Fractional Flow Reserve versus Angiography for Guiding Percutaneous Coronary Intervention
About: This article is published in Yearbook of Cardiology.The article was published on 2010-01-01. It has received 720 citations till now. The article focuses on the topics: Fractional flow reserve & Percutaneous coronary intervention.
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TL;DR: The If Inhibitor Ivabradine in Patients With Coronary Artery Disease and Left Ventricular Dysfunction is evaluated as well as patients with Diabetes mellitus for Optimal management of Multivessel disease.
Abstract: 99mTc
: technetium-99m
201TI
: thallium 201
ABCB1
: ATP-binding cassette sub-family B member 1
ABI
: ankle-brachial index
ACC
: American College of Cardiology
ACCF
: American College of Cardiology Foundation
ACCOMPLISH
: Avoiding Cardiovascular Events Through Combination Therapy in Patients Living With Systolic Hypertension
ACE
: angiotensin converting enzyme
ACIP
: Asymptomatic Cardiac Ischaemia Pilot
ACS
: acute coronary syndrome
ADA
: American Diabetes Association
ADP
: adenosine diphosphate
AHA
: American Heart Association
ARB
: angiotensin II receptor antagonist
ART
: Arterial Revascularization Trial
ASCOT
: Anglo-Scandinavian Cardiac Outcomes Trial
ASSERT
: Asymptomatic atrial fibrillation and Stroke Evaluation in pacemaker patients and the atrial fibrillation Reduction atrial pacing Trial
AV
: atrioventricular
BARI 2D
: Bypass Angioplasty Revascularization Investigation 2 Diabetes
BEAUTIFUL
: Morbidity-Mortality Evaluation of the If Inhibitor Ivabradine in Patients With Coronary Artery Disease and Left Ventricular Dysfunction
BIMA
: bilateral internal mammary artery
BMI
: body mass index
BMS
: bare metal stent
BNP
: B-type natriuretic peptide
BP
: blood pressure
b.p.m.
: beats per minute
CABG
: coronary artery bypass graft
CAD
: coronary artery disease
CAPRIE
: Clopidogrel vs. Aspirin in Patients at Risk of Ischaemic Events
CASS
: Coronary Artery Surgery Study
CCB
: calcium channel blocker
CCS
: Canadian Cardiovascular Society
CFR
: coronary flow reserve
CHARISMA
: Clopidogrel for High Atherothrombotic Risk and Ischaemic Stabilization, Management and Avoidance
CI
: confidence interval
CKD
: chronic kidney disease
CKD-EPI
: Chronic Kidney Disease Epidemiology Collaboration
CMR
: cardiac magnetic resonance
CORONARY
: The CABG Off or On Pump Revascularization Study
COURAGE
: Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation
COX-1
: cyclooxygenase-1
COX-2
: cyclooxygenase-2
CPG
: Committee for Practice Guidelines
CT
: computed tomography
CTA
: computed tomography angiography
CV
: cardiovascular
CVD
: cardiovascular disease
CXR
: chest X-ray
CYP2C19*2
: cytochrome P450 2C19
CYP3A
: cytochrome P3A
CYP3A4
: cytochrome P450 3A4
CYP450
: cytochrome P450
DANAMI
: Danish trial in Acute Myocardial Infarction
DAPT
: dual antiplatelet therapy
DBP
: diastolic blood pressure
DECOPI
: Desobstruction Coronaire en Post-Infarctus
DES
: drug-eluting stents
DHP
: dihydropyridine
DSE
: dobutamine stress echocardiography
EACTS
: European Association for Cardiothoracic Surgery
EECP
: enhanced external counterpulsation
EMA
: European Medicines Agency
EASD
: European Association for the Study of Diabetes
ECG
: electrocardiogram
Echo
: echocardiogram
ED
: erectile dysfunction
EF
: ejection fraction
ESC
: European Society of Cardiology
EXCEL
: Evaluation of XIENCE PRIME or XIENCE V vs. Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization
FAME
: Fractional Flow Reserve vs. Angiography for Multivessel Evaluation
FDA
: Food & Drug Administration (USA)
FFR
: fractional flow reserve
FREEDOM
: Design of the Future Revascularization Evaluation in patients with Diabetes mellitus: Optimal management of Multivessel disease
GFR
: glomerular filtration rate
HbA1c
: glycated haemoglobin
HDL
: high density lipoprotein
HDL-C
: high density lipoprotein cholesterol
HR
: hazard ratio
HRT
: hormone replacement therapy
