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Prognostic Implication of Thermodilution Coronary Flow Reserve in Patients Undergoing Fractional Flow
Joo Myung Lee1, Ki Hong Choi1, Doyeon Hwang2
1Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
Insights
Low coronary flow reserve (CFR) significantly increases the risk of adverse events in patients undergoing fractional flow reserve (FFR) measurement. Even with normal FFR, low CFR independently predicts poor outcomes, highlighting its prognostic value.
Area of Science:
- Cardiovascular medicine
- Interventional cardiology
- Diagnostic imaging and physiology
Background:
- Limited data exist on the long-term prognostic implications of thermodilution-derived coronary flow reserve (CFR) in patients with coronary artery disease.
- Fractional flow reserve (FFR) is a standard measure, but its prognostic value may be enhanced by assessing microvascular function via CFR.
Purpose of the Study:
- To investigate the prognostic significance of coronary flow reserve (CFR) in patients who have undergone fractional flow reserve (FFR) measurement.
- To evaluate the association between CFR, FFR, and long-term clinical outcomes, specifically the vessel-oriented composite outcome (VOCO).
Main Methods:
- A total of 519 patients (737 vessels) without revascularization were analyzed.
- Patients were classified based on FFR (threshold ≤0.8) and CFR (threshold ≤2.0) measured using a pressure-temperature sensor-tipped wire.
- Clinical outcomes, including cardiac death, vessel-specific myocardial infarction, and revascularization, were assessed over a 5-year follow-up period.
Main Results:
- Modest categorical agreement (kappa = 0.080) was observed between FFR and CFR, with 30.6% of cases showing discordant results.
- Low CFR was associated with a significantly higher risk of VOCO (HR: 3.171; p < 0.001) compared to high CFR.
- In patients with high FFR, low CFR independently predicted VOCO (HR: 4.999; p < 0.001), and the group with both low FFR and low CFR exhibited the highest VOCO risk (17.9%).
Conclusions:
- Patients with low CFR demonstrate a significantly elevated risk of clinical events over 5 years.
- Low CFR serves as an independent predictor of adverse outcomes, even in patients with a normal FFR.
- These findings underscore the prognostic value of CFR assessment in conjunction with FFR measurements for comprehensive risk stratification.
Objectives:
This study investigated the prognostic implication of coronary flow reserve (CFR) in patients who underwent fractional flow reserve (FFR) measurement.
Background:
Limited data are available regarding the long-term prognosis associated with thermodilution CFR in patients with coronary artery disease.
Methods:
A total of 519 patients (737 vessels) who did not undergo revascularization were classified according to FFR and CFR values. Low FFR and low CFR were defined with upper thresholds of 0.8 and 2.0, respectively. FFR and CFR were measured by a pressure-temperature sensor-tipped wire. Clinical outcomes were assessed by the vessel-oriented composite outcome (VOCO) (a composite of cardiac death, vessel-specific myocardial infarction, and vessel-specific revascularization) during 5 years of follow-up.
Results:
The categorical agreement (kappa = 0.080; p = 0.024) between FFR and CFR were modest, and 30.6% of the population showed discordant results between FFR and CFR. During 5 years of follow-up, patients with low CFR had a significantly higher risk of VOCO than did those with high CFR (hazard ratio [HR]: 3.171; 95% CI: 1.664 to 6.042; p < 0.001). Among patients with high FFR, there were no differences in clinical risk factor profiles, FFR, or stenosis severity between the high-CFR and low-CFR groups, and low CFR was an independent predictor for VOCO (HR: 4.999; 95% CI: 2.104 to 11.879; p < 0.001). In a 4-group classification according to both FFR and CFR, patients with low FFR and low CFR had the highest risk of VOCO (17.9%; overall p < 0.001).
Conclusions:
Patients with low CFR had a significantly higher risk of clinical events during 5 years of follow-up. Low CFR was an independent predictor for patient-oriented composite outcome among patients with high FFR. These results support the value of CFR in patients who undergo FFR measurement. (Clinical, Physical and Prognostic Implication of Microvascular Status; NCT02186093).
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