Coronary Artery Disease
Outcomes of Coronary Stenoses Deferred Revascularization for Borderline Versus Nonborderline Fractional Flow Reserve Values

https://doi.org/10.1016/j.amjcard.2014.03.004Get rights and content

Current evidence supports deferral of revascularization for lesions with fractional flow reserve (FFR) values >0.80. The natural history after deferral of revascularization of lesions with borderline FFR values is unknown. This study evaluated the outcomes of patients after deferred revascularization of coronary stenoses based on a borderline FFR value. We retrospectively studied 720 patients with 881 intermediate-severity coronary stenoses who underwent FFR assessment from October 2002 to July 2010 and were deferred revascularization. Patients were divided into gray zone (0.75 to 0.80), borderline (0.81 to 0.85), and nonborderline (>0.85) FFR groups. Any subsequent percutaneous coronary intervention or coronary artery bypass grafting of a deferred stenosis during follow-up was classified as a deferred lesion intervention (DLI). Patient and/or lesion characteristics and clinical outcomes were compared between the FFR groups using univariate and propensity score–adjusted inverse probability of weighting Cox proportional hazards analyses. During a mean follow-up of 4.5 ± 2.1 years, 157 deferred lesions (18%) underwent DLI by percutaneous coronary intervention (n = 117) or coronary artery bypass grafting (n = 40). No statistically significant differences were observed in clinical outcomes between the gray zone and borderline FFR groups. Lesions with a borderline FFR were associated with a significantly higher risk of DLI compared with lesions with nonborderline FFR values (hazard ratio 1.63, 95% confidence interval 1.14 to 2.33, p = 0.007). Lesions deferred revascularization because of a borderline FFR (0.81 to 0.85) were associated with a higher risk of DLI compared with lesions with a nonborderline FFR (>0.85). Further study is needed to determine the optimal management of coronary stenoses with a borderline FFR value.

Section snippets

Methods

This study is a retrospective, single-center, observational study approved by the Institutional Review Board. All patients in the study provided informed written consent for the procedure(s). From October 2002 to July 2010, a total of 1,872 patients underwent FFR assessment. Of the 1,872 patients, 742 patients with 906 coronary stenoses were deferred revascularization based on FFR assessment. Of the 742 patients, we excluded 21 patients without any clinical follow-up after FFR assessment and

Results

As listed in Table 1, the gray zone (FFR 0.75 to 0.80) group had higher rates of smoking and chronic kidney disease compared with the borderline group (FFR 0.81 to 0.85). FFR assessment was performed during an acute coronary syndrome (ACS) in 1/2 of the patients; primarily for unstable angina (39%) and less often for AMI (12%), where 11% underwent FFR assessment during a non–ST elevation myocardial infarction and 1% had a nonculprit vessel assessed during an ST elevation myocardial infarction.

Discussion

The results of our study on the clinical outcomes of coronary stenoses deferred revascularization based on FFR assessment suggest that borderline FFR values (0.81 to 0.85) are associated with a significantly higher rate of DLI compared with nonborderline FFR values (>0.85). No differences were observed comparing clinical outcomes between the gray zone FFR (0.75 to 0.80) group and borderline FFR group. The differences in the rates of DLI between the borderline and nonborderline FFR groups were

Disclosures

Drs. Depta, Patel, Masrani, Raymer, Ms. Facey, Patel, and Kurz and Mr. Novak have no conflicts of interest to disclose; Dr. Zajarias is a Steering Committee member of Partner 2 trial; Dr. Lasala is on a Boston Scientific Advisory Board; Dr. Singh is a consultant for Abbott Vascular, Boston Scientific, and Volcano Corp. and is on the speakers' bureaus of or receives honoraria from The Medicines Company, Medtronic Vascular, Volcano Corp., and St. Jude Medical Corp.; and Dr. Bach receives research

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    This study was supported by Department of Medicine, Division of Medical Education, Mentors in Medicine grant from Washington University School of Medicine, St. Louis, Missouri.

    See page 1792 for disclosure information.

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