hs-CRP
: high-sensitivity C-reactive protein
HU
: Hounsfield units
ICA
: invasive coronary angiography
IMA
: internal mammary artery
IONA
: Impact Of Nicorandil in Angina
ISCHEMIA
: International Study of Comparative Health Effectiveness with Medical and Invasive Approaches
IVUS
: intravascular ultrasound
JSAP
: Japanese Stable Angina Pectoris
KATP
: ATP-sensitive potassium channels
LAD
: left anterior descending
LBBB
: left bundle branch block
LIMA
: Left internal mammary artery
LDL
: low density lipoprotein
LDL-C
: low density lipoprotein cholesterol
LM
: left main
LMS
: left main stem
LV
: left ventricular
LVEF
: left ventricular ejection fraction
LVH
: left ventricular hypertrophy
MACE
: major adverse cardiac events
MASS
: Medical, Angioplasty, or Surgery Study
MDRD
: Modification of Diet in Renal Disease
MERLIN
: Metabolic Efficiency with Ranolazine for Less Ischaemia in Non-ST-Elevation Acute Coronary Syndromes
MERLIN-TIMI 36
: Metabolic Efficiency with Ranolazine for Less Ischemia in Non-ST-Elevation Acute Coronary Syndromes: Thrombolysis In Myocardial Infarction
MET
: metabolic equivalents
MI
: myocardial infarction
MICRO-HOPE
: Microalbuminuria, cardiovascular and renal sub-study of the Heart Outcomes Prevention Evaluation study
MPI
: myocardial perfusion imaging
MRI
: magnetic resonance imaging
NO
: nitric oxide
NSAIDs
: non-steroidal anti-inflammatory drugs
NSTE-ACS
: non-ST-elevation acute coronary syndrome
NYHA
: New York Heart Association
OAT
: Occluded Artery Trial
OCT
: optical coherence tomography
OMT
: optimal medical therapy
PAR-1
: protease activated receptor type 1
PCI
: percutaneous coronary intervention
PDE5
: phosphodiesterase type 5
PES
: paclitaxel-eluting stents
PET
: positron emission tomography
PRECOMBAT
: Premier of Randomized Comparison of Bypass Surgery vs. Angioplasty Using Sirolimus-Eluting Stent in Patients with Left Main Coronary Artery Disease
PTP
: pre-test probability
PUFA
: polyunsaturated fatty acid
PVD
: peripheral vascular disease
QoL
: quality of life
RBBB
: right bundle branch block
REACH
: Reduction of Atherothrombosis for Continued Health
RITA-2
: Second Randomized Intervention Treatment of Angina
ROOBY
: Veterans Affairs Randomized On/Off Bypass
SAPT
: single antiplatelet therapy
SBP
: systolic blood pressure
SCAD
: stable coronary artery disease
SCORE
: Systematic Coronary Risk Evaluation
SCS
: spinal cord stimulation
SES
: sirolimus-eluting stents
SIMA
: single internal mammary artery
SPECT
: single photon emission computed tomography
STICH
: Surgical Treatment for Ischaemic Heart Failure
SWISSI II
: Swiss Interventional Study on Silent Ischaemia Type II
SYNTAX
: SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery
TC
: total cholesterol
TENS
: transcutaneous electrical neural stimulation
TERISA
: Type 2 Diabetes Evaluation of Ranolazine in Subjects With Chronic Stable Angina
TIME
: Trial of Invasive vs. Medical therapy
TIMI
: Thrombolysis In Myocardial Infarction
TMR
: transmyocardial laser revascularization
TOAT
: The Open Artery Trial
WOEST
: What is the Optimal antiplatElet and anticoagulant therapy in patients with oral anticoagulation and coronary StenTing
Guidelines summarize and evaluate all evidence available, at the time of the writing process, on a particular issue with the aim of assisting physicians in selecting the best management strategies for an individual patient with a given condition, taking into account the impact on outcome, as well …
3,879 citations
Cites background from "Fractional Flow Reserve versus Angi..."
...Under such circumstances, the indication for revascularization should depend on the result of intraprocedural fractional flow reserve (FFR) testing when indicated.(110)...
[...]
...80, studies in the BMS era have demonstrated that medical treatment provides better outcomes than immediate revascularization.(110,172,399) Accordingly, a patient with a stenosis and an FFR ....
