National Heart and Lung Institute, Imperial College London, London, United Kingdom; Department of Cardiovascular Medicine, St. Marianna University School of Medicine Yokohama City Seibu Hospital, Yokohama, Japan.
National Heart and Lung Institute, Imperial College London, London, United Kingdom; Cardiovascular Science, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom.
JACC Cardiovasc Interv. 2020 Jul 27;13(14):1655-1664. doi: 10.1016/j.jcin.2020.02.035. Epub 2020 May 13.
The aim of this study was to assess the long-term clinical outcomes of patients with left main coronary artery (LM) stenosis in whom treatment strategy was based on the instantaneous wave-free ratio (iFR).
The overall safety of iFR to guide revascularization decision making in patients with stable coronary artery disease has been established. However, no study has examined the safety of deferral of revascularization of LM disease on the basis of iFR.
This multicenter observational study included 314 patients in whom LM stenosis was deferred (n = 163 [51.9%]) or revascularized (n = 151 [48.1%]) according to the iFR cutoff ≤0.89. The primary endpoint was a composite of all-cause death, nonfatal myocardial infarction, and ischemia-driven target lesion revascularization. The secondary endpoints were each individual component of the primary endpoint and also cardiac death.
At a median follow-up period of 30 months, the primary endpoint occurred in 15 patients (9.2%) in the deferred group and 22 patients (14.6%) in the revascularized group (hazard ratio: 1.45; 95% confidence interval: 0.75 to 2.81; p = 0.26), indicating no evidence of a significant difference between the 2 groups. For the secondary endpoints, findings in the iFR-based deferral and revascularization groups were as follows: all-cause death, 3.7% versus 4.6%; cardiac death, 1.2% versus 2.0%; nonfatal myocardial infarction, 2.5% versus 5.3%; and target lesion revascularization, 4.3% versus 5.3% (p > 0.05 for all).
Deferral of revascularization of LM stenosis on the basis of iFR appears to be safe, with similar long-term outcomes to those in patients in whom LM revascularization was performed according to iFR values.
本研究旨在评估以瞬时无波比（iFR）为指导的左主干（LM）狭窄患者的长期临床结局。
iFR 指导稳定型冠状动脉疾病患者血运重建决策的总体安全性已得到确立。然而，尚无研究探讨基于 iFR 延迟 LM 病变血运重建的安全性。
这项多中心观察性研究纳入了 314 例 LM 狭窄患者，根据 iFR 截断值≤0.89 对其进行 LM 狭窄延迟（n=163 [51.9%]）或血运重建（n=151 [48.1%]）。主要终点为全因死亡、非致死性心肌梗死和缺血驱动的靶病变血运重建的复合终点。次要终点为主要终点的每个单独组成部分以及心脏死亡。
在中位随访 30 个月期间，延迟组有 15 例患者（9.2%）和血运重建组有 22 例患者（14.6%）发生主要终点事件（风险比：1.45；95%置信区间：0.75 至 2.81；p=0.26），表明两组之间没有显著差异的证据。对于次要终点，iFR 指导下延迟和血运重建组的结果如下：全因死亡，3.7%比 4.6%；心脏死亡，1.2%比 2.0%；非致死性心肌梗死，2.5%比 5.3%；靶病变血运重建，4.3%比 5.3%（所有 p 值均＞0.05）。
基于 iFR 延迟 LM 狭窄血运重建似乎是安全的，与根据 iFR 值进行 LM 血运重建的患者具有相似的长期结局。
