Deferring treatment through angioplasty in non-ischemic lesions by fractional flow reserve (FFR) is associated with excellent long-term prognosis in patients with chronic ischemic heart disease.
FFR is beginning to be used for clinical decision-making in patients with acute coronary syndromes, and its long-term effect on stable chronic patients has not been established.
This study tries to determine the safety of deferring non-significant lesions by FFR in patients with acute coronary syndromes. For that purpose, the study included 206 consecutive patients with 262 intermediate lesions admitted for acute coronary syndrome and 370 patients with 528 intermediate lesions admitted for stable chronic angina in whom angioplasty was deferred on the basis of a FFR without evidence of myocardial ischemia (>0.75).
The primary endpoint was a composite of acute myocardial infarction and target vessel failure (major adverse cardiovascular events [MACE]).
In the entire cohort, in the long-term (3.4 ± 1.6 years), the rate of combined events was higher in the group with acute coronary syndrome than in the stable chronic group (23% vs. 11%, p <0.0001).
After a propensity score analysis that matched 200 patients in each group, the combined events rate is significantly higher for those with acute coronary syndrome (25% vs. 12%; p <0.0001).
Acute coronary syndrome patients presented a hazard ratio of 2.8 compared to stable patients (95% confidence interval [CI]: 1.9 to 4.0; p <0.0001).
In both the matched and unmatched cohorts, and across all FFR categories, patients with acute coronary syndrome presented higher rates of myocardial infarction and target vessel revascularization compared with stable patients (p <0.05).
In this study, the best FFR cutoff was <0.84 for patients with acute coronary syndrome (MACE 21% vs. 36%; p = 0.007) and <0.81 for stable patients (MACE 17% vs. 9%; p = 0.01).
Conclusion
Deferring coronary angioplasty on the basis of non-ischemic FFR in patients presenting acute coronary syndrome is significantly associated with worse outcomes when compared to stable chronic patients.
This study warns about risks derived from using FFR for clinical decision-making in acute patients.
Original title: Long-Term Prognosis of Deferred Acute Coronary Syndrome Lesions Based on Nonischemic Fractional Flow Reserve.
Reference: Abdul Hakeem et al. J Am Coll Cardiol. 2016;68(11):1181-1191.
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