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TL;DR: The 2017-18 FACC/FAHA curriculum vitae will focus on adolescent and young adult FACC and FAHA education, as well as leadership, self-confidence, and self-consistency.
Abstract: Jeffrey L. Anderson, MD, FACC, FAHA, Chair
Jonathan L. Halperin, MD, FACC, FAHA, Chair-Elect
Nancy M. Albert, PhD, RN, FAHA
Biykem Bozkurt, MD, PhD, FACC, FAHA
Ralph G. Brindis, MD, MPH, MACC
Lesley H. Curtis, PhD, FAHA
David DeMets, PhD[¶¶][1]
Lee A. Fleisher, MD, FACC, FAHA
Samuel
2,291 citations
TL;DR: Guidelines and Expert Consensus Documents summarize and evaluate all available evidence with the aim of assisting physicians in selecting the best management strategy for an individual patient suffering from a given condition, taking into account the impact on outcome and the risk benefit ratio of diagnostic or therapeutic means.
Abstract: Guidelines and Expert Consensus Documents summarize and
evaluate all available evidence with the aim of assisting
physicians in selecting the best management strategy for an
individual patient suffering from a given condition, taking
into account the impact on outcome and the risk benefit
ratio of diagnostic or therapeutic means. Guidelines are no
substitutes for textbooks and their legal implications have
been discussed previously. Guidelines and recommendations should help physicians to make decisions in their daily
practice. However, the ultimate judgement regarding the
care of an individual patient must be made by his/her
responsible physician(s).
The recommendations for formulating and issuing ESC
Guidelines and Expert Consensus Documents can be found
on the ESC website (http://www.escardio.org/knowledge/
guidelines/rules).
Members of this Task Force were selected by the European
Society of Cardiology (ESC) and the European Association for
Cardio-Thoracic Surgery (EACTS) to represent all physicians
involved with the medical and surgical care of patients
with coronary artery disease (CAD). A critical evaluation
of diagnostic and therapeutic procedures is performed
including assessment of the risk benefit ratio. Estimates
of expected health outcomes for society are included,
where data exist. The level of evidence and the strength
of recommendation of particular treatment options are
weighed and graded according to predefined scales, as
outlined in Tables 1 and 2.
The members of the Task Force have provided disclosure
statements of all relationships that might be perceived as
real or potential sources of conflicts of interest. These
disclosure forms are kept on file at European Heart House,
headquarters of the ESC. Any changes in conflict of interest
that arose during the writing period were notified to the ESC.
The Task Force report received its entire financial support
from the ESC and EACTS, without any involvement of the
pharmaceutical, device, or surgical industry.
ESC and EACTS Committees for Practice Guidelines are
responsible for the endorsement process of these joint
Guidelines. The finalized document has been approved by all
the experts involved in the Task Force, and was submitted to
outside specialists selected by both societies for review. The
document is revised, and finally approved by ESC and EACTS and subsequently published simultaneously in the European
Heart Journal and the European Journal of Cardio-Thoracic
Surgery.
After publication, dissemination of the Guidelines is of
paramount importance. Pocket-sized versions and personal
digital assistant-downloadable versions are useful at the
point of care.
Some surveys have shown that the intended users are
sometimes unaware of the existence of guidelines, or simply
do not translate them into practice. Thus, implementation
programmes are needed because it has been shown that
the outcome of disease may be favourably influenced by the
thorough application of clinical recommendations.
1,544 citations
Cites background or methods from "Fractional Flow Reserve versus Angi..."
...For lesions with borderline clinical significance and in patients with MVD, FFR measurement provides important information for treatment decision making [28]....
[...]
...Deferral of PCI [15,28] or CABG [27] in patients with FFR >0....
[...]
...on the basis of visual assessment or quantitative coronary angiography [27,28]....
[...]
...In case of multiple angiographically significant non-culprit stenoses or lesions whose severity is difficult to assess, liberal use of FFR measurement is recommended in order to decide on the treatment strategy [28]....
[...]
...The concept that avoiding unnecessary stenting actually improves outcome was demonstrated in the DEFER [15] and FAME [28] trials....
[...]
TL;DR: Noninvasive FFR derived from CCTA is a novel method with high diagnostic performance for the detection and exclusion of coronary lesions that cause ischemia.
1,112 citations
Cites background or methods from "Fractional Flow Reserve versus Angi..."
...80 on a per-patient nd per-vessel basis (3)....
[...]
...served for ICA, and prior multicenter studies support a i distinct benefit for adjunctive physiological assessment of anatomic CAD stenoses by FFR (3,5,6,29)....
