Angiography-Based Fractional Flow Reserve: State of the Art

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Abstract

Purpose of Review

Three-dimensional quantitative coronary angiography-based methods of fractional flow reserve (FFR) derivation have emerged as an appealing alternative to conventional pressure-wire-based physiological lesion assessment and have the potential to further extend the use of physiology in general. Here, we summarize the current evidence related to angiography-based FFR and perspectives on future developments.

Recent Findings

Growing evidence suggests good diagnostic performance of angiography-based FFR measurements, both in chronic and acute coronary syndromes, as well as in specific lesion subsets, such as long and calcified lesions, left main coronary stenosis, and bifurcations. More recently, promising results on the superiority of angiography-based FFR as compared to angiography-guided PCI have been published.

Summary

Currently available angiography -FFR indices proved to be an excellent alternative to invasive pressure wire-based FFR. Dedicated prospective outcome data comparing these indices to routine guideline recommended PCI including the use of FFR are eagerly awaited.

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Most cited references 75

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2018 ESC/EACTS Guidelines on myocardial revascularization

Terje Steigen, Sjoerd Hofma, Robert Xuereb … (2018)

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Fractional flow reserve versus angiography for guiding percutaneous coronary intervention.

Pim A.L. Tonino, Bernard De Bruyne, Nico H.J. Pijls … (2009)

In patients with multivessel coronary artery disease who are undergoing percutaneous coronary intervention (PCI), coronary angiography is the standard method for guiding the placement of the stent. It is unclear whether routine measurement of fractional flow reserve (FFR; the ratio of maximal blood flow in a stenotic artery to normal maximal flow), in addition to angiography, improves outcomes. In 20 medical centers in the United States and Europe, we randomly assigned 1005 patients with multivessel coronary artery disease to undergo PCI with implantation of drug-eluting stents guided by angiography alone or guided by FFR measurements in addition to angiography. Before randomization, lesions requiring PCI were identified on the basis of their angiographic appearance. Patients assigned to angiography-guided PCI underwent stenting of all indicated lesions, whereas those assigned to FFR-guided PCI underwent stenting of indicated lesions only if the FFR was 0.80 or less. The primary end point was the rate of death, nonfatal myocardial infarction, and repeat revascularization at 1 year. The mean (+/-SD) number of indicated lesions per patient was 2.7+/-0.9 in the angiography group and 2.8+/-1.0 in the FFR group (P=0.34). The number of stents used per patient was 2.7+/-1.2 and 1.9+/-1.3, respectively (P<0.001). The 1-year event rate was 18.3% (91 patients) in the angiography group and 13.2% (67 patients) in the FFR group (P=0.02). Seventy-eight percent of the patients in the angiography group were free from angina at 1 year, as compared with 81% of patients in the FFR group (P=0.20). Routine measurement of FFR in patients with multivessel coronary artery disease who are undergoing PCI with drug-eluting stents significantly reduces the rate of the composite end point of death, nonfatal myocardial infarction, and repeat revascularization at 1 year. (ClinicalTrials.gov number, NCT00267774.) 2009 Massachusetts Medical Society

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Fractional Flow Reserve–Guided PCI versus Medical Therapy in Stable Coronary Disease

Bernard De Bruyne, Nico H.J. Pijls, Bindu Kalesan … (2012)

The preferred initial treatment for patients with stable coronary artery disease is the best available medical therapy. We hypothesized that in patients with functionally significant stenoses, as determined by measurement of fractional flow reserve (FFR), percutaneous coronary intervention (PCI) plus the best available medical therapy would be superior to the best available medical therapy alone. In patients with stable coronary artery disease for whom PCI was being considered, we assessed all stenoses by measuring FFR. Patients in whom at least one stenosis was functionally significant (FFR, ≤0.80) were randomly assigned to FFR-guided PCI plus the best available medical therapy (PCI group) or the best available medical therapy alone (medical-therapy group). Patients in whom all stenoses had an FFR of more than 0.80 were entered into a registry and received the best available medical therapy. The primary end point was a composite of death, myocardial infarction, or urgent revascularization. Recruitment was halted prematurely after enrollment of 1220 patients (888 who underwent randomization and 332 enrolled in the registry) because of a significant between-group difference in the percentage of patients who had a primary end-point event: 4.3% in the PCI group and 12.7% in the medical-therapy group (hazard ratio with PCI, 0.32; 95% confidence interval [CI], 0.19 to 0.53; P<0.001). The difference was driven by a lower rate of urgent revascularization in the PCI group than in the medical-therapy group (1.6% vs. 11.1%; hazard ratio, 0.13; 95% CI, 0.06 to 0.30; P<0.001); in particular, in the PCI group, fewer urgent revascularizations were triggered by a myocardial infarction or evidence of ischemia on electrocardiography (hazard ratio, 0.13; 95% CI, 0.04 to 0.43; P<0.001). Among patients in the registry, 3.0% had a primary end-point event. In patients with stable coronary artery disease and functionally significant stenoses, FFR-guided PCI plus the best available medical therapy, as compared with the best available medical therapy alone, decreased the need for urgent revascularization. In patients without ischemia, the outcome appeared to be favorable with the best available medical therapy alone. (Funded by St. Jude Medical; ClinicalTrials.gov number, NCT01132495.).

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Author and article information

Contributors

Joost Daemen:

ORCID: http://orcid.org/0000-0001-8628-1410

j.daemen@erasmusmc.nl

Journal

Journal ID (nlm-ta): Curr Cardiol Rep

Journal ID (iso-abbrev): Curr Cardiol Rep

Title: Current Cardiology Reports

Publisher: Springer US (New York )

ISSN (Print): 1523-3782

ISSN (Electronic): 1534-3170

Publication date (Electronic): 18 April 2022

Publication date PMC-release: 18 April 2022

Publication date (Print): 2022

Volume: 24

Issue: 6

Pages: 667-678

Affiliations

[1 ]GRID grid.5645.2, ISNI 000000040459992X, Department of Cardiology, , Thoraxcenter, Erasmus University Medical Center, ; room Rg-628, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands

[2 ]GRID grid.13339.3b, ISNI 0000000113287408, First Department of Cardiology, , Medical University of Warsaw, ; Warsaw, Poland

Author information

Joost Daemen http://orcid.org/0000-0001-8628-1410

Article

Publisher ID: 1687

DOI: 10.1007/s11886-022-01687-4

PMC ID: 9188492

PubMed ID: 35435570

SO-VID: 3932bbfc-6566-44aa-a39c-ba4757696f86

License:

Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

History

Date accepted : 18 March 2022

Custom metadata

ScienceOpen disciplines: Cardiovascular Medicine

Keywords: angiography-based ffr,percutaneous coronary intervention,functional lesion assessment,quantitative flow ratio,vessel ffr,ffrangio

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ScienceOpen disciplines: Cardiovascular Medicine

Keywords: angiography-based ffr, percutaneous coronary intervention, functional lesion assessment, quantitative flow ratio, vessel ffr, ffrangio

Angiography-Based Fractional Flow Reserve: State of the Art

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Abstract

Purpose of Review

Recent Findings

Summary

Related collections

Cardiovascular Innovations and Applications

Most cited references 75

2018 ESC/EACTS Guidelines on myocardial revascularization

Fractional flow reserve versus angiography for guiding percutaneous coronary intervention.

Fractional Flow Reserve–Guided PCI versus Medical Therapy in Stable Coronary Disease

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