Physiology (FFR & IFR) is Essential in Daily Pratice

Martine GilardBrest University - France

Background

Functional assessment

FFR/ IFR

Invasive assessment of atherosclerotic coronary artery lesionMorphological assessment

IVUS

OCT

X-ray Angio

Coronary angiography and functional impact

Gould KL. JACC Cardiovasc Imaging: 2009;2:1009

A “significant“ coronary stenosis

Coronary angiography and functional impact

Tonino et al. N Engl J Med 2009;360:213-24

FAME Study

1329 lesions

Coronary angiography and functional impact

Rational

Revascularisation has improved survival in patients with moderate to severe ischemia. Whereas medical treatment resulted in better survival than revascularisation in patients with no or mild ischemia

In clinical practice

One or multivessel disease

Left main stenosis

Lesions of bifurcation

CABG stenosis

Acute Coronary Syndrome

Mono or MVDLM

stenosisLesions

bifurcationCABG

stenosisACS

DEFER

2007

FAME

2009

FAME II

2012

FFR

Pijls et al. J Am Coll Cardiol 2007;49:2105–11

Mono or MVDLM

stenosisLesions

bifurcationCABG

stenosisACS

CV death and AMI 5-year FU

Van Numen et al. Lancet 2017;386:1853-60

Mono or MVDLM

stenosisLesions

bifurcationCABG

stenosisACS

FAME: CV death and AMI 5-year FU

Mono or MVDLM

stenosisLesions

bifurcationCABG

stenosisACS

Instantaneous wave-free ratio (IFR)

75 %25 %Without adenosine

Davies et al N Engl J Med 2017;376:1824-34

Mono or MVDLM

stenosisLesions

bifurcationCABG

stenosisACS

DEFINE-FLAIR: 2 492 ptsPrimary end point: Death, MI, unplanned revascularisation

Götberg et al N Engl J Med 2017;376:1813-23

Mono or MVDLM

stenosisLesions

bifurcationCABG

stenosisACS

iFR SWEDEHEART: 2 037 ptsPrimary end point: Death, MI, unplanned revascularisation

Mono or MVDLM

stenosisLesions

bifurcationCABG

stenosisACS

However

FAME FLAIR SWED

1-year MACE (%) 13% 7% 6.7

FFR mean 0.71 0.83 0.82

%FFR≤0.8 63% 35% 29%

Multivessel CAD 100% 42% 35.7%

CCS class II-IV 74% 48% 64%

Prior MI 37% 30% 33.1%

Population Risk HIGH low low

Low risk population in IFR trials Large inferiority margin

Adjedj al. Circulation 2016; 133(5): 502-508.

Mono or MVDLM

stenosisLesions

bifurcationCABG

stenosisACS

However

FU too short

Death & AMI

iFR FFR RR (IC) p

DEFINE-FLAIR 53 (4.6%) 41 (3.5%) 1.39 (0.89-1.98) 0.16

SWEDEHEART 37 (3.7%) 29 (2.9%) 1.27 (0.79-2.05) 0.33

Overall 90 70 1.30 (0.96-1.76) 0.09

Berry C et al. Circulation 2017; 36:2389–2391.

Elgendy et al Clin. Cardiol.2014; 37: 371–380

Mono or MVDLM

stenosisLesions

bifurcationCABG

stenosisACS

Left Main and FFR

Koo et al., Euro Heart J 2008; 29:726-732

Mono or MVDLM

stenosisLesions

bifurcationCABG

stenosisACS

Side branch > 2 mm et > 50% stenosis

Only 26 lesionswith FFR> 0.75

Koo et al., Euro Heart J 2008; 29:726-732

Mono or MVDLM

stenosisLesions

bifurcationCABG

stenosisACS

Side branch > 2 mm et > 50% stenosis

Botman et al. Ann Thorac Surg 2007;83:2093–7

Mono or MVDLM

stenosisLesions

bifurcationCABG

stenosisACS

153 patients525 lesions

FFR of lesions and angiographic CABG patency at 1 year

Mono or MVDLM

stenosisLesions

bifurcationCABG

stenosisACS

Maximal coronary hyperaemia which may be less readily achieved in patients with ACS because of coronary microvascular dysfunction

Layland et al European Heart J 2015;36:100-11

350 patients6 UK centres

FAMOUS-NSTEMI

Layland et al European Heart J 2015;36:100-11

Mono or MVDLM

stenosisLesions

bifurcationCABG

stenosisACS

n=14

n=144

n=18

n=11

n=125

N=40

Pronostic value of FFR

Zhang et al Heart 2015;101:455-62

Global Death

Pronostic value of FFR

Zhang et al Heart 2015;101:455-62

AMI

Economic evaluation of FFR in FAME

Fearon et al Circulation 2010;122:2545-50

FFR améliore le pronostic et économise les ressources

Guidelines ESC

Guidelines on myocardial revascularization Eur Heart J 2014;35:2541-2619

Take Home Messages

We must avoid unnecessary treatment of lesionsthat are not haemodynamically relevant

FFR is the current standart of care for the functionalassessment of coronary lesion severity

FFR guided PCI, as compared with angiographyguidance, improves the outcomes