Routine invasive physiology assessment at time of angiography reclassifies treatment strategies in a big number of patients with lesions in 2 or 3 vessels, according to the multicenter prospective study DEFINE REAL, recently published in JACC Cardiovascular Interventions.

The information obtained by measuring fractional flow reserve (FFR) or instantaneous wave free ratio (iFR) made interventionists modify their original plans in 45% of cases. Reclassification was higher as more vessels were assessed, reaching an astonishing 66.7% for cases when 3 epicardial vessels were assessed.

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These findings now published in JACC had been originally presented at EuroPCR and are consistent with prior studies (R3F, RIPCORD, POST-IT), though these mostly included patients with one vessel disease. DEFINE REAL is the first invasive physiology study to focus on patients with multivessel disease.

The message is loud and clear and, at the same time, challenging: invasive physiology study of all vessels is mandatory, even in patients with non-invasive tests suggesting ischemia prior catheterization. In turn, this raises the question: does the change of strategy convey a change in prognosis?

DEFINE REAL was carried out in 18 centers across 9 countries and included 484 patients with multivessel disease undergoing diagnostic angiography (73.3% presented 2 vessel disease, and 26.7% 3 vessel disease).

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Researchers first defined an initial strategy based on  angiography and clinical assessment, then performed a physiology assessment, one third with iFR and the rest with FFR, and the final strategy was defined.

The change of plans, thanks to FFR/iFR, increased the use of medical treatment and myocardial revascularization surgery and modestly reduced the use of PCI.

The use of iFR was associated with less symptoms and the chance to assess more vessels, which resulted in a higher rate of reclassification than that obtained with the use of FFR (57.5% vs 39.9%).

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This study does not provide any information on clinical results, which remains to be sorted out by future studies. For now, the best we have are the SYNTAX II outcomes, published last year, which showed physiology assessment had very good results.

Título original: Impact of routine invasive physiology at time of angiography in patients with multivessel coronary artery disease on reclassification of revascularization strategy: results from the DEFINE REAL study.

Referencia: Van Belle E et al. J Am Coll Cardiol Intv. 2018;11:354-365.

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