FFR influences lesion management in clinical practice
medwireNews: Lesion management strategy changes in nearly half of patients who undergo fractional flow reserve (FFR) measurement in clinical practice, show the findings of the POST-IT trial.
In the observational POST-IT (Portuguese Study on the Evaluation of FFR-Guided Treatment of Coronary Disease) trial, 44.2% of 918 patients (and 45.2% of 1293 lesions) had their management changed based on FFR findings, report Sergio Baptista (Hospital Prof Doutor Fernando da Fonseca, Amadora, Portugal) and co-workers in Circulation: Cardiovascular Interventions.
A total of 360 patients had medical therapy planned as their initial strategy, but FFR findings led to 23.1% of these patients being switched to percutaneous coronary intervention (PCI) and 4.4% to coronary artery bypass graft (CABG). And of the 319 patients originally destined for PCI, 24.8% were switched to medical therapy and 3.4% to CABG.
Likewise, 18.4% of 38 patients with planned CABG were changed to medical therapy and 23.7% underwent PCI.
In a linked editorial, Eric Van Belle (University Hospital, Lille, France) and co-authors highlight the 21.9% of patients whose initial postangiography management strategy was to undergo FFR.
“The request of a noninvasive test after angiography may seem surprising but make[s] sense when considering that, as reported many times and as also observed in the present study, only half of the patients are referred to coronary angiography with an ischemic test performed before”, they write.
And they stress that FFR allowed all of these patients to be assigned to a therapeutic management strategy (45.3% medical, 41.3% PCI, 13.4% CABG) with no need for further testing.
These findings therefore underline the concept of FFR during angiography as a “one stop-shop” with “the potential to reduce drastically the use of noninvasive tests”, say the editorialists.
Excluding patients with an initial management strategy of further testing, the overall proportion undergoing PCI rose as a result of FFR findings, from 34.8% to 44.0%. Van Belle et al say that this contradicts expectations, based on the DEFER study, that use of FFR will result in a “drastic reduction” in PCI. They believe the increase found in POST-IT and other studies is probably because of the broader patient population relative to that in studies showing a reduction.
Overall, the editorialists say, “it is clear that the ultimate goal and ultimate effect of routine FFR combined with angiography is not to decrease the number of PCI but rather to define the appropriate treatment to each individual patient.”
During 1 year of follow-up, 6.9% of patients had a major adverse cardiovascular event (MACE). The rate was lower in patients in whom intervention was deferred on the basis of FFR findings, at 5.3%, showing that FFR identified low-risk patients whose treatment could be deferred, says the team. Conversely, there was a high MACE rate of 13.6% among patients whose lesions were left untreated despite an FFR of 0.8 or below, mostly driven by a high rate of unplanned revascularisation.
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