Clinical Events After Deferral of LAD Revascularization Following Physiological Coronary Assessment

Sayan Sen; Yousif Ahmad; Hakim-Moulay Dehbi; James P. Howard; Juan F. Iglesias; Rasha Al-Lamee; Ricardo Petraco; Sukhjinder Nijjer; Ravinay Bhindi; Sam Lehman; Darren Walters; James Sapontis; Luc Janssens; Christiaan J. Vrints; Ahmed Khashaba; Mika Laine; Eric Van Belle; Florian Krackhardt; Waldemar Bojara; Olaf Going; Tobias Härle; Ciro Indolfi; Giampaolo Niccoli; Flavio Ribichini; Nobuhiro Tanaka; Hiroyoshi Yokoi; Hiroaki Takashima; Yuetsu Kikuta; Andrejs Erglis; Hugo Vinhas; Pedro Canas Silva; Sérgio B. Baptista; Ali Alghamdi; Farrel Hellig; Bon Kwon Koo; Chang Wook Nam; Eun Seok Shin; Joon Hyung Doh; Salvatore Brugaletta; Eduardo Alegria-Barrero; Martijin Meuwissen; Jan J. Piek; Niels van Royen; Murat Sezer; Carlo Di Mario; Robert T. Gerber; Iqbal S. Malik; Andrew S.P. Sharp; Suneel Talwar; Kare Tang; Habib Samady; John Altman; Arnold H. Seto; Jasvindar Singh; Allen Jeremias; Hitoshi Matsuo; Rajesh K. Kharbanda; Manesh R. Patel; Patrick Serruys; Javier Escaned; Justin E. Davies

doi:10.1016/j.jacc.2018.10.070

Clinical Events After Deferral of LAD Revascularization Following Physiological Coronary Assessment

Sayan Sen, Yousif Ahmad, Hakim-Moulay Dehbi, James P. Howard, Juan F. Iglesias, Rasha Al-Lamee, Ricardo Petraco, Sukhjinder Nijjer, Ravinay Bhindi, Sam Lehman, Darren Walters, James Sapontis, Luc Janssens, Christiaan J. Vrints, Ahmed Khashaba, Mika Laine, Eric Van Belle, Florian Krackhardt, Waldemar Bojara, Olaf GoingTobias Härle, Ciro Indolfi, Giampaolo Niccoli, Flavio Ribichini, Nobuhiro Tanaka, Hiroyoshi Yokoi, Hiroaki Takashima, Yuetsu Kikuta, Andrejs Erglis, Hugo Vinhas, Pedro Canas Silva, Sérgio B. Baptista, Ali Alghamdi, Farrel Hellig, Bon Kwon Koo, Chang Wook Nam, Eun Seok Shin, Joon Hyung Doh, Salvatore Brugaletta, Eduardo Alegria-Barrero, Martijin Meuwissen, Jan J. Piek, Niels van Royen, Murat Sezer, Carlo Di Mario, Robert T. Gerber, Iqbal S. Malik, Andrew S.P. Sharp, Suneel Talwar, Kare Tang, Habib Samady, John Altman, Arnold H. Seto, Jasvindar Singh, Allen Jeremias, Hitoshi Matsuo, Rajesh K. Kharbanda, Manesh R. Patel, Patrick Serruys, Javier Escaned, Justin E. Davies

College of Medicine and Public Health

Research output: Contribution to journal › Article › peer-review

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Abstract

Background: Physicians are not always comfortable deferring treatment of a stenosis in the left anterior descending (LAD) artery because of the perception that there is a high risk of major adverse cardiac events (MACE). The authors describe, using the DEFINE-FLAIR (Functional Lesion Assessment of Intermediate Stenosis to Guide Revascularisation) trial, MACE rates when LAD lesions are deferred, guided by physiological assessment using fractional flow reserve (FFR) or the instantaneous wave-free ratio (iFR). Objectives: The purpose of this study was to establish the safety of deferring treatment in the LAD using FFR or iFR within the DEFINE-FLAIR trial. Methods: MACE rates at 1 year were compared between groups (iFR and FFR) in patients whose physiological assessment led to LAD lesions being deferred. MACE was defined as a composite of cardiovascular death, myocardial infarction (MI), and unplanned revascularization at 1 year. Patients, and staff performing follow-up, were blinded to whether the decision was made with FFR or iFR. Outcomes were adjusted for age and sex. Results: A total of 872 patients had lesions deferred in the LAD (421 guided by FFR, 451 guided by iFR). The event rate with iFR was significantly lower than with FFR (2.44% vs. 5.26%; adjusted HR: 0.46; 95% confidence interval [CI]: 0.22 to 0.95; p = 0.04). This was driven by significantly lower unplanned revascularization with iFR and numerically lower MI (unplanned revascularization: 2.22% iFR vs. 4.99% FFR; adjusted HR: 0.44; 95% CI: 0.21 to 0.93; p = 0.03; MI: 0.44% iFR vs. 2.14% FFR; adjusted HR: 0.23; 95% CI: 0.05 to 1.07; p = 0.06). Conclusions: iFR-guided deferral appears to be safe for patients with LAD lesions. Patients in whom iFR-guided deferral was performed had statistically significantly lower event rates than those with FFR-guided deferral.

