FREEDOM with FFR: Different Outcomes?

The FREEDOM has clearly established the benefit of myocardial revascularization surgery (CABG) over percutaneous coronary intervention (PCI) in diabetic patients with multivessel disease. Coronary physiology as guideline for revascularization works best precisely in this kind of patients and its impact has never been studied in diabetics. 

El estudio FREEDOM con FFR ¿Cuál hubiera sido su resultado?

This study, published in Circ Cardiovasc Interv, assessed the long-term outcomes of FFR guided PCI vs. CABG in diabetic patients with multivessel disease. 

Between 2010 and 2018 it included 4622 diabetic patients receiving a coronary angiogram for the purpose of this study. Inclusion criteria included the presence of at least 2 vessels with >50% diameter stenosis, where at least one intermediate lesion (30 to 70% diameter stenosis) was deferred thanks to FFR. Primary end point was a combination of all cause death, MI, revascularization, and stroke. 

Finally, 209 patients undergoing surgery and 209 undergoing FFR guided PCI were included.

Primary end point rate at 5 years resulted significantly higher in the FFR guided PCI group (44.5% vs 31.9%; HR, 1.60 CI 95%, 1.15–2.22; p=0.005). This difference was driven mainly by repeat revascularization (24.9% vs 8.2%; HR 3.51 CI 95%, 1.93 to 6.40; p<0.001).

Read also: More Evidence for Short Term DAPT: Approaching “the Class Effect”.

If we only take death, MI or stroke into account, the outcome is practically the same (28.8% vs 27.5%; HR, 1.05 CI 95%, 0.72 to 1.53; p=0.81).

This differs from the FREEDOM outcomes, where at 3.8 years there was a significant difference in mortality in favor of surgery. 


Diabetic patients with multivessel disease benefit from surgery at the expense of a lower revascularization rate compared against FFR guided PCI. 

At 5 years, there were no significant differences in the “hard” combined end point of all cause death, MI or stroke between CABG and FFR guided PCI. 

Original Title: Coronary Artery Bypass Grafting or Fractional Flow Reserve–Guided Percutaneous Coronary Intervention in Diabetic Patients With Multivessel Disease.

Reference: Giuseppe Di Gioia et al. Circ Cardiovasc Interv. 2020;13:e009157. DOI: 10.1161/CIRCINTERVENTIONS.120.009157.

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