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Reclassification of Treatment Strategy With Instantaneous Wave-Free Ratio and Fractional Flow Reserve : A Substudy From the iFR-SWEDEHEART Trial

Andell, Pontus LU ; Berntorp, Karolina LU orcid ; Christiansen, Evald H. ; Gudmundsdottir, Ingibjörg J. ; Sandhall, Lennart ; Venetsanos, Dimitrios ; Erlinge, David LU orcid ; Fröbert, Ole ; Koul, Sasha LU and Reitan, Christian LU , et al. (2018) In JACC: Cardiovascular Interventions 11(20). p.2084-2094
Abstract

Objectives: The authors sought to compare reclassification of treatment strategy following instantaneous wave-free ratio (iFR) and fractional flow reserve (FFR). Background: iFR was noninferior to FFR in 2 large randomized controlled trials in guiding coronary revascularization. Reclassification of treatment strategy by FFR is well-studied, but similar reports on iFR are lacking. Methods: The iFR-SWEDEHEART (Instantaneous Wave-Free Ratio Versus Fractional Flow Reserve in Patients With Stable Angina Pectoris or Acute Coronary Syndrome Trial) study randomized 2,037 participants with stable angina or acute coronary syndrome to treatment guided by iFR or FFR. Interventionalists entered the preferred treatment (optimal medical therapy [OMT],... (More)

Objectives: The authors sought to compare reclassification of treatment strategy following instantaneous wave-free ratio (iFR) and fractional flow reserve (FFR). Background: iFR was noninferior to FFR in 2 large randomized controlled trials in guiding coronary revascularization. Reclassification of treatment strategy by FFR is well-studied, but similar reports on iFR are lacking. Methods: The iFR-SWEDEHEART (Instantaneous Wave-Free Ratio Versus Fractional Flow Reserve in Patients With Stable Angina Pectoris or Acute Coronary Syndrome Trial) study randomized 2,037 participants with stable angina or acute coronary syndrome to treatment guided by iFR or FFR. Interventionalists entered the preferred treatment (optimal medical therapy [OMT], percutaneous coronary intervention [PCI], or coronary artery bypass grafting [CABG]) on the basis of coronary angiograms, and the final treatment decision was mandated by the iFR/FFR measurements. Results: In the iFR/FFR (n = 1,009/n = 1,004) populations, angiogram-based treatment approaches were similar (p = 0.50) with respect to OMT (38%/35%), PCI of 1 (37%/39%), 2 (15%/16%), and 3 vessels (2%/2%) and CABG (8%/8%). iFR and FFR reclassified 40% and 41% of patients, respectively (p = 0.78). The majority of reclassifications were conversion of PCI to OMT in both the iFR/FFR groups (31.4%/29.0%). Reclassification increased with increasing number of lesions evaluated (odds ratio per evaluated lesion for FFR: 1.46 [95% confidence interval: 1.22 to 1.76] vs. iFR 1.37 [95% confidence interval: 1.18 to 1.59]). Reclassification rates for patients with 1, 2, and 3 assessed vessels were 36%, 52%, and 53% (p < 0.01). Conclusions: Reclassification of treatment strategy of intermediate lesions was common and occurred in 40% of patients with iFR or FFR. The most frequent reclassification was conversion from PCI to OMT regardless of physiology modality. Irrespective of the physiological index reclassification of angiogram-based treatment strategy increased with the number of lesions evaluated.

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organization
publishing date
type
Contribution to journal
publication status
published
subject
keywords
coronary artery bypass grafting, coronary artery disease, coronary physiology, FFR, iFR, percutaneous coronary intervention
in
JACC: Cardiovascular Interventions
volume
11
issue
20
pages
11 pages
publisher
Elsevier
external identifiers
  • pmid:30336812
  • scopus:85054316651
ISSN
1936-8798
DOI
10.1016/j.jcin.2018.07.035
project
Evaluation of a new method to determine the severity of a coronary artery stenosis in patients with stable angina and acute coronary syndrome
language
English
LU publication?
yes
id
040f93e9-5e22-498b-96bf-3596e1d13748
date added to LUP
2018-10-30 11:08:43
date last changed
2024-04-15 15:25:28
@article{040f93e9-5e22-498b-96bf-3596e1d13748,
  abstract     = {{<p>Objectives: The authors sought to compare reclassification of treatment strategy following instantaneous wave-free ratio (iFR) and fractional flow reserve (FFR). Background: iFR was noninferior to FFR in 2 large randomized controlled trials in guiding coronary revascularization. Reclassification of treatment strategy by FFR is well-studied, but similar reports on iFR are lacking. Methods: The iFR-SWEDEHEART (Instantaneous Wave-Free Ratio Versus Fractional Flow Reserve in Patients With Stable Angina Pectoris or Acute Coronary Syndrome Trial) study randomized 2,037 participants with stable angina or acute coronary syndrome to treatment guided by iFR or FFR. Interventionalists entered the preferred treatment (optimal medical therapy [OMT], percutaneous coronary intervention [PCI], or coronary artery bypass grafting [CABG]) on the basis of coronary angiograms, and the final treatment decision was mandated by the iFR/FFR measurements. Results: In the iFR/FFR (n = 1,009/n = 1,004) populations, angiogram-based treatment approaches were similar (p = 0.50) with respect to OMT (38%/35%), PCI of 1 (37%/39%), 2 (15%/16%), and 3 vessels (2%/2%) and CABG (8%/8%). iFR and FFR reclassified 40% and 41% of patients, respectively (p = 0.78). The majority of reclassifications were conversion of PCI to OMT in both the iFR/FFR groups (31.4%/29.0%). Reclassification increased with increasing number of lesions evaluated (odds ratio per evaluated lesion for FFR: 1.46 [95% confidence interval: 1.22 to 1.76] vs. iFR 1.37 [95% confidence interval: 1.18 to 1.59]). Reclassification rates for patients with 1, 2, and 3 assessed vessels were 36%, 52%, and 53% (p &lt; 0.01). Conclusions: Reclassification of treatment strategy of intermediate lesions was common and occurred in 40% of patients with iFR or FFR. The most frequent reclassification was conversion from PCI to OMT regardless of physiology modality. Irrespective of the physiological index reclassification of angiogram-based treatment strategy increased with the number of lesions evaluated.</p>}},
  author       = {{Andell, Pontus and Berntorp, Karolina and Christiansen, Evald H. and Gudmundsdottir, Ingibjörg J. and Sandhall, Lennart and Venetsanos, Dimitrios and Erlinge, David and Fröbert, Ole and Koul, Sasha and Reitan, Christian and Götberg, Matthias}},
  issn         = {{1936-8798}},
  keywords     = {{coronary artery bypass grafting; coronary artery disease; coronary physiology; FFR; iFR; percutaneous coronary intervention}},
  language     = {{eng}},
  number       = {{20}},
  pages        = {{2084--2094}},
  publisher    = {{Elsevier}},
  series       = {{JACC: Cardiovascular Interventions}},
  title        = {{Reclassification of Treatment Strategy With Instantaneous Wave-Free Ratio and Fractional Flow Reserve : A Substudy From the iFR-SWEDEHEART Trial}},
  url          = {{http://dx.doi.org/10.1016/j.jcin.2018.07.035}},
  doi          = {{10.1016/j.jcin.2018.07.035}},
  volume       = {{11}},
  year         = {{2018}},
}