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Angiographic Quantitative Flow Ratio-Guided Treatment of Patients With Physiologically Intermediate Coronary Lesions
Jiannan Dai1, Changdong Guan2,3, Xueming Xu1
1Department of Cardiology The Second Affiliated Hospital of Harbin Medical University Harbin Heilongjiang Province China.
Insights
Quantitative Flow Ratio (QFR) guidance did not significantly improve 2-year outcomes for intermediate coronary lesions compared to angiography. This analysis of the FAVOR III China trial found no major benefit in major adverse cardiac events for QFR-guided interventions.
Area of Science:
- Cardiology
- Interventional Cardiology
- Medical Imaging
Background:
- The FAVOR III China trial showed benefits of quantitative flow ratio (QFR) guided percutaneous coronary intervention (PCI) over angiography.
- Uncertainty exists regarding QFR's efficacy in intermediate lesions ('uncertainty zone').
- This study investigates QFR vs. angiography guidance in these specific lesions.
Purpose of the Study:
- To evaluate the impact of QFR-guided PCI versus angiography-guided PCI on patient management and outcomes.
- To specifically analyze outcomes in patients with "uncertainty-zone" coronary lesions.
Main Methods:
- A prespecified subgroup analysis of the FAVOR III China trial.
- Identified 873 patients (22.9%) with uncertainty-zone lesions (offline QFR 0.75-0.85).
- Compared major adverse cardiac events (MACE) at 2 years between QFR-guided and angiography-guided PCI groups.
Main Results:
- At 2 years, MACE occurred in 7.0% of the QFR group and 8.3% of the angiography group (HR 0.85).
- Landmark analysis showed differing treatment effects before and after 1 year (P_interaction=0.03).
- QFR guidance showed benefit after 1 year, driven by reduced myocardial infarctions and revascularizations.
Conclusions:
- QFR-guided revascularization did not significantly improve 2-year clinical outcomes in this subgroup of patients with intermediate coronary lesions.
- The findings suggest that the benefits observed in the overall FAVOR III China trial may not extend to this specific patient subgroup.
Background:
The FAVOR III (Comparison of Quantitative Flow Ratio Guided and Angiography Guided Percutaneous Intervention in Patients With Coronary Artery Disease) China trial reported improved clinical outcomes with percutaneous coronary intervention guided by quantitative flow ratio (QFR) compared with angiography. Whether these benefits also apply for patients presenting with "uncertainty-zone" lesions of intermediate physiological significance is uncertain. This study aims to examine the impact of QFR guidance versus angiography guidance on the management and outcomes of percutaneous coronary intervention in uncertainty-zone lesions.
Methods And Results:
In this prespecified subgroup analysis, offline QFR assessment categorized 873 patients (22.9%) into the uncertainty-zone subgroup, defined as having an offline QFR of 0.75 to 0.85 in all coronary arteries with a lesion causing ≥50% diameter stenosis. At 2 years, the rate of major adverse cardiac events, a composite of all-cause death, myocardial infarction, or ischemia-driven revascularization, occurred in 31 patients (7.0%) in the QFR-guided group and 35 patients (8.3%) in the angiography-guided group (hazard ratio [HR], 0.85 [95% CI, 0.52-1.37]). In landmark analysis, the relative treatment effect of QFR guidance versus angiography guidance on major adverse cardiac events differed before 1 year (4.7% versus 3.8%; HR, 1.25 [95% CI, 0.65-2.40]) and after 1 year (2.3% versus 5.5%; HR, 0.41 [95% CI, 0.20-0.87]) (Pinteraction=0.03), driven by fewer nonprocedural myocardial infarctions and ischemia-driven revascularizations in the QFR-guided group after 1-year follow-up.
Conclusions:
In the modest-sized subgroup of patients with physiologically intermediate lesions randomized in the FAVOR III China trial, 2-year clinical outcomes were not significantly improved with a QFR-guided revascularization strategy compared with angiography guidance.
Registration:
URL: https://www.clinicaltrials.gov; Identifier: NCT03656848.
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