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Assessment of Coronary Stenoses for Percutaneous Coronary Intervention: A Systematic Review and Network Meta-Analysis
Marc-André d'Entremont1, Denise Tiong2, Behnam Sadeghirad3
1Population Health Research Institute, Hamilton, Ontario, Canada; Hamilton Health Sciences, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Centre Hospitalier Universitaire de Sherbrooke (CHUS), Sherbrooke, Quebec, Canada.
Insights
Quantitative flow ratio (QFR) significantly reduces major adverse cardiovascular events (MACE) compared to other methods for guiding percutaneous coronary intervention (PCI). This finding suggests QFR may be the optimal choice for PCI decisions, pending further validation.
Area of Science:
- Cardiology
- Interventional Cardiology
- Medical Imaging
Background:
- Comparative efficacy of methods for assessing coronary stenosis significance in the catheterization lab is unclear.
- Percutaneous coronary intervention (PCI) decisions require accurate stenosis assessment.
Purpose of the Study:
- To compare the efficacy of available methods for guiding PCI decisions.
- To evaluate the impact of different functional assessment techniques on major adverse cardiovascular events (MACE).
Main Methods:
- A frequentist random-effects network meta-analysis of 15 randomized trials (16,333 participants) was conducted.
- Data from Medline, Embase, and CENTRAL databases were systematically searched up to October 5, 2023.
- The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to assess evidence certainty.
Main Results:
- Quantitative flow ratio (QFR) was associated with a decreased risk of MACE compared to coronary angiography (CA), fractional flow reserve (FFR), and instantaneous wave-free ratio (iFR) (high to moderate certainty).
- FFR and iFR likely did not decrease MACE risk compared to CA (moderate certainty).
- Intravascular imaging showed no significant MACE reduction compared to CA (low certainty).
Conclusions:
- PCI decisions guided by QFR were linked to reduced MACE compared to CA, FFR, and iFR in a mixed population.
- These findings are hypothesis-generating and warrant validation in large, randomized head-to-head trials.
Abstract:
Evidence regarding the comparative efficacy of the different methods to determine the significance of coronary stenoses in the catheterization laboratory is lacking. We aimed to compare all available methods guiding the decision to perform percutaneous coronary intervention (PCI). We searched Medline, Embase, and CENTRAL until October 5, 2023. We included trials that randomized patients with greater than 30% stenoses who were considered for PCI and reported major adverse cardiovascular events (MACE). We performed a frequentist random-effects network meta-analysis and assessed the certainty of evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. We included 15 trials with 16,333 participants with a mean weighted follow-up of 34 months. The trials contained a median of 49.3% (interquartile range: 32.6%, 100%) acute coronary syndrome participants. Quantitative flow ratio (QFR) was associated with a decreased risk of MACE compared with coronary angiography (CA) (risk ratio [RR] 0.68, 95% confidence interval [CI] 0.56 to 0.82, high certainty), fractional flow reserve (FFR) (RR 0.73, 95% CI 0.58 to 0.92, moderate certainty), and instantaneous wave-free ratio (iFR) (RR 0.63, 95% CI 0.49 to 0.82, moderate certainty), and ranked first for MACE (88.1% probability of being the best). FFR (RR 0.93, 95% CI 0.82 to 1.06, moderate certainty) and iFR (RR 1.07, 95% CI 0.90 to 1.28, moderate certainty) likely did not decrease the risk of MACE compared with CA. Intravascular imaging may not be associated with a significant decrease in MACE compared with CA (RR 0.85, 95% CI 0.62 to 1.17, low certainty) when used to guide the decision to perform PCI. In conclusion, a decision to perform PCI based on QFR was associated with a decreased risk of MACE compared with CA, FFR, and iFR in a mixed stable coronary disease and acute coronary syndrome population. These hypothesis-generating findings should be validated in large, randomized, head-to-head trials.
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