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• WHEN THE RECOMMENDATION OF THE GUIDELINES ABOUT FRACTIONAL FLOW RESERVE WILL BE FOLLOWED?
  Inigo Lozano
  Published on: 23 November 2015
• The role of FFR in clinical practice
  Marco Araco
  Published on: 23 November 2015

• Published on: 23 November 2015

  WHEN THE RECOMMENDATION OF THE GUIDELINES ABOUT FRACTIONAL FLOW RESERVE WILL BE FOLLOWED?

  • Inigo Lozano, Interventional Cardiology
  • Other Contributors:
    • Ramon Lopez-Palop

  We have read with great interest the article written by Zhang et al[1] and we want to congratulate the authors on his contribution in this relevant issue. Since the first publication in 1995 by Pijls et al, fractional flow reserve has constantly progressed with undoubted success. After initially being validated as alternative to the non-invasive tests, the DEFER trial showed that a strategy of PCI based in FFR achieves b...

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  We have read with great interest the article written by Zhang et al[1] and we want to congratulate the authors on his contribution in this relevant issue. Since the first publication in 1995 by Pijls et al, fractional flow reserve has constantly progressed with undoubted success. After initially being validated as alternative to the non-invasive tests, the DEFER trial showed that a strategy of PCI based in FFR achieves better outcomes than the PCI guided by angiography in stable patients with one- vessel disease. In the following years this hypothesis was also confirmed in multivessel disease with the FAME and FAME-2 trials and even in non-ST elevation acute coronary syndromes with the subgroup of patients of the FAME and the recently published FAMOUS-NSTEMI trial. Finally, in FAME the possibility of differing between the angiographic and functional concepts of multivessel disease was also demonstrated. The article written by Zhang resumes perfectly the advantages of this technique. However, despite the robust evidence supporting its value and after having received the highest level of recommendation in the European and ACC/AHA guidelines, its utilization is still low and in many centres even anecdotal. It has also been recently published a disappointing median time lag of 14 years needed between guideline recommendation to 90 % practice uptake for class I therapies in acute coronary syndromes[2]. Although issues associated with reimbursement have been argued, there exist additional reasons which play an important role in the low percentage of FFR: as an example in Spain where most of the activity is performed in public hospitals without difficulties associated to reimbursement, in 2013 only 4.097 cases were reported, which represented 2,9% of the coronary angiographies and 6,2% of the PCIs[3]. We believe that fractional flow reserve has changed the conception of the cardiac catheterization laboratory and nowadays a complete diagnosis, risk stratification and adequate treatment in a one- stage manner can be offer to the still high number of patients with stable caronary disease who have not been adequately studied before the catheterization and to most of the non-ST elevation acute coronary syndromes, avoiding in many cases a second visit to the lab satisfying their expectancies and reducing unnecessary delays and costs.

  Reference List

  (1) Zhang D, Lv S, Song X, Yuan F, Xu F, Zhang M, Yan S, Cao X. Fractional flow reserve versus angiography for guiding percutaneous coronary intervention: a meta-analysis. Heart 2015.

  (2) Putera M, Roark R, Lopes RD, Udayakumar K, Peterson ED, Califf RM, Shah BR. Translation of acute coronary syndrome therapies: From evidence to routine clinical practice. Am Heart J 2015; 169(2):266-273.

  (3) Garcia dB, Hernandez HF, Rumoroso C, Jr., Trillo NR. Spanish Cardiac Catheterization and Coronary Intervention Registry. 23rd official report of the Spanish Society of Cardiology Working Group on Cardiac Catheterization and Interventional Cardiology (1990-2013). Rev Esp Cardiol (Engl Ed) 2014; 67(12):1013-1023.

  Conflict of Interest:

  None declared

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  Conflict of Interest:
  None declared.

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• Published on: 23 November 2015

  The role of FFR in clinical practice

  • Marco Araco, Cardiology Fellow

  Only recently the FAME-2 trial1 showed for the first time that, in patients with stable coronary artery disease (SCAD) and "significant" myocardial ischemia, there is a prognostic advantage of PCI over optimal medical therapy (OMT), and that this advantage is consistent in patients with either single or multi-vessel coronary artery disease. The clinical outcome of patients with coronary stenoses not associated with signi...

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  Only recently the FAME-2 trial1 showed for the first time that, in patients with stable coronary artery disease (SCAD) and "significant" myocardial ischemia, there is a prognostic advantage of PCI over optimal medical therapy (OMT), and that this advantage is consistent in patients with either single or multi-vessel coronary artery disease. The clinical outcome of patients with coronary stenoses not associated with significant ischemia is favorable with OMT alone, which is therefore a safe and convenient therapeutic strategy. Among patients with SCAD the risk of death and MI is proportional to the extent of ischemic myocardium/number of diseased vessels. Only patients with significant ischemia benefit from revascularization. Several studies however, including the COURAGE and BARI-2D trials2,3, failed to demonstrate a mortality benefit of PCI over OMT, most likely because of the inclusion on these studies of low risk patients with only limited ischemia or even no ischemia. It's common practice, in most cath-labs, to stent intermediate coronary stenoses only based on an angiographic estimation of severity. This meta- analysis and the FAME-2 trial shows, instead, that revascularization with PCI is safer and only confers a survival benefit when a given coronary lesion is associated with significant myocardial ischemia, as proven by FFR measurements. The use of FFR technique, which is simple and relatively safe, should be therefore implemented in every day practice.

  1- Fractional flow reserve-guided PCI for stable coronary artery disease. De Bruyne B, Fearon WF, Pijls NH, Barbato E, Tonino P, Piroth Z, Jagic N, Mobius-Winckler S, Rioufol G, Witt N, Kala P, MacCarthy P, Engstr?m T, Oldroyd K, Mavromatis K, Manoharan G, Verlee P, Frobert O, Curzen N, Johnson JB, Limacher A, N?esch E, J?ni P; FAME 2 Trial Investigators. N Engl J Med. 2014 Sep 25;371(13):1208-17.

  2- Optimal medical therapy with or without PCI for stable coronary disease. Boden WE, O'Rourke RA, Teo KK, Hartigan PM, Maron DJ, Kostuk WJ, Knudtson M, Dada M, Casperson P, Harris CL, Chaitman BR, Shaw L, Gosselin G, Nawaz S, Title LM, Gau G, Blaustein AS, Booth DC, Bates ER, Spertus JA, Berman DS, Mancini GB, Weintraub WS; COURAGE Trial Research Group. N Engl J Med. 2007 Apr 12;356(15):1503-16.

  3- A randomized trial of therapies for type 2 diabetes and coronary artery disease. BARI 2D Study Group, Frye RL, August P, Brooks MM, Hardison RM, Kelsey SF, MacGregor JM, Orchard TJ, Chaitman BR, Genuth SM, Goldberg SH, Hlatky MA, Jones TL, Molitch ME, Nesto RW, Sako EY, Sobel BE. N Engl J Med. 2009 Jun 11;360(24):2503-15.

  Conflict of Interest:

  None declared

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  Conflict of Interest:
  None declared.

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