Hybrid EFR-FFR decision-making strategy: implications for enhancing universal adoption of physiology-guided coronary revascularisation

Ricardo Petraco; Jin Joo Park; Sayan Sen; Sukhjinder S. Nijjer; Iqbal S. Malik; Mauro Echavarria-Pinto; Kaleab N. Asrress; Chang-Wook Nam; Enrico Macias; Rodney A. Foale; Amarjit Sethi; Ghada W. Mikhail; Raffi Kaprielian; Christopher S. Baker; David Lefroy; Michael Bellamy; Mahmud Al-Bustami; Masood A. Khan; Nieves Gonzalo; Alun D. Hughes; Darrel P. Francis; Jamil Mayet; Carlo Di Mario; Simon Redwood; Javier Escaned; Bon-Kwon Koo; Justin E. Davies

doi:10.4244/EIJV8I10A179

Hybrid EFR-FFR decision-making strategy: implications for enhancing universal adoption of physiology-guided coronary revascularisation

Ricardo Petraco^*, Jin Joo Park, Sayan Sen, Sukhjinder S. Nijjer, Iqbal S. Malik, Mauro Echavarria-Pinto, Kaleab N. Asrress, Chang-Wook Nam, Enrico Macias, Rodney A. Foale, Amarjit Sethi, Ghada W. Mikhail, Raffi Kaprielian, Christopher S. Baker, David Lefroy, Michael Bellamy, Mahmud Al-Bustami, Masood A. Khan, Nieves Gonzalo, Alun D. HughesDarrel P. Francis, Jamil Mayet, Carlo Di Mario, Simon Redwood, Javier Escaned, Bon-Kwon Koo, Justin E. Davies

^*Corresponding author for this work

Cardiovascular Sciences

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

102 Citations (Scopus)

Abstract

Aims: Adoption of fractional flow reserve (FFR) remains low (6-8%), partly because of the time, cost and potential inconvenience associated with vasodilator administration. The instantaneous wave-Free Ratio (iFR) is a pressure-only index of stenosis severity calculated without vasodilator drugs. Before outcome trials test iFR as a sole guide to revascularisation, we evaluate the merits of a hybrid iFR-FFR decision-making strategy for universal physiological assessment.

Methods and results: Coronary pressure traces from 577 stenoses were analysed. iFR was calculated as the ratio between Pd and Pa in the resting diastolic wave-free window. A hybrid iFR-FFR strategy was evaluated, by allowing iFR to defer some stenoses (where negative predictive value is high) and treat others (where positive predictive value is high), with adenosine being given only to patients with iFR in between those values. For the most recent fixed FFR cut-off (0.8), an iFR of 0.93 could be used to defer revascularisation (NPV of 91%). Limiting vasodilator drugs to cases with iFR values between 0.86 to 0.93 would obviate the need for vasodilator drugs in 57% of patients, whilst maintaining 95% agreement with an FFR-only strategy. If the 0.75-0.8 FFR grey zone is accounted for, vasodilator drug requirement would decrease by 76%.

Conclusion: A hybrid iFR-FFR decision-making strategy for revascularisation could increase adoption of physiology-guided PCI, by more than halving the need for vasodilator administration, whilst maintaining high classification agreement with an FFR-only strategy.

Original language	English
Pages (from-to)	1157-1165
Number of pages	9
Journal	Eurointervention
Volume	8
Issue number	10
DOIs	https://doi.org/10.4244/EIJV8I10A179
Publication status	Published - Feb 2013

Keywords

instantaneous wave-free ratio
fractional flow reserve
physiology-guided PCI
adenosine
FRACTIONAL FLOW RESERVE
CARDIAC-CATHETERIZATION
INTERVENTION
STENOSIS
DISEASE
ANGIOGRAPHY
ASSOCIATION
CARDIOLOGY
ADENOSINE

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Petraco, R., Park, J. J., Sen, S., Nijjer, S. S., Malik, I. S., Echavarria-Pinto, M., Asrress, K. N., Nam, C.-W., Macias, E., Foale, R. A., Sethi, A., Mikhail, G. W., Kaprielian, R., Baker, C. S., Lefroy, D., Bellamy, M., Al-Bustami, M., Khan, M. A., Gonzalo, N., ... Davies, J. E. (2013). Hybrid EFR-FFR decision-making strategy: implications for enhancing universal adoption of physiology-guided coronary revascularisation. Eurointervention, 8(10), 1157-1165. https://doi.org/10.4244/EIJV8I10A179

