Diabetes does not seem to alter the results of a fractional flow reserve (FFR) measurement in a given lesion. Recently, expert opinions and small studies had questioned the reliability of FFR in this specific patient subgroup. This new observational study soon to be published in JAMA vanquishes all doubts and confirms the efficacy of this method in patients with diabetes.
According to this new observational analysis from the PRIME-FFR study, FFR can safely guide the decision-making process in patients both with and without diabetes.
There were some concerns about microcirculatory responsiveness to adenosine and the potential for accelerated atherosclerosis in deferred lesions in diabetic patients, but these uncertainties seem less warranted after reading the analysis.
For this analysis, investigators used data from the PRIME-FFR study, which in turn combines data from two prospective multicenter registries: POST-IT and R3F. In total, there were 1983 patients; one third of them had a history of diabetes.
FFR was measured on average for 1.4 lesions per patient and, in patients with and without diabetes, there were the same independent risk factors for lower FFR values (age, anterior descending artery disease, stenosis percentage, lesion length, and number of diseased vessels).
Similar proportions of patients with and without diabetes were reclassified by FFR results from one revascularization strategy to another (41.2% and 37.5%, respectively; p = 0.13).
Patients with diabetes were actually more likely to shift from initial medical therapy to revascularization compared with patients without diabetes (41.5% vs. 31.5%; p = 0.001).
Combined events (all-cause death, infarction, or unplanned revascularization) at one year were more frequent in diabetic patients (11.3% vs. 9%). Such rate did not differ between patients who were and were not reclassified by FFR.
Patients with deferred revascularization based on FFR >0.8 had similar event rates regardless of their diabetes status (8.4% vs. 7.9%; p = 0.87).
Patients for whom FFR results were disregarded while deciding the revascularization strategy experienced almost twice as many events as other patients (17.5% vs. 9.2%; p = 0.002).
Given the scarce evidence we have, this work seems the best alternative to bring peace of mind and confirm that we should make our decisions based on FFR results, regardless of patient glycemic levels.
Original Title: Usefulness of routine fractional flow reserve for clinical management of coronary artery disease in patients with diabetes.
Reference: Van Belle E et al. JAMA Cardiol. 2020; Epub ahead of print.
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