Original title: Long-term outcomes of fractional flow reserve-guided vs. angiography-guided percutaneous coronary intervention in contemporary practice. Reference: Li J et al. Eur Heart J. 2013; Epub ahead of print

Precision of the fractional flow reserve (FFR) to estimate the functional compromise of coronary stenosis and its ability to reduce events to decide PTCA, based on their outcome has already been established in randomized jobs. 

However, in daily clinical practice using FFR is not protocolar, leaving at surgeon’s discretion the use, according to angiographic findings as well as the decision for PTCA once measurements are performed. This selective use may have different results than randomized trials.

This register conducted at the Mayo Clinic between 2002 and 2009 included 7358 consecutive patients who underwent PCI in that period. Of these, in 6268 patients (85.2%) PTCA was guided only by angiography and the remaining patients 1090 (14.8%) underwent FFR. Overall a FFR <0.75 were indicative of PTCA and was at the discretion of surgeon with measurements between 0.75 and 0.80. After adjusting for baseline characteristics, the 4-year follow-up there was a trend to lower death and myocardial infarction with the use of FFR (RR 0.85, 95% CI: 0.71-1.01, p = 0.06). 

But by excluding patients with measurements between 0.75 and 0.8 the incidence of death and myocardial infarction was significantly lower if the FFR group (RR 0.8, 95% CI: 0.66 to 0.96, p = 0.02). Not perform angioplasty after measuring FFR, significantly reduced both the risk of infarction (p = 0.004) and the combination of death / myocardial infarction (p = 0.02).

Conclusion 

In this record of daily practice we observed a favorable progress at long-term by means of fractional flow reserve to guide or not, the procedure of coronary angioplasty.

Commentary

Other works has shown that routine FFR changes behaviour in 32% of the injuries and in 48% of patients compared to angiography alone, so its use only for angiographically intermediate injuries (as habitually seen in daily practice) could decrease its potential benefit. The reason to perform an analysis excluding patients with measurements between 0.75 and 0.8 was because 40% of them, did not underwent PTCA and today it is clearer that the cut should be in 0.8 (note that most patients were included prior to publication of FAME study). Excluding these patients the benefit is significant and the results are more like those of FAME. The study also shows the long-term safety of not treating the lesions with FFR not significant, it actually resulted in a decrease of events.

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