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Prognostic Implications of Prestent Pullback Pressure Gradient and Poststent Quantitative Flow Ratio in Patients
Neng Dai1,2, Sheng Yuan3,4, Kefei Dou3,4
1Department of Cardiology Zhongshan HospitalFudan UniversityShanghai Institute of Cardiovascular Diseases Shanghai China.
Insights
Pre-procedure coronary artery disease patterns, assessed by quantitative flow ratio-pullback pressure gradient (QFR-PPG), predict outcomes after stenting, even with successful post-procedure QFR. Combining pre- and post-procedure QFR improves risk assessment for stented vessels.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Medical Imaging and Diagnostics
Background:
- Coronary diffuse disease is linked to poor outcomes, but its impact post-percutaneous coronary intervention (PCI) is not well understood.
- Assessing physiological patterns before and after PCI is crucial for predicting patient prognosis.
Purpose of the Study:
- To investigate the prognostic significance of pre-PCI focal or diffuse coronary artery disease patterns, evaluated using quantitative flow ratio-pullback pressure gradient (QFR-PPG).
- To determine if pre-PCI QFR-PPG provides prognostic information independent of post-PCI quantitative flow ratio (QFR).
Main Methods:
- Quantitative flow ratio-derived pullback pressure gradient (QFR-PPG) was measured to classify 1685 vessels based on pre-PCI physiological patterns.
- Vessels were categorized by dichotomous pre-PCI QFR-PPG and post-PCI QFR.
- A 2-year vessel-oriented composite outcome (VOCO) was compared across these groups.
Main Results:
- Low pre-PCI QFR-PPG (3.9%) and low post-PCI QFR (9.8%) were associated with higher VOCO risk.
- Even with high post-PCI QFR, low pre-PCI QFR-PPG vessels showed increased VOCO risk (3.7% vs 1.8%).
- Pre-PCI QFR-PPG had a direct prognostic effect not mediated by post-PCI QFR, improving risk stratification when combined with post-PCI QFR.
Conclusions:
- The prognostic value of pre-PCI QFR-PPG persists after successful PCI, primarily due to its independent effect.
- Integrating pre-PCI and post-PCI physiological data (QFR-PPG and QFR) enhances risk stratification for stented coronary arteries.
- This combined approach offers superior discriminant and reclassification abilities compared to clinical factors alone.
Abstract:
Background Coronary diffuse disease associates with poor outcomes, but little is known about its role after percutaneous coronary intervention (PCI). We aimed to investigate the prognostic implication of pre-PCI focal or diffuse disease patterns combined with post-PCI quantitative flow ratio (QFR). Methods and Results Pre-PCI QFR derived pullback pressure gradient (PPG) (QFR-PPG) was measured to assess physiological disease patterns for 1685 included vessels; the vessels were classified according to dichotomous pre-PCI QFR-PPG and post-PCI QFR. Vessel-oriented composite outcome, a composite of vessel-related ischemia-driven revascularization, vessel-related myocardial infarction, or cardiac death at 2 years was compared among these groups. Vessels with low pre-PCI PPG (3.9% versus 2.0%, hazard ratio [HR], 1.93; 95% CI, 1.08-3.44; P=0.02) or low post-PCI QFR (9.8% versus 2.7%, HR, 3.78; 95% CI, 1.61-8.87; P=0.001) demonstrated higher vessel-oriented composite outcome risk after stent implantation. Of note, despite high post-PCI QFR achieved, vessels with low pre-PCI QFR-PPG presented higher risk of vessel-oriented composite outcome than those with high pre-PCI QFR-PPG (3.7% versus 1.8%, HR, 2.03; 95% CI, 1.09-3.76; P=0.03) and pre-PCI QFR-PPG demonstrated direct prognostic effect not mediated by post-PCI QFR. Integration of groups classified by pre-PCI QFR-PPG and post-PCI QFR showed significantly higher discriminant and reclassification abilities than clinical factors (C-index 0.77 versus 0.72, P=0.03; integrated discrimination improvement 0.93%, P=0.04; net reclassification index 0.33, P=0.02). Conclusions Prognostic value of pre-PCI focal or diffuse disease patterns assessed by QFR-PPG index was retained even after successful PCI, which is mostly explained by its direct effect that was not mediated by post-PCI QFR. Integration of both pre-PCI and post-PCI physiological information can provide better risk stratification in vessels with stent implantation. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT05104580.
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