The inclusion of fractional flow reserve (FFR) has changed how coronary interventions are treated. Current guidelines endorse its use in intermediate lesions with no evidence of ischemia in non-invasive studies in patients with multivessel disease.
The original RIPCORD (Routine Pressure Wire Assessment Influence Management Strategy at Coronary Angiography for Diagnosis of Chest Pain) study proposed routine assessment using a pressure wire prior to a strategy defined as optimal medical treatment (OMT), angioplasty (percutaneous coronary intervention, PCI), or myocardial revascularization surgery (coronary artery bypass surgery, CABG). In this study, the therapeutic plan was changed in 26% of cases after a FFR functional assessment.
RIPCORD 2 was an open, prospective, randomized study to evaluate whether systematic FFR assessment in all relevant coronary arteries at diagnosis could improve the use of resources, quality of life, and clinical outcomes compared with conventional angiography.
Researchers included patients with stable angina or non-ST elevation acute coronary syndrome (ACS) with planned coronary angiography. FFR was conducted in all relevant arteries, regardless of the presence or absence of atheroma, except in patients with TIMI <3 occlusion or subocclusion. Pressure wires (PW) COMET (Boston Scientific) were used. The studied outcomes were total hospital costs and quality of life.
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The study randomized 1100 patients from 17 sites in the United Kingdom (UK) between 2016 and 2018. Half the population had ACS, the mean age was 64 years old, 75% of patients were male, 19% had diabetes, and over two thirds had either no lesion or single-vessel lesion. PW-related complications were 1.8%.
Using FFR results, treating physicians could determine a definite treatment plan in >98% of cases, while in the angiography arm 14.7% of cases required another assessment to define the course of action.
There were no significant differences regarding the visual analogue scale quality of life endpoint: 75 (RIC, 60-87) for angiography vs. 75 (RIC 60-90) for the FFR arm (p = 0.88). Average hospital costs were similar between arms: GBP 4136 for the angiography arm vs. GBP 4510 for patients treated with angiography plus FFR (RIC GBP 2721-7415; p = 0.137).
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There were no significant differences between individual events nor regarding the composite of major cardiovascular events.
Conclusions:
This study showed that a routine systematic FFR strategy did not have an impact on costs compared with angiography-guided treatment. Consequently, it did not improve quality of life at 1 year.
Dr. Omar Tupayachi.
Member of the Editorial board of SOLACI.org.
Original Title: Routine Pressure Wire Assessment Versus Conventional Angiography in the Management of Patients With Coronary Artery Disease: The RIPCORD 2 Trial.
Font: Stables, Rodney H et al. “Routine Pressure Wire Assessment Versus Conventional Angiography in the Management of Patients With Coronary Artery Disease: The RIPCORD 2 Trial.” Circulation vol. 146,9 (2022): 687-698. doi:10.1161/CIRCULATIONAHA.121.057793.
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