[...]
...80) and obstructive stenosis by angiography ( 50%) (3)....
[...]
...In the FAME (Fractional Flow Reserve versus Angiography for Multivessel Evaluation) study of 1,005 patients with multivessel CAD, those that underwent FFR-guided revascularization—as compared with patients undergoing anatomically guided revascularization—experienced lower rates of adverse events, placement of fewer coronary stents, and lower healthcare costs (3,5)....
[...]
TL;DR: FFR derived from CTA was demonstrated as superior to measures of CTA stenosis severity for determination of lesion-specific ischemia, and a review on the scientific principles that underlie this technology is presented.
951 citations
Cites methods from "Fractional Flow Reserve versus Angi..."
...FFR uses a pressure wire to determine the ratio of maximal coronary blood flow through a stenotic artery to the blood flow in the hypothetical case that the artery was normal, and it is the only diagnostic method to date for ischemia detection to demonstrably advance eventfree survival (7,8)....
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References
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TL;DR: Routine measurement of FFR in patients with multivessel coronary artery disease who are undergoing PCI with drug-eluting stents significantly reduces the rate of the composite end point of death, nonfatal myocardial infarction, and repeat revascularization at 1 year.
Abstract: Background In patients with multivessel coronary artery disease who are undergoing percutaneous coronary intervention (PCI), coronary angiography is the standard method for guiding the placement of the stent. It is unclear whether routine measurement of fractional flow reserve (FFR; the ratio of maximal blood flow in a stenotic artery to normal maximal flow), in addition to angiography, improves outcomes. Methods In 20 medical centers in the United States and Europe, we randomly assigned 1005 patients with multivessel coronary artery disease to undergo PCI with implantation of drug-eluting stents guided by angiography alone or guided by FFR measurements in addition to angiography. Before randomization, lesions requiring PCI were identified on the basis of their angiographic appearance. Patients assigned to angiography-guided PCI underwent stenting of all indicated lesions, whereas those assigned to FFR-guided PCI underwent stenting of indicated lesions only if the FFR was 0.80 or less. The primary end point was the rate of death, nonfatal myocardial infarction, and repeat revascularization at 1 year. Results The mean (±SD) number of indicated lesions per patient was 2.7±0.9 in the angiography group and 2.8±1.0 in the FFR group (P = 0.34). The number of stents used per patient was 2.7±1.2 and 1.9±1.3, respectively (P<0.001). The 1-year event rate was 18.3% (91 patients) in the angiography group and 13.2% (67 patients) in the FFR group (P = 0.02). Seventy-eight percent of the patients in the angiography group were free from angina at 1 year, as compared with 81% of patients in the FFR group (P = 0.20). Conclusions Routine measurement of FFR in patients with multivessel coronary artery disease who are undergoing PCI with drug-eluting stents significantly reduces the rate of the composite end point of death, nonfatal myocardial infarction, and repeat revascularization at 1 year. (ClinicalTrials.gov number, NCT00267774.)
3,479 citations
TL;DR: Five-year outcome after deferral of PCI of an intermediate coronary stenosis based on FFR >/=0.75 is excellent and the risk of cardiac death or myocardial infarction related to this stenosis is <1% per year and not decreased by stenting.
1,405 citations
TL;DR: The majority of Medicare patients with stable coronary artery disease do not have documentation of ischemia by noninvasive testing prior to elective PCI, according to a retrospective cohort study using claims data from a 20% random sample of 2004 Medicare fee-for-service beneficiaries.
