Juwon Kim1, Doosup Shin2, Joo Myung Lee3, Seung Hun Lee4, David Hong1, Ki Hong Choi1, Doyeon Hwang5, Coen K M Boerhout6, Guus A de Waard7, Ji-Hyun Jung8, Hernan Mejia-Renteria9, Masahiro Hoshino10, Mauro Echavarria-Pinto11, Martijn Meuwissen12, Hitoshi Matsuo13, Maribel Madera-Cambero14, Ashkan Eftekhari15, Mohamed A Effat16, Tadashi Murai10, Koen Marques7, Joon-Hyung Doh17, Evald H Christiansen15, Rupak Banerjee18, Hyun Kuk Kim19, Chang-Wook Nam20, Giampaolo Niccoli21, Masafumi Nakayama22, Nobuhiro Tanaka23, Eun-Seok Shin24, Steven A J Chamuleau25, Niels van Royen26, Paul Knaapen7, Bon Kwon Koo5, Tsunekazu Kakuta10, Javier Escaned9, Jan J Piek6, Tim P van de Hoef27. 1. Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea. 2. Division of Cardiovascular Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA. 3. Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea. Electronic address: drone80@hanmail.net. 4. Division of Cardiology, Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Korea. 5. Seoul National University Hospital, Department of Internal Medicine, Cardiovascular Center, Seoul, Korea. 6. Department of Cardiology, Amsterdam University Medical Center, Academic Medical Center, Amsterdam, the Netherlands. 7. Department of Cardiology, Amsterdam University Medical Center, VU University Medical Center, Amsterdam, the Netherlands. 8. Sejong General Hospital, Sejong Heart Institute, Bucheon, Korea. 9. Hospital Clínico San Carlos, Instituto de Investigación Sanitaria Hospital Clínico San Carlos, Universidad Complutense de Madrid, Madrid, Spain. 10. Department of Cardiology, Tsuchiura Kyodo General Hospital, Tsuchiura City, Japan. 11. Hospital General Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estad Querétaro, Facultad de Medicina, Universidad Autónoma de Querétaro, Querétaro, Mexico. 12. Department of Cardiology, Amphia Hospital, Breda, the Netherlands. 13. Department of Cardiovascular Medicine, Gifu Heart Center, Gifu, Japan. 14. Department of Cardiology, Tergooi Hospital, Blaricum, the Netherlands. 15. Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark. 16. Division of Cardiovascular Health and Disease, University of Cincinnati, Cincinnati, Ohio, USA. 17. Department of Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea. 18. Department of Mechanical and Materials Engineering, University of Cincinnati, Veterans Affairs Medical Center, Cincinnati, Ohio, USA. 19. Department of Internal Medicine and Cardiovascular Center, Chosun University Hospital, University of Chosun College of Medicine, Gwangju, Korea. 20. Department of Medicine, Keimyung University Dongsan Medical Center, Daegu, Korea. 21. University of Parma, Parma, Italy. 22. Department of Cardiovascular Medicine, Gifu Heart Center, Gifu, Japan; Toda Central General Hospital, Cardiovascular Center, Toda, Japan. 23. Department of Cardiology, Tokyo Medical University Hachioji Medical Center, Tokyo, Japan. 24. Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea. 25. Department of Cardiology, Amsterdam University Medical Center, Academic Medical Center, Amsterdam, the Netherlands; Department of Cardiology, Amsterdam University Medical Center, VU University Medical Center, Amsterdam, the Netherlands. 26. Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands. 27. Department of Cardiology, Amsterdam University Medical Center, Academic Medical Center, Amsterdam, the Netherlands; Department of Cardiology, Amsterdam University Medical Center, VU University Medical Center, Amsterdam, the Netherlands; Department of Cardiology, NoordWest Ziekenhuisgroep, the Netherlands.
