Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
Division of Cardiovascular Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA.
JACC Cardiovasc Interv. 2022 May 23;15(10):1033-1043. doi: 10.1016/j.jcin.2022.01.297. Epub 2022 Apr 27.
The authors sought to evaluate comparative prognosis between deferred versus performed percutaneous coronary intervention (PCI) according to coronary flow reserve (CFR) values of patients with intermediate fractional flow reserve (FFR).
For coronary stenosis with intermediate FFR, the prognostic value of PCI remains controversial. The prognostic impact of PCI may be different according to CFR in patients with intermediate FFR.
From the ILIAS Registry (Inclusive Invasive Physiological Assessment in Angina Syndromes Registry, N = 2,322), 400 patients (412 vessels) with intermediate FFR (0.75-0.80) were selected. Patients were stratified into preserved CFR (>2.0, n = 253) and depressed CFR (≤2.0, n = 147) cohorts. Per-vessel clinical outcomes during 5 years of follow-up were compared between deferred versus performed PCI groups in both cohorts. The primary outcome was target vessel failure (TVF), a composite of cardiac death, target vessel myocardial infarction, or target vessel revascularization.
Among the study population, PCI was deferred for 210 patients (219 vessels, 53.2%) (deferred group) and performed for 190 patients (193 vessels, 46.8%) (performed group). The risk of TVF was comparable between the deferred and performed groups (12.8% vs 14.2%; adjusted HR: 1.403; 95% CI: 0.584-3.369; P = 0.448). When stratified by CFR, PCI was performed in 39.1% (100/261 vessels) of the preserved CFR cohort and 61.9% (93/151 vessels) of the depressed CFR cohort. Within the preserved CFR cohort, the risk of TVF did not differ significantly between the deferred and performed groups (11.0% vs 13.9%; adjusted HR: 0.770; 95% CI: 0.262-2.266; P = 0.635). However, in the depressed CFR cohort, the deferred group had a significantly higher risk of TVF than the performed group (17.2% vs 14.2%; adjusted HR: 4.932; 95% CI: 1.312-18.53; P = 0.018). A significant interaction was observed between CFR and the treatment decision (interaction P = 0.049). Results were consistent after inverse probability weighting adjustment.
In patients with intermediate FFR of 0.75 to 0.80, the prognostic value of PCI differed according to CFR, with a significant interaction. PCI was associated with a lower risk of TVF compared with the deferral strategy when CFR was depressed (≤2.0), but there was no difference when CFR was preserved (>2.0). CFR could be used as an additional risk stratification tool to determine treatment strategies in patients with intermediate FFR. (Inclusive Invasive Physiological Assessment in Angina Syndromes Registry [ILIAS Registry]; NCT04485234).
作者旨在评估根据有中间型血流储备分数（FFR）患者的冠状动脉血流储备（CFR）值，延迟与即刻行经皮冠状动脉介入治疗（PCI）之间的预后比较。
对于中间型 FFR 的冠状动脉狭窄，PCI 的预后价值仍存在争议。对于中间型 FFR 的患者，PCI 的预后影响可能因 CFR 而不同。
来自 ILIAS 注册研究（包括心绞痛综合征的有创生理评估研究，N=2322），纳入 400 例中间型 FFR（0.75-0.80）患者（412 支血管）。患者被分为保留型 CFR（>2.0，n=253）和降低型 CFR（≤2.0，n=147）两组。比较两组患者在 5 年随访期间每支血管的临床预后。主要终点是靶血管失败（TVF），包括心脏死亡、靶血管心肌梗死或靶血管血运重建的复合终点。
在研究人群中，210 例患者（219 支血管，53.2%）（延迟组）行 PCI 治疗，190 例患者（193 支血管，46.8%）（即刻组）行 PCI 治疗。延迟组和即刻组的 TVF 风险无显著差异（12.8% vs 14.2%；调整后的 HR：1.403；95%CI：0.584-3.369；P=0.448）。按 CFR 分层，在保留型 CFR 组中，93 例（61.9%）行 PCI，在降低型 CFR 组中，100 例（39.1%）行 PCI。在保留型 CFR 组中，延迟组和即刻组的 TVF 风险无显著差异（11.0% vs 13.9%；调整后的 HR：0.770；95%CI：0.262-2.266；P=0.635）。然而，在降低型 CFR 组中，延迟组的 TVF 风险显著高于即刻组（17.2% vs 14.2%；调整后的 HR：4.932；95%CI：1.312-18.53；P=0.018）。CFR 与治疗决策之间存在显著的交互作用（交互 P=0.049）。在逆概率加权调整后，结果保持一致。
在中间型 FFR 为 0.75 至 0.80 的患者中，PCI 的预后价值因 CFR 而异，且存在显著的交互作用。与延迟策略相比，当 CFR 降低（≤2.0）时，PCI 与 TVF 风险降低相关，但当 CFR 保留（>2.0）时，两者无差异。CFR 可作为一种额外的风险分层工具，以确定中间型 FFR 患者的治疗策略。（包括心绞痛综合征的有创生理评估研究 [ILIAS 注册研究]；NCT04485234）。
