Author + information
- Received May 14, 2018
- Revision received July 16, 2018
- Accepted July 24, 2018
- Published online October 15, 2018.
- Pontus Andell, MD, PhDa,∗ (, )
- Karolina Berntorp, MDa,
- Evald H. Christiansen, MD, PhDb,
- Ingibjörg J. Gudmundsdottir, MD, DMc,
- Lennart Sandhall, MDd,
- Dimitrios Venetsanos, MD, PhDe,
- David Erlinge, MD, PhDa,
- Ole Fröbert, MD, PhDf,
- Sasha Koul, MD, PhDa,
- Christian Reitan, MDa and
- Matthias Götberg, MD, PhDa
- aDepartment of Cardiology, Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
- bDepartment of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- cDepartment of Cardiology, University Hospital of Iceland, Reykjavik, Iceland
- dDepartments of Cardiology and Radiology, Helsingborg Hospital, Helsingborg, Sweden
- eDepartments of Cardiology and of Medical and Health Sciences, Linköping University, Linköping, Sweden
- fDepartment of Cardiology, Faculty of Health, Örebro University, Örebro, Sweden
- ↵∗Address for correspondence:
Dr. Pontus Andell, Department of Cardiology, Lund University, SE-221 85, Lund, Sweden.
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.
- coronary artery bypass grafting
- coronary artery disease
- coronary physiology
- percutaneous coronary intervention
Dr. Sandhall has received lecture fees from Philips Volcano and Boston Scientific; and consulting fees from Boston Scientific. Dr. Götberg has received lecture fees from Philips Volcano; consulting fees and lecture fees from Boston Scientific; and fees for serving on an advisory board from Medtronic. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received May 14, 2018.
- Revision received July 16, 2018.
- Accepted July 24, 2018.
- 2018 American College of Cardiology Foundation
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