Using Post-PCI FFR Assessment to Improve Final FFR Values

A fractional flow reserve (FFR)-guided optimization strategy due to suboptimal results following angiography-guided percutaneous coronary intervention (PCI) reduced the proportion of patients with suboptimal results, according to study findings published in the European Heart Journal.

The Trial of Angiography vs pressure-Ratio-Guided Enhancement Techniques – Fractional Flow Reserve (TARGET-FFR) (ClinicalTrials.gov Identifier: NCT03259815) was a prospective, single-center, randomized controlled study conducted at the Golden Jubilee National Hospital in the United Kingdom between 2018 and 2019. Patients (N=260) undergoing PCI were randomly assigned 1:1 to receive physiology-guided incremental optimization strategy (PIOS; n=131) or a coronary physiology assessment (n=129). For the PIOS intervention, patients with suboptimal results were assessed for FFR, and the operators planned additional intervention. The primary endpoint was final post-PCI FFR greater than or equal to 0.90. Secondary endpoints included patients with final FFR less than or equal to 0.80.

The patient population was 86.9% men with a mean age of 59±12 years; body mass index (BMI) was 29.1±5.7; 56.2% had hypercholesterolemia; 44.6% hypertension; 38.5% a previous PCI; and 24.2% heart failure. Baseline characteristics were well balanced between cohorts, except that more of the control group were on oral nitrates (P =.01).

Initial post-PCI FFR was 0.83±0.09 in the intervention and 0.85±0.09 in the control cohort (P =.26).

A total of 30.5% randomly assigned to the PIOS treatment underwent further investigation. Among the optimization strategy recipients, the target vessel was the left anterior descending artery for 85%.

Among the PIOS cohort, the proportion of patients who had an initial post-PCI FFR less than or equal to 0.80 was 29.1% and improved to 18.6% with additional FFR-guided optimization. Similarly, the proportion of vessels with initial post-PCI FFR greater than or equal to 0.90 was 35.9% increasing to 38.1% with additional PCI.

At a 3-month follow-up, patients who had low, intermediate, and high changes in FFR differed significantly for angina frequency (P <.001), Seattle Angina Questionnaire summary (P =.01), and physical limitation (P =.02) scores, in which greater FFR change associated with higher scores.

At a median follow-up of 2 years, there was 1 target vessel failure, and the patient suffered a presumed cardiac death. This patient had been randomly assigned to the PIOS treatment but did not receive optimization.

This study may have been limited by not assessing FFR prior to PCI, which could have influenced stenting decisions.

“TARGET-FFR provides the first randomized data on the incidence of physiologically suboptimal results following standard-of-care PCI and confirms the feasibility of routine post-PCI FFR assessment,” the study authors said. “It found that persistently abnormal post-PCI FFR values are common and that a strategy of routine post-PCI physiology guidance can safely and effectively improve the final FFR values in a significant number of the worst-affected patients.”

Disclosure: Multiple authors declared affiliations with industry. Please refer to the original article for a full list of disclosures.

Reference

Collison D, Didagelos M, Aetesam-ur-Rahman M, et al. Post-stenting fractional flow reserve vs coronary angiography for optimization of percutaneous coronary intervention (TARGET-FFR). Eur Heart J. 2021;ehab449. doi:10.1093/eurheartj/ehab449