Original language	English
Pages (from-to)	444-453
Number of pages	10
Journal	Journal of The American College of Cardiology
Volume	73
Issue number	4
DOIs	https://doi.org/10.1016/j.jacc.2018.10.070
Publication status	Published - 5 Feb 2019

Bibliographical note

OPEN ACCESS ARTICLE UNDER THE CC BY LICENSE (http://creativecommons.org/licenses/by/4.0/).

Keywords

coronary stenosis
fractional flow reserve
instantaneous wave-free ratio

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10.1016/j.jacc.2018.10.070Licence: CC BY

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Sen, S., Ahmad, Y., Dehbi, H.-M., Howard, J. P., Iglesias, J. F., Al-Lamee, R., Petraco, R., Nijjer, S., Bhindi, R., Lehman, S., Walters, D., Sapontis, J., Janssens, L., Vrints, C. J., Khashaba, A., Laine, M., Van Belle, E., Krackhardt, F., Bojara, W., ... Davies, J. E. (2019). Clinical Events After Deferral of LAD Revascularization Following Physiological Coronary Assessment. Journal of The American College of Cardiology, 73(4), 444-453. https://doi.org/10.1016/j.jacc.2018.10.070

@article{ed82a39bca424103aa80e0c3a9510fca,

title = "Clinical Events After Deferral of LAD Revascularization Following Physiological Coronary Assessment",

abstract = "Background: Physicians are not always comfortable deferring treatment of a stenosis in the left anterior descending (LAD) artery because of the perception that there is a high risk of major adverse cardiac events (MACE). The authors describe, using the DEFINE-FLAIR (Functional Lesion Assessment of Intermediate Stenosis to Guide Revascularisation) trial, MACE rates when LAD lesions are deferred, guided by physiological assessment using fractional flow reserve (FFR) or the instantaneous wave-free ratio (iFR). Objectives: The purpose of this study was to establish the safety of deferring treatment in the LAD using FFR or iFR within the DEFINE-FLAIR trial. Methods: MACE rates at 1 year were compared between groups (iFR and FFR) in patients whose physiological assessment led to LAD lesions being deferred. MACE was defined as a composite of cardiovascular death, myocardial infarction (MI), and unplanned revascularization at 1 year. Patients, and staff performing follow-up, were blinded to whether the decision was made with FFR or iFR. Outcomes were adjusted for age and sex. Results: A total of 872 patients had lesions deferred in the LAD (421 guided by FFR, 451 guided by iFR). The event rate with iFR was significantly lower than with FFR (2.44% vs. 5.26%; adjusted HR: 0.46; 95% confidence interval [CI]: 0.22 to 0.95; p = 0.04). This was driven by significantly lower unplanned revascularization with iFR and numerically lower MI (unplanned revascularization: 2.22% iFR vs. 4.99% FFR; adjusted HR: 0.44; 95% CI: 0.21 to 0.93; p = 0.03; MI: 0.44% iFR vs. 2.14% FFR; adjusted HR: 0.23; 95% CI: 0.05 to 1.07; p = 0.06). Conclusions: iFR-guided deferral appears to be safe for patients with LAD lesions. Patients in whom iFR-guided deferral was performed had statistically significantly lower event rates than those with FFR-guided deferral.",

keywords = "coronary stenosis, fractional flow reserve, instantaneous wave-free ratio",

author = "Sayan Sen and Yousif Ahmad and Hakim-Moulay Dehbi and Howard, {James P.} and Iglesias, {Juan F.} and Rasha Al-Lamee and Ricardo Petraco and Sukhjinder Nijjer and Ravinay Bhindi and Sam Lehman and Darren Walters and James Sapontis and Luc Janssens and Vrints, {Christiaan J.} and Ahmed Khashaba and Mika Laine and {Van Belle}, Eric and Florian Krackhardt and Waldemar Bojara and Olaf Going and Tobias H{\"a}rle and Ciro Indolfi and Giampaolo Niccoli and Flavio Ribichini and Nobuhiro Tanaka and Hiroyoshi Yokoi and Hiroaki Takashima and Yuetsu Kikuta and Andrejs Erglis and Hugo Vinhas and Silva, {Pedro Canas} and Baptista, {S{\'e}rgio B.} and Ali Alghamdi and Farrel Hellig and Koo, {Bon Kwon} and Nam, {Chang Wook} and Shin, {Eun Seok} and Doh, {Joon Hyung} and Salvatore Brugaletta and Eduardo Alegria-Barrero and Martijin Meuwissen and Piek, {Jan J.} and {van Royen}, Niels and Murat Sezer and {Di Mario}, Carlo and Gerber, {Robert T.} and Malik, {Iqbal S.} and Sharp, {Andrew S.P.} and Suneel Talwar and Kare Tang and Habib Samady and John Altman and Seto, {Arnold H.} and Jasvindar Singh and Allen Jeremias and Hitoshi Matsuo and Kharbanda, {Rajesh K.} and Patel, {Manesh R.} and Patrick Serruys and Javier Escaned and Davies, {Justin E.}",