Abstract: Context Guidelines call for documenting ischemia in patients with stable coronary artery disease prior to elective percutaneous coronary intervention (PCI). Objective To determine the frequency and predictors of stress testing prior to elective PCI in a Medicare population. Design, Setting, and Patients Retrospective, observational cohort study using claims data from a 20% random sample of 2004 Medicare fee-for-service beneficiaries aged 65 years or older who had an elective PCI (N = 23 887). Main Outcome Measures Percentage of patients who underwent stress testing within 90 days prior to elective PCI; variation in stress testing prior to PCI across 306 hospital referral regions; patient, physician, and hospital characteristics that predicted the appropriate use of stress testing prior to elective PCI. Results In the United States, 44.5% (n = 10 629) of patients underwent stress testing within the 90 days prior to elective PCI. There was wide regional variation among the hospital referral regions with stress test rates ranging from 22.1% to 70.6% (national mean, 44.5%; interquartile range, 39.0%-50.9%). Female sex (adjusted odds ratio [AOR], 0.91; 95% confidence interval [CI], 0.86-0.97), age of 85 years or older (AOR, 0.83; 95% CI, 0.72-0.95), a history of congestive heart failure (AOR, 0.85; 95% CI, 0.79-0.92), and prior cardiac catheterization (AOR, 0.45; 95% CI, 0.38-0.54) were associated with a decreased likelihood of prior stress testing. A history of chest pain (AOR, 1.28; 95% CI, 1.09-1.54) and black race (AOR, 1.26; 95% CI, 1.09-1.46) increased the likelihood of stress testing prior to PCI. Patients treated by physicians performing 150 or more PCIs per year were less likely to have stress testing prior to PCI (AOR, 0.84; 95% CI, 0.77-0.93). No hospital characteristics were associated with receipt of stress testing. Conclusion The majority of Medicare patients with stable coronary artery disease do not have documentation of ischemia by noninvasive testing prior to elective PCI.
226 citations
TL;DR: Routine use of FFR during diagnostic catheterization is feasible, safe, and provide help to guide decision making in equivocal lesions, according to a 4-year single centre experience.
Abstract: Aims In patients submitted to coronary angiography, fractional flow reserve (FFR) assessment by a pressure wire can be used to guide the decision for revascularization. Routine application of FFR assessment and 1-year outcome of patients are poorly documented. The aim of this study was to report a 4-year single-centre experience where the use of FFR for decision making in equivocal lesions is encouraged. Methods and results A prospective registry was designed to collect clinical and angiographic characteristics, as well as 1-year clinical follow-up for all patients submitted to FFR assessment. The decisional cut-off point for revascularization was 0.80. Over a 4-year period, out of 6415 coronary angiographies, FFR was measured in 407 (6.3%) patients (469 lesions). FFR was assessed through 4 or 5 Fr diagnostic catheters in 330 (81%). Median FFR value was 0.87 (0.80; 0.93). On the basis of FFR results, 271 (67%) patients were treated with medical therapy alone. A subset of 71 (17%) patients were not treated in accordance with the results of FFR. All patients but four (i.e. 99%) had 1-year clinical follow-up. Three hundred and forty four (85%) were free from clinical event, six (1.5%) patients died, five (4%) had an acute coronary syndrome, and 20 (5%) underwent target-vessel revascularization. Event-free survival was comparable in patients with vs. without revascularization (0.94+ 0.02 and 0.93+ 0.01, respectively). Patients had significantly better 1-year outcome when treated in accordance with the results of the FFR assessment. Conclusion In routine practice, FFR assessment during diagnostic angiography was performed in 6.3%. On the basis of FFR, two-thirds of patients with ‘intermediate’ lesions were left unrevascularized, with a favourable outcome, when FFR was above 0.80. These data suggest that routine use of FFR during diagnostic catheterization is feasible, safe, and provide help to guide decision making.
117 citations
TL;DR: No reduction in death and myocardial infarction has been observed in trials of patients with stable coronary artery disease (CAD), however, and the appropriate utilization rates of PCI in patients with chronic stable angina and preserved left ventricular function should lead to more cost-effective care.
Abstract: As it approaches its fourth decade, percutaneous coronary intervention (PCI) is now the most widely used revascularization strategy around the world and has been tested in multiple clinical scenarios against both medical and surgical therapies For each patient group and clinical scenario setting, the goals of therapy must be specifically defined and clearly understood as an integral component of the process of selecting the optimal strategy for the individual patient In patients with chronic stable, often mild angina, the major achievable goals of PCI are to affect symptoms, either by decreasing them or preventing them, reduce the need for subsequent procedures, and relieve ischemia Achievement of these goals has been documented in multiple randomized trials of PCI versus medical therapy In these trials of patients with stable coronary artery disease (CAD), however, no reduction in death and myocardial infarction has been observed, and these limitations of PCI in this clinical setting need to be emphasized Given the typically diffuse nature of CAD and the fact that PCI only treats a segment within a coronary artery, this is not surprising Although optimal medical therapy forms the cornerstone of management for any patient with CAD, among stable patients who do fail medical therapy, percutaneous coronary revascularization plays a well-documented significant role in improving symptoms and preventing the subsequent need for revascularization The appropriate utilization rates of PCI in patients with chronic stable angina and preserved left ventricular function should lead to more cost-effective care of patients with stable CAD
46 citations