We Should Revascularize Patients with Stable Coronary Syndromes and Ischemia Assessed by iFR

Chronic stable angina has shown a good response to medical treatment, and the Ischemia study has recently demonstrated the safety of such treatment in stable chronic angina with moderate to severe ischemia. However, this study excluded left main coronary artery (LMCA) lesions.

Debemos revascularizar los pacientes con síndromes coronarios estables e isquemia evaluada mediante iFR

The FAME Study has shown the safety and efficacy of fractional flow reserve (FFR), as well as a reduction in the need for stent. However, in stable syndromes with ischemia assessed based on left main coronary artery physiology, it has not been analyzed whether current medical treatment is safe.

Researchers conducted a review of the DEFINE LM registry, which included 225 patients with stable chronic angina and significant lesions for ischemia, determined by instantaneous wave-free ratio (iFR) ≤0.89. Of these, 74 patients were deferred for medical treatment, while 151 patients underwent revascularization.

The Primary Endpoint (PEP) was defined as major adverse cardiovascular events (MACE), which includes mortality from any cause, non-fatal acute myocardial infarction, and revascularization of the LMCA lesion due to ischemia.

Since the populations were different, researchers conducted a propensity score match analysis, which resulted in 74 patients in each group.

The mean age of the participants was 71 years; 52% of patients were men and 80% had hypertension. Additionally, 42% had diabetes, 24% had chronic renal insufficiency, and 30% had experienced a previous myocardial infarction.

The most common lesion in the left main coronary artery was distal (80%), followed by ostium lesions, while the lesion in the body of the LMCA was less frequent. There were no differences in the number of diseased vessels or in the presence of chronic total occlusion (CTO).

The SYNTAX Score was 22.

In the group of patients who underwent revascularization, percutaneous coronaryintervention (PCI) was performed in 44 cases, and myocardial revascularization surgery (MRS) was performed in 30 cases.

Follow-up was conducted over 34 months (22-40). Regarding the PEP, there was a benefit in favor of revascularization was, with an incidence of 14.9% versus 28.4% (hazard ratio 0.42 [95% confidence interval (CI), 0.20-0.89]; p=0.023). Furthermore, there was a reduction in cardiac mortality and LMCA-related myocardial infarction (0% vs. 8.1%; p=0.004), as well as in the need for revascularization of LMCA lesions (5.4% vs. 17.6%; hazard ratio, 0.20 [95% CI, 0.056-0.70]; p=0.012).

The predictor of MACE reduction was LMCA revascularization.

Conclusion

In summary, patients who underwent revascularization for stable coronary disease and significant lesions identified by iFR physiology had a more favorable long-term outcome compared to those whose revascularization was deferred.