ESC Focus on Interventions & PC - 13
ESC Congress 2017
In Review
Interventions &
Peripheral Circulation
Written by Toni Rizzo
After percutaneous coronary intervention (PCI), fractional flow reserve (FFR) is often < 1.0 due to residual
diffuse disease, suboptimal stent deployment, or underestimated second stenosis. In a recent study of patients
undergoing PCI [Piroth Z et al. Circ Cardiovasc Interv.
2017], two-thirds of post-PCI FFR values of the treated
lesion remain < 0.92, the lowest limit of normal. The incidence of future cardiovascular events was lowest in the
patients who had a post-PCI FFR ≥ 0.92. The objectives
of this study, presented by Stephane Fournier, MD, OLV
Hospital, Aalst, Belgium, was to investigate whether the
change in FFR (∆FFR) was associated with vessel-oriented clinical events (VOCE) at 2 years.
The study was a subanalysis of the FAME 1 and FAME
2 studies. In the FAME studies, a total of 1499 lesions
with pre-PCI FFR ≤ 0.80 were treated with PCI. All of
the treated lesions with available post-PCI FFR values
(n = 838) were included in the subanalysis. The primary
endpoint was VOCE at 2 years, defined as the composite
of vessel-related cardiovascular death, vessel-related
unplanned hospitalisation with urgent revascularisation, and vessel-related myocardial infarction (MI).
The post-PCI ∆FFR frequency distribution included
277 lesions in the lower tertile (∆FFR ≤ 0.18), 282 lesions
in the middle tertile (∆FFR > 0.19 and ≤ 0.31), and 278
lesions in the upper tertile (∆FFR > 0.31). Previous PCI
was present in 29.6% of patients in the lower tertile,
22.3% of the middle tertile, and 15.5% of the upper tertile (P < .001). The pre-PCI FFR was 0.76 in the lower
tertile, 0.69 in the middle tertile, and 0.50 in the upper
tertile (P < .001). The post-PCI FFR was 0.87 in the lower
tertile, 0.91 in the middle tertile, and 0.92 in the upper
tertile (P < .001).
Factors that predicted ∆FFR included male gender
(HR, -0.016; 95% CI, -0.027 to -0.006; P = .003), diabetes
(HR, -0.012; 95% CI, -0.022 to -0.002; P = .024), previous
PCI (HR, -0.020; 95% CI, -0.030 to -0.010; P < .001), and
pre-PCI FFR (HR, -0.958; 95% CI, -0.988 to -0.928;
P <.001).
The primary endpoint of VOCE occurred in 9.0% of
the lower tertile compared with 4.7% of the upper tertile (adjusted P = .010; Table 1). There were no significant
Table 1. VOCE in the Lower vs Upper Tertiles of Change in FFR
Tertiles
Lower
Upper
VOCE (n ; %)
P-value
P-value
(unadjusted) (adjusted*)
25 (9.0)
13 (4.7)
.043
.010
Death (n ; %)
4 (1.4)
4 (1.4)
.966
.689
MI (n ; %)
5 (1.8)
4 (1.4)
.733
.318
20 (7.2)
7 (2.5)
.010
.002
TVR (n ; %)
*Adjusted for post-PCI FFR, pre-PCI FFR < 0.70, smoker status, previous PCI,
and family history.
FFR, fractional flow reserve; MI, myocardial infarction; PCI, percutaneous coronary intervention; TVR, target vessel revascularisation; VOCE, vessel-oriented
clinical events.
differences between the lower versus upper tertiles in
the individual components of death and MI. Target vessel revascularisation was more common in the lower
versus upper tertile (7.2% vs 2.5%; P = .002).
The time-to-events curve of VOCE showed that the
lower the ∆FFR, the higher the percentage of VOCE. The
difference was only significant between the lower and
upper tertiles (P = .038; Figure 1).
Figure 1. Time to Events Curve of VOCE
20
Percentage of VOCE
Improvement in FFR After PCI
Predicts Lower Event Rate at 2
Years
Lower Tertile
Middle Tertile
Upper Tertile
P = .138
Lower versus Upper: P = .038
15
10
5
0
0
120
240
480
360
600
720
Days
Reproduced with permission from S Fournier, MD.
Comparison of the area under the curve versus prePCI stenosis severity showed that the lower the pre-PCI
FFR (the tighter the stenosis), the larger the predictive
value of ∆FFR as compared with post-PCI FFR.
Dr Fournier concluded that the higher the postPCI FFR value, the lower the event rate; however, the
likelihood ratio for event occurrence is weak. A larger
improvement in FFR was associated with a lower event
rate, suggesting that reduction in ischaemic potential is
an independent predictor of VOCE at 2 years.
Official Peer-Reviewed Highlights From ESC Congress 2017
13
Table of Contents for the Digital Edition of ESC Focus on Interventions & PC
Contents
ESC Focus on Interventions & PC - Cover1
ESC Focus on Interventions & PC - Cover2
ESC Focus on Interventions & PC - 1
ESC Focus on Interventions & PC - 2
ESC Focus on Interventions & PC - Contents
ESC Focus on Interventions & PC - 4
ESC Focus on Interventions & PC - 5
ESC Focus on Interventions & PC - 6
ESC Focus on Interventions & PC - 7
ESC Focus on Interventions & PC - 8
ESC Focus on Interventions & PC - 9
ESC Focus on Interventions & PC - 10
ESC Focus on Interventions & PC - 11
ESC Focus on Interventions & PC - 11A
ESC Focus on Interventions & PC - 11B
ESC Focus on Interventions & PC - 11C
ESC Focus on Interventions & PC - 11D
ESC Focus on Interventions & PC - 12
ESC Focus on Interventions & PC - 13
ESC Focus on Interventions & PC - 14
ESC Focus on Interventions & PC - 15
ESC Focus on Interventions & PC - 16
ESC Focus on Interventions & PC - 17
ESC Focus on Interventions & PC - 18
ESC Focus on Interventions & PC - 19
ESC Focus on Interventions & PC - 20
ESC Focus on Interventions & PC - Cover3
ESC Focus on Interventions & PC - Cover4
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