Physiological Patterns of Coronary Artery Disease and Drug-Coated Balloon Performance

Diffuse coronary artery disease (CAD) challenges stent-based percutaneous coronary intervention (PCI). Drug-coated balloons (DCBs) offer a stentless strategy, but the physiological response in focal compared with diffuse disease remains unclear.

The authors aimed to investigate the impact of physiological patterns on angiographic and physiological outcomes after DCB-PCI.

In this international cohort, patients underwent DCB-PCI for de novo lesions with angiographic follow-up at 5 months (IQR: 3-7). Quantitative coronary angiography and Murray's law-based quantitative flow ratio (μFR) were analyzed by a core laboratory. Virtual μFR pull backs generated the pull back pressure gradient index (PPGi), classifying disease as focal (PPGi ≥0.78) or diffuse (PPGi <0.78).

Among 230 patients/lesions, 139 of 230 (60.4%) were focal and 91 of 230 (39.6%) diffuse. Baseline μFR was comparable between diffuse and focal disease (0.64 [0.45-0.80] vs 0.61 [0.32-0.79]; P = 0.21). After PCI, diffuse disease showed lower acute functional gain (ΔμFR 0.23 [0.09-0.36] vs 0.29 [0.12-0.51]; P = 0.03), lower post-PCI μFR (0.89 [0.82-0.93] vs 0.91 [0.86-0.94]; P = 0.03), and more suboptimal physiology (19 of 91, 20.9% vs 12 of 139, 8.6%; P = 0.01). At follow-up, late functional loss was minimal and similar (+0.01 [-0.04 to 0.06] vs -0.01 [-0.04 to 0.04]; P = 0.53), yet diffuse CAD maintained lower μFR (0.88 [0.78-0.93] vs 0.91 [0.85-0.95]; P = 0.03) and more ischemic physiology (27 of 91, 29.7% vs 16 of 139, 11.5%; P = 0.01).

PPGi stratifies outcomes after DCB-PCI: diffuse CAD shows smaller acute μFR gain and more suboptimal post-PCI physiology, despite minimal late angiographic and functional loss, highlighting the importance of optimal acute physiological results, particularly in diffuse disease.