note = "OPEN ACCESS ARTICLE UNDER THE CC BY LICENSE (http://creativecommons.org/licenses/by/4.0/).",

year = "2019",

month = feb,

day = "5",

doi = "10.1016/j.jacc.2018.10.070",

language = "English",

volume = "73",

pages = "444--453",

journal = "Journal of The American College of Cardiology",

issn = "0735-1097",

publisher = "Elsevier",

number = "4",

}

Sen, S, Ahmad, Y, Dehbi, H-M, Howard, JP, Iglesias, JF, Al-Lamee, R, Petraco, R, Nijjer, S, Bhindi, R, Lehman, S, Walters, D, Sapontis, J, Janssens, L, Vrints, CJ, Khashaba, A, Laine, M, Van Belle, E, Krackhardt, F, Bojara, W, Going, O, Härle, T, Indolfi, C, Niccoli, G, Ribichini, F, Tanaka, N, Yokoi, H, Takashima, H, Kikuta, Y, Erglis, A, Vinhas, H, Silva, PC, Baptista, SB, Alghamdi, A, Hellig, F, Koo, BK, Nam, CW, Shin, ES, Doh, JH, Brugaletta, S, Alegria-Barrero, E, Meuwissen, M, Piek, JJ, van Royen, N, Sezer, M, Di Mario, C, Gerber, RT, Malik, IS, Sharp, ASP, Talwar, S, Tang, K, Samady, H, Altman, J, Seto, AH, Singh, J, Jeremias, A, Matsuo, H, Kharbanda, RK, Patel, MR, Serruys, P, Escaned, J & Davies, JE 2019, 'Clinical Events After Deferral of LAD Revascularization Following Physiological Coronary Assessment', Journal of The American College of Cardiology, vol. 73, no. 4, pp. 444-453. https://doi.org/10.1016/j.jacc.2018.10.070

TY - JOUR

T1 - Clinical Events After Deferral of LAD Revascularization Following Physiological Coronary Assessment

AU - Sen, Sayan

AU - Ahmad, Yousif

AU - Dehbi, Hakim-Moulay

AU - Howard, James P.

AU - Iglesias, Juan F.

AU - Al-Lamee, Rasha

AU - Petraco, Ricardo

AU - Nijjer, Sukhjinder

AU - Bhindi, Ravinay

AU - Lehman, Sam

AU - Walters, Darren

AU - Sapontis, James

AU - Janssens, Luc

AU - Vrints, Christiaan J.

AU - Khashaba, Ahmed

AU - Laine, Mika

AU - Van Belle, Eric

AU - Krackhardt, Florian

AU - Bojara, Waldemar

AU - Going, Olaf

AU - Härle, Tobias

AU - Indolfi, Ciro

AU - Niccoli, Giampaolo

AU - Ribichini, Flavio

AU - Tanaka, Nobuhiro

AU - Yokoi, Hiroyoshi

AU - Takashima, Hiroaki

AU - Kikuta, Yuetsu

AU - Erglis, Andrejs

AU - Vinhas, Hugo

AU - Silva, Pedro Canas

AU - Baptista, Sérgio B.

AU - Alghamdi, Ali

AU - Hellig, Farrel

AU - Koo, Bon Kwon

AU - Nam, Chang Wook

AU - Shin, Eun Seok

AU - Doh, Joon Hyung

AU - Brugaletta, Salvatore

AU - Alegria-Barrero, Eduardo

AU - Meuwissen, Martijin

AU - Piek, Jan J.

AU - van Royen, Niels

AU - Sezer, Murat

AU - Di Mario, Carlo

AU - Gerber, Robert T.

AU - Malik, Iqbal S.

AU - Sharp, Andrew S.P.

AU - Talwar, Suneel

AU - Tang, Kare

AU - Samady, Habib

AU - Altman, John

AU - Seto, Arnold H.

AU - Singh, Jasvindar

AU - Jeremias, Allen

AU - Matsuo, Hitoshi

AU - Kharbanda, Rajesh K.

