assessment of Intermediate Stenosis to Guide Revascularisation) trial, MACE rates when LAD lesions are deferred, guided by physiological assessment using fractional flow reserve (FFR) or the instantaneous wave-free ratio (iFR). OBJECTIVES: The purpose of this study was to establish the safety of deferring treatment in the LAD using FFR or iFR within the DEFINE-FLAIR trial. METHODS: MACE rates at 1 year were compared between groups (iFR and FFR) in patients whose physiological assessment led to LAD lesions being deferred. MACE was defined as a composite of cardiovascular death, myocardial infarction (MI), and unplanned revascularization at 1 year. Patients, and staff performing follow-up, were blinded to whether the decision was made with FFR or iFR. Outcomes were adjusted for age and sex. RESULTS: A total of 872 patients had lesions deferred in the LAD (421 guided by FFR, 451 guided by iFR). The event rate with iFR was significantly lower than with FFR (2.44% vs. 5.26%; adjusted HR: 0.46; 95% confidence interval [CI]: 0.22 to 0.95; p = 0.04). This was driven by significantly lower unplanned revascularization with iFR and numerically lower MI (unplanned revascularization: 2.22% iFR vs. 4.99% FFR; adjusted HR: 0.44; 95% CI: 0.21 to 0.93; p = 0.03; MI: 0.44% iFR vs. 2.14% FFR; adjusted HR: 0.23; 95% CI: 0.05 to 1.07; p = 0.06). CONCLUSIONS: iFR-guided deferral appears to be safe for patients with LAD lesions. Patients in whom iFR-guided deferral was performed had statistically significantly lower event rates than those with FFR-guided deferral.
Date Issued
2019-02-05
Date Acceptance
2018-10-22
Citation
Journal of the American College of Cardiology, 2019, 73 (4), pp.444-453
ISSN
0735-1097
Publisher
Elsevier
Start Page
444
End Page
453
Journal / Book Title
Journal of the American College of Cardiology
Volume
73
Issue
4
Copyright Statement
© 2019 The Authors. Published by Elsevier on behalf of the American College of Cardiology Foundation. This is an open access article under a CC BY licence (http://creativecommons.org/licenses/by/4.0/)
Sponsor
The Academy of Medical Sciences
National Institute for Health Research
Imperial College Healthcare Charity Grant
Identifier
https://www.ncbi.nlm.nih.gov/pubmed/30704577
PII: S0735-1097(18)39304-5
Grant Number
na
RDB02
RF16\100033
Subjects
coronary stenosis
fractional flow reserve
instantaneous wave-free ratio
Publication Status
Published
Coverage Spatial
United States
Date Publish Online
2019-01-28