Abstract
OBJECTIVES: The authors sought to evaluate comparative prognosis between deferred versus performed percutaneous coronary intervention (PCI) according to coronary flow reserve (CFR) values of patients with intermediate fractional flow reserve (FFR). BACKGROUND: For coronary stenosis with intermediate FFR, the prognostic value of PCI remains controversial. The prognostic impact of PCI may be different according to CFR in patients with intermediate FFR. METHODS: From the ILIAS Registry (Inclusive Invasive Physiological Assessment in Angina Syndromes Registry, N = 2,322), 400 patients (412 vessels) with intermediate FFR (0.75-0.80) were selected. Patients were stratified into preserved CFR (>2.0, n = 253) and depressed CFR (≤2.0, n = 147) cohorts. Per-vessel clinical outcomes during 5 years of follow-up were compared between deferred versus performed PCI groups in both cohorts. The primary outcome was target vessel failure (TVF), a composite of cardiac death, target vessel myocardial infarction, or target vessel revascularization. RESULTS: Among the study population, PCI was deferred for 210 patients (219 vessels, 53.2%) (deferred group) and performed for 190 patients (193 vessels, 46.8%) (performed group). The risk of TVF was comparable between the deferred and performed groups (12.8% vs 14.2%; adjusted HR: 1.403; 95% CI: 0.584-3.369; P = 0.448). When stratified by CFR, PCI was performed in 39.1% (100/261 vessels) of the preserved CFR cohort and 61.9% (93/151 vessels) of the depressed CFR cohort. Within the preserved CFR cohort, the risk of TVF did not differ significantly between the deferred and performed groups (11.0% vs 13.9%; adjusted HR: 0.770; 95% CI: 0.262-2.266; P = 0.635). However, in the depressed CFR cohort, the deferred group had a significantly higher risk of TVF than the performed group (17.2% vs 14.2%; adjusted HR: 4.932; 95% CI: 1.312-18.53; P = 0.018). A significant interaction was observed between CFR and the treatment decision (interaction P = 0.049). Results were consistent after inverse probability weighting adjustment. CONCLUSIONS: In patients with intermediate FFR of 0.75 to 0.80, the prognostic value of PCI differed according to CFR, with a significant interaction. PCI was associated with a lower risk of TVF compared with the deferral strategy when CFR was depressed (≤2.0), but there was no difference when CFR was preserved (>2.0). CFR could be used as an additional risk stratification tool to determine treatment strategies in patients with intermediate FFR. (Inclusive Invasive Physiological Assessment in Angina Syndromes Registry [ILIAS Registry]; NCT04485234).
OBJECTIVES: The authors sought to evaluate comparative prognosis between deferred versus performed percutaneous coronary intervention (PCI) according to coronary flow reserve (CFR) values of patients with intermediate fractional flow reserve (FFR). BACKGROUND: For coronary stenosis with intermediate FFR, the prognostic value of PCI remains controversial. The prognostic impact of PCI may be different according to CFR in patients with intermediate FFR. METHODS: From the ILIAS Registry (Inclusive Invasive Physiological Assessment in Angina Syndromes Registry, N = 2,322), 400 patients (412 vessels) with intermediate FFR (0.75-0.80) were selected. Patients were stratified into preserved CFR (>2.0, n = 253) and depressed CFR (≤2.0, n = 147) cohorts. Per-vessel clinical outcomes during 5 years of follow-up were compared between deferred versus performed PCI groups in both cohorts. The primary outcome was target vessel failure (TVF), a composite of cardiac death, target vessel myocardial infarction, or target vessel revascularization. RESULTS: Among the study population, PCI was deferred for 210 patients (219 vessels, 53.2%) (deferred group) and performed for 190 patients (193 vessels, 46.8%) (performed group). The risk of TVF was comparable between the deferred and performed groups (12.8% vs 14.2%; adjusted HR: 1.403; 95% CI: 0.584-3.369; P = 0.448). When stratified by CFR, PCI was performed in 39.1% (100/261 vessels) of the preserved CFR cohort and 61.9% (93/151 vessels) of the depressed CFR cohort. Within the preserved CFR cohort, the risk of TVF did not differ significantly between the deferred and performed groups (11.0% vs 13.9%; adjusted HR: 0.770; 95% CI: 0.262-2.266; P = 0.635). However, in the depressed CFR cohort, the deferred group had a significantly higher risk of TVF than the performed group (17.2% vs 14.2%; adjusted HR: 4.932; 95% CI: 1.312-18.53; P = 0.018). A significant interaction was observed between CFR and the treatment decision (interaction P = 0.049). Results were consistent after inverse probability weighting adjustment. CONCLUSIONS: In patients with intermediate FFR of 0.75 to 0.80, the prognostic value of PCI differed according to CFR, with a significant interaction. PCI was associated with a lower risk of TVF compared with the deferral strategy when CFR was depressed (≤2.0), but there was no difference when CFR was preserved (>2.0). CFR could be used as an additional risk stratification tool to determine treatment strategies in patients with intermediate FFR. (Inclusive Invasive Physiological Assessment in Angina Syndromes Registry [ILIAS Registry]; NCT04485234).