AU - Patel, Manesh R.

AU - Serruys, Patrick

AU - Escaned, Javier

AU - Davies, Justin E.

N1 - OPEN ACCESS ARTICLE UNDER THE CC BY LICENSE (http://creativecommons.org/licenses/by/4.0/).

PY - 2019/2/5

Y1 - 2019/2/5

N2 - Background: Physicians are not always comfortable deferring treatment of a stenosis in the left anterior descending (LAD) artery because of the perception that there is a high risk of major adverse cardiac events (MACE). The authors describe, using the DEFINE-FLAIR (Functional Lesion Assessment of Intermediate Stenosis to Guide Revascularisation) trial, MACE rates when LAD lesions are deferred, guided by physiological assessment using fractional flow reserve (FFR) or the instantaneous wave-free ratio (iFR). Objectives: The purpose of this study was to establish the safety of deferring treatment in the LAD using FFR or iFR within the DEFINE-FLAIR trial. Methods: MACE rates at 1 year were compared between groups (iFR and FFR) in patients whose physiological assessment led to LAD lesions being deferred. MACE was defined as a composite of cardiovascular death, myocardial infarction (MI), and unplanned revascularization at 1 year. Patients, and staff performing follow-up, were blinded to whether the decision was made with FFR or iFR. Outcomes were adjusted for age and sex. Results: A total of 872 patients had lesions deferred in the LAD (421 guided by FFR, 451 guided by iFR). The event rate with iFR was significantly lower than with FFR (2.44% vs. 5.26%; adjusted HR: 0.46; 95% confidence interval [CI]: 0.22 to 0.95; p = 0.04). This was driven by significantly lower unplanned revascularization with iFR and numerically lower MI (unplanned revascularization: 2.22% iFR vs. 4.99% FFR; adjusted HR: 0.44; 95% CI: 0.21 to 0.93; p = 0.03; MI: 0.44% iFR vs. 2.14% FFR; adjusted HR: 0.23; 95% CI: 0.05 to 1.07; p = 0.06). Conclusions: iFR-guided deferral appears to be safe for patients with LAD lesions. Patients in whom iFR-guided deferral was performed had statistically significantly lower event rates than those with FFR-guided deferral.

AB - Background: Physicians are not always comfortable deferring treatment of a stenosis in the left anterior descending (LAD) artery because of the perception that there is a high risk of major adverse cardiac events (MACE). The authors describe, using the DEFINE-FLAIR (Functional Lesion Assessment of Intermediate Stenosis to Guide Revascularisation) trial, MACE rates when LAD lesions are deferred, guided by physiological assessment using fractional flow reserve (FFR) or the instantaneous wave-free ratio (iFR). Objectives: The purpose of this study was to establish the safety of deferring treatment in the LAD using FFR or iFR within the DEFINE-FLAIR trial. Methods: MACE rates at 1 year were compared between groups (iFR and FFR) in patients whose physiological assessment led to LAD lesions being deferred. MACE was defined as a composite of cardiovascular death, myocardial infarction (MI), and unplanned revascularization at 1 year. Patients, and staff performing follow-up, were blinded to whether the decision was made with FFR or iFR. Outcomes were adjusted for age and sex. Results: A total of 872 patients had lesions deferred in the LAD (421 guided by FFR, 451 guided by iFR). The event rate with iFR was significantly lower than with FFR (2.44% vs. 5.26%; adjusted HR: 0.46; 95% confidence interval [CI]: 0.22 to 0.95; p = 0.04). This was driven by significantly lower unplanned revascularization with iFR and numerically lower MI (unplanned revascularization: 2.22% iFR vs. 4.99% FFR; adjusted HR: 0.44; 95% CI: 0.21 to 0.93; p = 0.03; MI: 0.44% iFR vs. 2.14% FFR; adjusted HR: 0.23; 95% CI: 0.05 to 1.07; p = 0.06). Conclusions: iFR-guided deferral appears to be safe for patients with LAD lesions. Patients in whom iFR-guided deferral was performed had statistically significantly lower event rates than those with FFR-guided deferral.

KW - coronary stenosis

KW - fractional flow reserve

KW - instantaneous wave-free ratio

UR - http://www.scopus.com/inward/record.url?scp=85060291589&partnerID=8YFLogxK

U2 - 10.1016/j.jacc.2018.10.070

DO - 10.1016/j.jacc.2018.10.070

M3 - Article

C2 - 30704577

AN - SCOPUS:85060291589

SN - 0735-1097

VL - 73

SP - 444

EP - 453

JO - Journal of The American College of Cardiology

JF - Journal of The American College of Cardiology

IS - 4

ER -

Clinical Events After Deferral of LAD Revascularization Following Physiological Coronary Assessment

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