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J Am Coll Cardiol. 2019 Feb 5;73(4):444-453. doi: 10.1016/j.jacc.2018.10.070.

Clinical Events After Deferral of LAD Revascularization Following Physiological Coronary Assessment.

Author information

1
Hammersmith Hospital, Imperial College London, Cancer Research UK, London, United Kingdom. Electronic address: sayan.sen@imperial.ac.uk.
2
Hammersmith Hospital, Imperial College London, Cancer Research UK, London, United Kingdom.
3
University College London Cancer Trials Centre, London, United Kingdom.
4
Lausanne University Hospital, Switzerland.
5
Royal North Shore Hospital, Sydney, New South Wales, Australia.
6
Flinders University, Adelaide, South Australia, Australia.
7
Prince Charles Hospital, Brisbane, Queensland, Australia.
8
MonashHeart and Monash University, Melbourne, Victoria, Australia.
9
Imelda Hospital, Bonheiden, Belgium.
10
Antwerp University Hospital, Antwerp, Belgium.
11
Ain Shams University, Cairo, Egypt.
12
Helsinki University Hospital, Helsinki, Finland.
13
INSERM Unité 1011, Lille, France.
14
Institut Coeur Poumon, Lille University Hospital, and Charite Campus Virchow Klinikum, Universitaetsmedizin, Berlin, Germany.
15
Gemeinschaftsklinikum Mittelrhein, Kemperhof Koblenz, Koblenz, Germany.
16
Sana Klinikum Lichtenberg, Lichtenberg, Germany.
17
Klinikum Oldenburg, European Medical School, Carl von Ossietzky University, Oldenburg, Germany.
18
University Magna Graecia, Catanzaro, Italy.
19
Catholic University of the Sacred Heart, Rome, Italy.
20
University Hospital Verona, Verona, Italy.
21
Tokyo Medical University, Tokyo, Japan.
22
Fukuoka Sannou Hospital, Fukuoka, Japan.
23
Aichi Medical University Hospital, Aichi, Japan.
24
Fukuyama Cardiovascular Hospital, Fukuyama, Japan.
25
Pauls Stradins Clinical University Hospital, Riga, Latvia.
26
Hospital Garcia de Horta, Lisbon, Portugal.
27
Hospital Santa Maria, Lisbon, Portugal.
28
Hospital Prof. Doutor Fernando Fonseca, Amadora, Portugal.
29
King Abdulaziz Medical City Cardiac Center, Riyadh, Saudi Arabia.
30
Sunninghill Hospital, Johannesburg, Germany.
31
Seoul National University Hospital, Seoul, South Korea.
32
Keimyung University Dongsan Medical Center, Daegu, South Korea.
33
Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, South Korea.
34
Inje University Ilsan Paik Hospital, Daehwa-Dong, South Korea.
35
Cardiovascular Institute, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.
36
Hospital Universitario de Torrejón and Universidad Francisco de Vitoria, Madrid, Spain.
37
Amphia Hospital, Breda, Amsterdam, the Netherlands.
38
AMC Heart Center, Academic Medical Center, Amsterdam, the Netherlands.
39
VU University Medical Center, Amsterdam, the Netherlands.
40
Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey.
41
Royal Brompton Hospital, and University of Florence, Florence, Italy.
42
Conquest Hospital, St. Leonards-on-Sea, United Kingdom.
43
Royal Devon and Exeter Hospital and University of Exeter, Exeter, United Kingdom.
44
Royal Bournemouth General Hospital, Bournemouth, United Kingdom.
45
Essex Cardiothoracic Centre, Basildon, and Anglia Ruskin University, Chelmsford, United Kingdom.
46
Emory University, Atlanta, Georgia.
47
Colorado Heart and Vascular, Lakewood, Colorado.
48
Veterans Affairs Long Beach Healthcare System, Long Beach, California.
49
Washington University School of Medicine, St. Louis, Missouri.
50
Stony Brook University Medical Center, New York, New York.
51
Gifu Heart Center, Gifu, Japan.
52
John Radcliffe Hospital, Oxford University Hospitals Foundation Trust, Oxford, United Kingdom.
53
Duke University, Durham, North Carolina.
54
Hospital Clinico San Carlos and Universidad Complutense de Madrid, Madrid, Spain.

Abstract

BACKGROUND:

Physicians are not always comfortable deferring treatment of a stenosis in the left anterior descending (LAD) artery because of the perception that there is a high risk of major adverse cardiac events (MACE). The authors describe, using the DEFINE-FLAIR (Functional Lesion Assessment of Intermediate Stenosis to Guide Revascularisation) trial, MACE rates when LAD lesions are deferred, guided by physiological assessment using fractional flow reserve (FFR) or the instantaneous wave-free ratio (iFR).

OBJECTIVES:

The purpose of this study was to establish the safety of deferring treatment in the LAD using FFR or iFR within the DEFINE-FLAIR trial.

METHODS:

MACE rates at 1 year were compared between groups (iFR and FFR) in patients whose physiological assessment led to LAD lesions being deferred. MACE was defined as a composite of cardiovascular death, myocardial infarction (MI), and unplanned revascularization at 1 year. Patients, and staff performing follow-up, were blinded to whether the decision was made with FFR or iFR. Outcomes were adjusted for age and sex.

RESULTS:

A total of 872 patients had lesions deferred in the LAD (421 guided by FFR, 451 guided by iFR). The event rate with iFR was significantly lower than with FFR (2.44% vs. 5.26%; adjusted HR: 0.46; 95% confidence interval [CI]: 0.22 to 0.95; p = 0.04). This was driven by significantly lower unplanned revascularization with iFR and numerically lower MI (unplanned revascularization: 2.22% iFR vs. 4.99% FFR; adjusted HR: 0.44; 95% CI: 0.21 to 0.93; p = 0.03; MI: 0.44% iFR vs. 2.14% FFR; adjusted HR: 0.23; 95% CI: 0.05 to 1.07; p = 0.06).

CONCLUSIONS:

iFR-guided deferral appears to be safe for patients with LAD lesions. Patients in whom iFR-guided deferral was performed had statistically significantly lower event rates than those with FFR-guided deferral.

KEYWORDS:

coronary stenosis; fractional flow reserve; instantaneous wave-free ratio

PMID:
30704577
PMCID:
PMC6354033
DOI:
10.1016/j.jacc.2018.10.070
[Indexed for MEDLINE]
Free PMC Article

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