Clinical Events After Deferral of LAD Revascularization Following Physiological Coronary Assessment

JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY

卷:73

Article

Sen, Sayan¹  Ahmad, Yousif¹  Dehbi, Hakim-Moulay²  Howard, James P.¹  Iglesias, Juan F.³  Al-Lamee, Rasha¹  Petraco, Ricardo¹  Nijjer, Sukhjinder¹  Bhindi, Ravinay⁴  Lehman, Sam⁵  Walters, Darren⁶  Sapontis, James^7,8  Janssens, Luc⁹  Vrints, Christiaan J.¹⁰  Khashaba, Ahmed¹¹  Laine, Mika¹²  Van Belle, Eric¹³  Krackhardt, Florian^14,15  Bojara, Waldemar¹⁶  Going, Olaf¹⁷  Haerle, Tobias¹⁸  Indolfi, Ciro¹⁹  Niccoli, Giampaolo²⁰  Ribichini, Flavio²¹  Tanaka, Nobuhiro²²  Yokoi, Hiroyoshi²³  Takashima, Hiroaki²⁴  Kikuta, Yuetsu²⁵  Erglis, Andrejs²⁶  Vinhas, Hugo²⁷  Silva, Pedro Canas²⁸  Baptista, Sergio B.²⁹  Alghamdi, Ali³⁰  Hellig, Farrel³¹  Koo, Bon-Kwon³²  Nam, Chang-Wook³³  Shin, Eun-Seok³⁴  Doh, Joon-Hyung³⁵  Brugaletta, Salvatore³⁶  Alegria-Barrero, Eduardo^37,38  Meuwissen, Martijin³⁹  Piek, Jan J.⁴⁰  van Royen, Niels⁴¹  Sezer, Murat⁴²  Di Mario, Carlo^43,44  Gerber, Robert T.⁴⁵  Malik, Iqbal S.¹  Sharp, Andrew S. P.^46,47  Talwar, Suneel⁴⁸  Tang, Kare^49,50  Samady, Habib⁵¹  Altman, John⁵²  Seto, Arnold H.⁵³  Singh, Jasvindar⁵⁴  Jeremias, Allen⁵⁵  Matsuo, Hitoshi⁵⁶  Kharbanda, Rajesh K.⁵⁷  Patel, Manesh R.⁵⁸  Serruys, Patrick¹  Escaned, Javier¹  Davies, Justin E.^59,60 

[1] Hammersmith Hosp, Imperial Coll London, Canc Res UK, London, England

[2] UCL, Canc Trials Ctr, London, England

[3] Lausanne Univ Hosp, Lausanne, Switzerland

[4] Royal North Shore Hosp, Sydney, NSW, Australia

[5] Flinders Univ S Australia, Adelaide, SA, Australia

[6] Prince Charles Hosp, Brisbane, Qld, Australia

[7] MonashHeart, Melbourne, Vic, Australia

[8] Monash Univ, Melbourne, Vic, Australia

[9] Imelda Hosp, Bonheiden, Belgium

[10] Antwerp Univ Hosp, Antwerp, Belgium

[11] Ain Shams Univ, Cairo, Egypt

[12] Helsinki Univ Hosp, Helsinki, Finland

[13] INSERM, Unite 1011, Lille, France

[14] Lille Univ Hosp, Inst Coeur Poumon, Berlin, Germany

[15] Univ Med, Charite Campus Virchow Klinikum, Berlin, Germany

[16] Gemeinschaftsklinikum Mittelrhein, Kemperhof Koblenz, Koblenz, Germany

[17] Sana Klinikum Lichtenberg, Lichtenberg, Germany

[18] Carl von Ossietzky Univ Oldenburg, European Med Sch, Klinikum Oldenburg, Oldenburg, Germany

[19] Magna Graecia Univ Catanzaro, Catanzaro, Italy

[20] Univ Cattolica Sacro Cuore, Rome, Italy

[21] Univ Hosp Verona, Verona, Italy

[22] Tokyo Med Univ, Tokyo, Japan

[23] Fukuoka Sannou Hosp, Fukuoka, Fukuoka, Japan

[24] Aichi Med Univ Hosp, Aichi, Japan

[25] Fukuyama Cardiovasc Hosp, Fukuyama, Hiroshima, Japan

[26] Pauls Stradins Clin Univ Hosp, Riga, Latvia

[27] Hosp Garcia Horta, Lisbon, Portugal

[28] Hosp Santa Maria, Lisbon, Portugal

[29] Hosp Prof Doutor Fernando Fonseca, Amadora, Portugal

[30] King Abdulaziz Med City Cardiac Ctr, Riyadh, Saudi Arabia

[31] Sunninghill Hosp, Johannesburg, Germany

[32] Seoul Natl Univ Hosp, Seoul, South Korea

[33] Keimyung Univ, Dongsan Med Ctr, Daegu, South Korea

[34] Univ Ulsan, Ulsan Univ Hosp, Coll Med, Ulsan, South Korea

[35] Inje Univ, Ilsan Paik Hosp, Goyang, Daehwa Dong, South Korea

[36] Hosp Clin Barcelona, Cardiovasc Inst, Inst Invest Biomed August Pi i Sunyer IDIBAPS, Barcelona, Spain

[37] Hosp Univ Torrejon, Madrid, Spain

[38] Univ Francisco Vitoria, Madrid, Spain

[39] Amphia Hosp, Amsterdam, Netherlands

[40] Acad Med Ctr, AMC Heart Ctr, Amsterdam, Netherlands

[41] Vrije Univ Amsterdam, Med Ctr, Amsterdam, Netherlands

[42] Istanbul Univ, Istanbul Fac Med, Istanbul, Turkey

[43] Royal Brompton Hosp, Florence, Italy

[44] Univ Florence, Florence, Italy

[45] Conquest Hosp, St Leonards On Sea, England

[46] Royal Devon & Exeter Hosp, Exeter, Devon, England

[47] Univ Exeter, Exeter, Devon, England

[48] Royal Bournemouth Gen Hosp, Bournemouth, Dorset, England

[49] Essex Cardiothorac Ctr, Basildon, England

[50] Anglia Ruskin Univ, Chelmsford, Essex, England

[51] Emory Univ, Atlanta, GA 30322 USA

[52] Colorado Heart & Vasc, Lakewood, CO USA

[53] Vet Affairs Long Beach Healthcare Syst, Long Beach, CA USA

[54] Washington Univ, Sch Med, St Louis, MO USA

[55] SUNY Stony Brook, Med Ctr, New York, NY USA

[56] Gifu Heart Ctr, Gifu, Japan

[57] Oxford Univ Hosp Fdn Trust, John Radcliffe Hosp, Oxford, England

[58] Duke Univ, Durham, NC USA

[59] Hosp Clin San Carlos, Madrid, Spain

[60] Univ Complutense Madrid, Madrid, Spain

关键词: coronary stenosis;    fractional flow reserve;    instantaneous wave-free ratio;   

DOI  :  10.1016/j.jacc.2018.10.070

来源: Elsevier

【 摘 要 】

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. (c) 2019 The Authors. Published by Elsevier on behalf of the American College of Cardiology Foundation. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

【 授权许可】

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