Department of Interventional Cardiology, Royal Papworth Hospital, Cambridge, UK.
Eastern Heart Clinic, Prince of Wales Hospital, Sydney, Australia.
Open Heart. 2019 Jan 13;6(1):e000934. doi: 10.1136/openhrt-2018-000934. eCollection 2019.
The utility of fractional flow reserve (FFR) to guide revascularisation in the management of acute coronary syndrome (ACS) remains unclear.
This study aims to compare the clinical outcomes of patients following FFR-guided revascularisation for either ACS or stable angina (SA) and in particular focuses on the outcome of those with deferred revascularisation after FFR.
A meta-analysis of existing literature was performed. Outcomes including the rate of major adverse cardiovascular events (MACE), recurrent myocardial infarction (MI), mortality and unplanned revascularisation were analysed.
A review of 937 records yielded 9 studies comparing 5457 patients, which were included in the analyses. Patients with ACS had a higher rate of recurrent MI (OR 1.81, p=0.02) and a strong trend towards more MACE and all-cause mortality compared with patients with SA when treated by an FFR-guided revascularisation strategy. Deferral of invasive therapy on the basis of FFR led to a higher rate of MACE (17.6% vs 7.3 %; p=0.004), recurrent MI (5.3% vs 1.5%, p=0.001) and target vessel revascularisation (16.4% vs 5.6 %; p=0.02) in patients with ACS, and a strong trend towards a higher cardiovascular mortality at follow-up when compared with patients with SA.
The event rate in patients with ACS is much higher than SA despite following an FFR-guided revascularisation strategy. Deferring revascularisation does not appear to be as safe for ACS as it is for SA using contemporary FFR cut-offs validated in SA. Refinement of the therapeutic strategy for patients with ACS with multivessel disease is needed to redress the balance.
在急性冠状动脉综合征（ACS）的管理中，分数血流储备（FFR）指导血运重建的效用尚不清楚。
本研究旨在比较 FFR 指导血运重建治疗 ACS 或稳定性心绞痛（SA）患者的临床结局，特别是关注 FFR 后延迟血运重建患者的结局。
对现有文献进行荟萃分析。分析的结局包括主要不良心血管事件（MACE）、复发性心肌梗死（MI）、死亡率和计划外血运重建的发生率。
对 937 份记录进行了审查，得到了 9 项比较 5457 例患者的研究，这些研究被纳入分析。与 SA 患者相比，ACS 患者接受 FFR 指导的血运重建策略治疗时，复发性 MI 的发生率更高（OR 1.81，p=0.02），且 MACE 和全因死亡率有更高的趋势。基于 FFR 延迟侵入性治疗导致 ACS 患者的 MACE 发生率更高（17.6%比 7.3%；p=0.004）、复发性 MI 发生率更高（5.3%比 1.5%；p=0.001）和靶血管血运重建发生率更高（16.4%比 5.6%；p=0.02），随访时心血管死亡率也有更高的趋势。
尽管采用了 FFR 指导的血运重建策略，但 ACS 患者的事件发生率仍远高于 SA。对于 ACS 患者来说，延迟血运重建似乎不像在 SA 中使用经过验证的现代 FFR 切点那样安全。需要改进多血管疾病 ACS 患者的治疗策略，以纠正这种不平衡。
