The predecessor of this research—RIPCORD, published in 2014—showed that using fractional flow reserve (FFR) changes the treatment strategy in about 25% of patients. That marked the rise of FFR. In fact, the DEFER, FAME, and FAME 2 studies offered results consistent with the original RIPCORD.
In this research, authors tested the hypothesis of systematic use of FFR (all lesions >30% at visual estimation) in the diagnostic angiography. That is, not just in intermediate lesions that could generate doubt, but in any irregularity observed in the main vessels or in any branch that could be potentially revascularizable (with a diameter of about 2.25 mm).
The functional assessment was not required for chronic total occlusions or lesions with a flow below TIMI 3.
This study included 1100 patients from several sites in the UK who underwent coronary angiography due to stable angina or NON-ST-segment elevation infarction (NSTEMI).
In the angiography arm, decisions were based on angiography alone. On the contrary, in the FFR strategy arm, decisions were made after measuring the entire coronary tree (the mean number of measurements was four vessels!). Potential treatment options based on findings were: medical treatment, angioplasty, myocardial revascularization surgery, or further testing to define the case.
There were two primary endpoints: hospital costs and quality of life in terms of EQ-5D score. The pre-specified secondary endpoint was a composite of cardiovascular events.
Most patients had single-vessel lesion. Furthermore, 8.7% of patients in the angiography arm and 7.8% of patients in the angioplasty arm presented a >50-% lesion in the left main coronary artery, and 17.6% and 17.3% presented a >70-% lesion in the proximal LAD, respectively.
After a year, there were no significant differences between strategies in both primary endpoints. Surprisingly, systematic FFR did not increase costs, but it did not improve quality of life either.
Additionally, FFR did not change the distribution between medical treatment, angioplasty, or surgery. In this regard, 29.9% vs. 31.9% received medical treatment, 60.9% vs. 56.2% underwent angioplasty, and 9.2% vs. 11.9% underwent surgery for angiography and FFR, respectively.
Read also: ESC 2021 | ACST-2: CAS vs Endarterectomy in Asymptomatic Patients.
There was no difference in terms of major cardiovascular events, such as death, infarction, stroke, or unplanned revascularization, either.
In the arm that underwent FFR systematically, procedures lasted over 20 minutes longer (42.4 vs. 69 minutes; p < 0.001), radiation doses were more frequent, and 1.8% of patients underwent coronary dissections.
The angiography arm had significantly more patients (14.7% vs. 1.8%; p < 0.0001) who required further testing to define the case (MRI, stress echo, SPECT, repeat angiography with FFR or imaging, etc.).
The clinical condition (stable angina or NSTEMI) did not modify events such as death, stroke, infarction, unplanned revascularization, or the combination of all.
Read also: FLOWER-MI: FFR vs. Angiography for Complete Revascularization in Infarction.
Routine FFR at the time of diagnostic angiography offers no advantage compared with conventional angiography alone.
The underutilization of this tool in the cath lab may be even greater after the results of RIPCORD 2, and that would be a mistake.
The available evidence for functional assessment should not be questioned, but used more cautiously. Perhaps measuring all lesions is unnecessary, and we should select intermediate lesions likely to cause more doubt about strategy. Such lesions are also those that offer the greatest relative benefit.
Original Title: RIPCORD 2: Does routine pressure wire assessment influence management strategy of coronary angiography for diagnosis of chest pain.
Reference: Presentado por Curzen N. en el ESC 2021 el 29 de agosto 2021.
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