@article{3ff7ad31abf84df19525b8cf1b2a4125,

title = "Hybrid EFR-FFR decision-making strategy: implications for enhancing universal adoption of physiology-guided coronary revascularisation",

abstract = "Aims: Adoption of fractional flow reserve (FFR) remains low (6-8%), partly because of the time, cost and potential inconvenience associated with vasodilator administration. The instantaneous wave-Free Ratio (iFR) is a pressure-only index of stenosis severity calculated without vasodilator drugs. Before outcome trials test iFR as a sole guide to revascularisation, we evaluate the merits of a hybrid iFR-FFR decision-making strategy for universal physiological assessment.Methods and results: Coronary pressure traces from 577 stenoses were analysed. iFR was calculated as the ratio between Pd and Pa in the resting diastolic wave-free window. A hybrid iFR-FFR strategy was evaluated, by allowing iFR to defer some stenoses (where negative predictive value is high) and treat others (where positive predictive value is high), with adenosine being given only to patients with iFR in between those values. For the most recent fixed FFR cut-off (0.8), an iFR of 0.93 could be used to defer revascularisation (NPV of 91%). Limiting vasodilator drugs to cases with iFR values between 0.86 to 0.93 would obviate the need for vasodilator drugs in 57% of patients, whilst maintaining 95% agreement with an FFR-only strategy. If the 0.75-0.8 FFR grey zone is accounted for, vasodilator drug requirement would decrease by 76%.Conclusion: A hybrid iFR-FFR decision-making strategy for revascularisation could increase adoption of physiology-guided PCI, by more than halving the need for vasodilator administration, whilst maintaining high classification agreement with an FFR-only strategy.",

keywords = "instantaneous wave-free ratio, fractional flow reserve, physiology-guided PCI, adenosine, FRACTIONAL FLOW RESERVE, CARDIAC-CATHETERIZATION, INTERVENTION, STENOSIS, DISEASE, ANGIOGRAPHY, ASSOCIATION, CARDIOLOGY, ADENOSINE",

author = "Ricardo Petraco and Park, {Jin Joo} and Sayan Sen and Nijjer, {Sukhjinder S.} and Malik, {Iqbal S.} and Mauro Echavarria-Pinto and Asrress, {Kaleab N.} and Chang-Wook Nam and Enrico Macias and Foale, {Rodney A.} and Amarjit Sethi and Mikhail, {Ghada W.} and Raffi Kaprielian and Baker, {Christopher S.} and David Lefroy and Michael Bellamy and Mahmud Al-Bustami and Khan, {Masood A.} and Nieves Gonzalo and Hughes, {Alun D.} and Francis, {Darrel P.} and Jamil Mayet and {Di Mario}, Carlo and Simon Redwood and Javier Escaned and Bon-Kwon Koo and Davies, {Justin E.}",

year = "2013",

month = feb,

doi = "10.4244/EIJV8I10A179",

language = "English",

volume = "8",

pages = "1157--1165",

journal = "Eurointervention",

issn = "1774-024X",

publisher = "EuroPCR",

number = "10",

}

Petraco, R, Park, JJ, Sen, S, Nijjer, SS, Malik, IS, Echavarria-Pinto, M, Asrress, KN, Nam, C-W, Macias, E, Foale, RA, Sethi, A, Mikhail, GW, Kaprielian, R, Baker, CS, Lefroy, D, Bellamy, M, Al-Bustami, M, Khan, MA, Gonzalo, N, Hughes, AD, Francis, DP, Mayet, J, Di Mario, C, Redwood, S, Escaned, J, Koo, B-K & Davies, JE 2013, 'Hybrid EFR-FFR decision-making strategy: implications for enhancing universal adoption of physiology-guided coronary revascularisation', Eurointervention, vol. 8, no. 10, pp. 1157-1165. https://doi.org/10.4244/EIJV8I10A179

TY - JOUR

T1 - Hybrid EFR-FFR decision-making strategy: implications for enhancing universal adoption of physiology-guided coronary revascularisation

AU - Petraco, Ricardo

AU - Park, Jin Joo

AU - Sen, Sayan

AU - Nijjer, Sukhjinder S.

AU - Malik, Iqbal S.

AU - Echavarria-Pinto, Mauro

AU - Asrress, Kaleab N.

AU - Nam, Chang-Wook

AU - Macias, Enrico

AU - Foale, Rodney A.

