AHA 2020 | The More Operators “Listen” to FFR, the Lower the Risk

When operators decide to proceed with PCI despite a negative FFR (fairly frequent in the daily practice) outcomes at 5 years are far worse. This information comes from a large Canadian register presented at AHA 2020 Scientific Sessions, simultaneously published in JAMA.

AHA 2020 | El riesgo aumenta cuando los operadores no “escuchan” al FFR

PCI to a non-ischemic lesion results in increased events risk at long term, just as treating an ischemic lesion with medical treatment would. 

Both the American and the European guidelines have emphasized the idea of using FFR to guide revascularization in intermediate lesions. Even though these recommendations have clearly been established, they are hardly followed in the daily practice. 

In the present study, researchers speculated with the fact that PCI to severe lesions with negative FFR would not present a major problem. Eventually, it would only increase healthcare costs. However, they observed increased events rate. 

The registry included 9106 patients (mean age 65) undergoing FFR in one vessel only between 2013 and 2018. It excluded STEMI or left main patients. 

Read also: AHA 2020 | AFFIRM-AHF: Ferric Carboxymaltose and Fewer Hospitalizations for Cardiac Failure.

Globally, 30% of patients showed ischemic lesions (FFR ≤ 0.8) and 70% non-ischemic lesions.

In the ischemic lesion group, 75% of patients received PCI and 25% medical treatment, despite a positive FFR. In this group, PCI reduced the primary end point of death, MI, unstable angina or urgent revascularization (31.5% vs 39.1%; HR 0.77; CI 95% 0.63-0.94).

On the other end, 87.4% of patients with non-ischemic lesions received medical treatment and 12.6% received PCI, despite a negative FFR. This unnecessary intervention was associated with a significant increase in events at 5 years (33.3% vs 24.4%; HR 1.37; CI 95% 1.14-1.65).

Read also: AHA 2020 | Statins: Confirmed Benefits for the Elderly.

What is interesting about this study is that FFR was measured, but then it was decided against its result. More often than not, interventionists in the daily practice often decide not to measure FFR because they rely on angiographies.  

Taking the time to measure FFR and then ignoring its results strikes as odd, but there must be a reason behind this decision. 

FFR is not binary and there are multiple factors an operator must take into account when deciding for or against revascularization. 

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Original Title: Association Between Adherence to Fractional Flow Reserve Treatment Thresholds and Major Adverse Cardiac Events in Patients With Coronary Artery Disease.

Reference: Maneesh Sud et al. JAMA. Published online November 13, 2020. doi:10.1001/jama.2020.22708 y presentado en el congreso AHA 2020.

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