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Published on: June 28, 2019
Long-Term Prognosis of Deferred Acute Coronary Syndrome Lesions Based on Nonischemic Fractional Flow Reserve
Abdul Hakeem1, Mohan M Edupuganti2, Ahmed Almomani2
1Division of Cardiovascular Medicine, Central Arkansas for Veterans Healthcare System, Little Rock, Arkansas; Division of Cardiovascular Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas.
Insights
Deferring percutaneous coronary intervention in acute coronary syndrome (ACS) patients based on fractional flow reserve (FFR) leads to worse outcomes compared to stable ischemic heart disease (SIHD) patients. Caution is advised when applying SIHD FFR criteria to ACS patients.
Area of Science:
- Cardiology
- Interventional Cardiology
- Clinical Prognostics
Background:
- Fractional flow reserve (FFR) guides percutaneous coronary intervention (PCI) decisions in stable ischemic heart disease (SIHD), showing excellent long-term prognosis when PCI is deferred for nonischemic lesions.
- The prognostic impact of deferring PCI based on FFR in acute coronary syndrome (ACS) patients with intermediate lesions remains less established.
Purpose of the Study:
- To investigate the clinical utility and long-term prognostic value of FFR in ACS patients where PCI was deferred due to nonischemic FFR values.
- To compare the outcomes of ACS patients with deferred PCI based on FFR against SIHD patients with similar FFR-guided deferred PCI.
Main Methods:
- A study cohort included 206 ACS patients and 370 SIHD patients with intermediate lesions where PCI was deferred if FFR > 0.75.
- The primary outcome was a composite of myocardial infarction and target vessel failure (major adverse cardiovascular events [MACE]).
- Propensity score matching was used to compare MACE rates between ACS and SIHD groups, with Cox proportional hazards analysis and ROC analysis for FFR cutoffs.
Main Results:
- Long-term MACE rates were significantly higher in the ACS group (23%) compared to the SIHD group (11%) (p < 0.0001).
- After propensity score matching, MACE remained significantly higher in ACS patients (25%) versus SIHD patients (12%) (p < 0.0001), with ACS having a hazard ratio of 2.8 for MACE.
- ACS patients consistently showed higher annualized myocardial infarction/target vessel revascularization rates than SIHD patients across FFR categories. Optimal FFR cutoffs for predicting MACE differed between groups (<0.84 for ACS, <0.81 for SIHD).
Conclusions:
- Deferring PCI based on nonischemic FFR in ACS patients is associated with significantly worse long-term outcomes compared to SIHD patients.
- Clinical decision-making for ACS patients using FFR criteria established in SIHD populations requires caution due to differing prognostic implications.
Background:
Deferring percutaneous coronary intervention in nonischemic lesions by fractional flow reserve (FFR) is associated with excellent long-term prognosis in patients with stable ischemic heart disease (SIHD). Although FFR is increasingly used for clinical decision making in acute coronary syndrome (ACS) patients with intermediate lesions, its effect on long-term prognosis has not been well established.
Objectives:
This study investigated the clinical and prognostic utility of FFR in ACS patients with percutaneous coronary intervention deferred on the basis of nonischemic FFR.
Methods:
We studied 206 consecutive ACS patients with 262 intermediate lesions and 370 patients with SIHD (528 lesions) in whom revascularization was deferred on the basis of a nonischemic FFR (>0.75). The primary outcome measure was a composite of myocardial infarction and target vessel failure (major adverse cardiovascular events [MACE]).
Results:
In the entire cohort, the long-term (3.4 ± 1.6 years) MACE rate was higher in the ACS group than in the SIHD group (23% vs. 11%, p < 0.0001). After propensity score matching (200 patients/group), MACE remained significantly higher (ACS 25% vs. SIHD 12%; p < 0.0001). On Cox proportional hazards analysis for MACE, ACS had a hazard ratio of 2.8 (95% confidence interval: 1.9 to 4.0; p < 0.0001). In both the matched and unmatched cohorts, across all FFR categories, ACS patients had a significantly higher annualized myocardial infarction/target vessel revascularization rate compared with SIHD (p < 0.05). Receiver-operating characteristic analysis identified FFR cutoffs (best predictive accuracy for MACE) of <0.84 for ACS (MACE 21% vs. 36%; p = 0.007) and <0.81 for SIHD (MACE 17% vs. 9%; p = 0.01).
Conclusions:
Deferring percutaneous coronary intervention on the basis of nonischemic FFR in patients with an initial presentation of ACS is associated with significantly worse outcomes than SIHD. Caution is warranted in using FFR values derived from patients with SIHD for clinical decision making in ACS patients.