AU - Sethi, Amarjit

AU - Mikhail, Ghada W.

AU - Kaprielian, Raffi

AU - Baker, Christopher S.

AU - Lefroy, David

AU - Bellamy, Michael

AU - Al-Bustami, Mahmud

AU - Khan, Masood A.

AU - Gonzalo, Nieves

AU - Hughes, Alun D.

AU - Francis, Darrel P.

AU - Mayet, Jamil

AU - Di Mario, Carlo

AU - Redwood, Simon

AU - Escaned, Javier

AU - Koo, Bon-Kwon

AU - Davies, Justin E.

PY - 2013/2

Y1 - 2013/2

N2 - Aims: Adoption of fractional flow reserve (FFR) remains low (6-8%), partly because of the time, cost and potential inconvenience associated with vasodilator administration. The instantaneous wave-Free Ratio (iFR) is a pressure-only index of stenosis severity calculated without vasodilator drugs. Before outcome trials test iFR as a sole guide to revascularisation, we evaluate the merits of a hybrid iFR-FFR decision-making strategy for universal physiological assessment.Methods and results: Coronary pressure traces from 577 stenoses were analysed. iFR was calculated as the ratio between Pd and Pa in the resting diastolic wave-free window. A hybrid iFR-FFR strategy was evaluated, by allowing iFR to defer some stenoses (where negative predictive value is high) and treat others (where positive predictive value is high), with adenosine being given only to patients with iFR in between those values. For the most recent fixed FFR cut-off (0.8), an iFR of 0.93 could be used to defer revascularisation (NPV of 91%). Limiting vasodilator drugs to cases with iFR values between 0.86 to 0.93 would obviate the need for vasodilator drugs in 57% of patients, whilst maintaining 95% agreement with an FFR-only strategy. If the 0.75-0.8 FFR grey zone is accounted for, vasodilator drug requirement would decrease by 76%.Conclusion: A hybrid iFR-FFR decision-making strategy for revascularisation could increase adoption of physiology-guided PCI, by more than halving the need for vasodilator administration, whilst maintaining high classification agreement with an FFR-only strategy.

AB - Aims: Adoption of fractional flow reserve (FFR) remains low (6-8%), partly because of the time, cost and potential inconvenience associated with vasodilator administration. The instantaneous wave-Free Ratio (iFR) is a pressure-only index of stenosis severity calculated without vasodilator drugs. Before outcome trials test iFR as a sole guide to revascularisation, we evaluate the merits of a hybrid iFR-FFR decision-making strategy for universal physiological assessment.Methods and results: Coronary pressure traces from 577 stenoses were analysed. iFR was calculated as the ratio between Pd and Pa in the resting diastolic wave-free window. A hybrid iFR-FFR strategy was evaluated, by allowing iFR to defer some stenoses (where negative predictive value is high) and treat others (where positive predictive value is high), with adenosine being given only to patients with iFR in between those values. For the most recent fixed FFR cut-off (0.8), an iFR of 0.93 could be used to defer revascularisation (NPV of 91%). Limiting vasodilator drugs to cases with iFR values between 0.86 to 0.93 would obviate the need for vasodilator drugs in 57% of patients, whilst maintaining 95% agreement with an FFR-only strategy. If the 0.75-0.8 FFR grey zone is accounted for, vasodilator drug requirement would decrease by 76%.Conclusion: A hybrid iFR-FFR decision-making strategy for revascularisation could increase adoption of physiology-guided PCI, by more than halving the need for vasodilator administration, whilst maintaining high classification agreement with an FFR-only strategy.

KW - instantaneous wave-free ratio

KW - fractional flow reserve

KW - physiology-guided PCI

KW - adenosine

KW - FRACTIONAL FLOW RESERVE

KW - CARDIAC-CATHETERIZATION

KW - INTERVENTION

KW - STENOSIS

KW - DISEASE

KW - ANGIOGRAPHY

KW - ASSOCIATION

KW - CARDIOLOGY

KW - ADENOSINE

U2 - 10.4244/EIJV8I10A179

DO - 10.4244/EIJV8I10A179

M3 - Article

SN - 1774-024X

VL - 8

SP - 1157

EP - 1165

JO - Eurointervention

JF - Eurointervention

IS - 10

ER -

Hybrid EFR-FFR decision-making strategy: implications for enhancing universal adoption of physiology-guided coronary revascularisation

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Keywords

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