Angiography as good as FFR & IVUS for post-PCI long-term survival

While fractional flow reserve (FFR) and intravascular ultrasound (IVUS) may reduce the need for repeat revascularization, they apparently don’t make a dent in long-term mortality compared with angiography-guided PCI. But FFR may help reduce stent use, according to results published online June 23 in JAMA Internal Medicine.

FFR-guided PCI became a recommended approach by the American College of Cardiology and the American Heart Association for assessing intermediate lesions in patients with stable angina. The guidelines also supported the use of IVUS for evaluating intermediate lesions in the left main artery.  But the recommendations were based on studies that did not provide long-term clinical endpoints, noted Georg M. Fröhlich, MD, of the Heart Hospital at University College London Hospital.

Fröhlich and colleagues designed an observational study with data from the pan-London PCI registry. The registry captures all patients treated with PCI at eight primary PCI centers in the London region. For their analysis, the researchers enrolled 41,688 patients who received elective or urgent PCI procedures between 2004 and 2011. The primary outcome was long-term all-cause mortality and patients were followed for a median 3.3 years.

They found that 6.6 percent underwent FFR-guided PCI, 4.4 percent IVUS-guided PCI and 89 percent standard angiography-guided PCI. The IVUS-guided group was more likely to receive left main stem PCI. Compared with angiography-guided PCI, neither FFR nor IVUS showed a survival benefit in adjusted and propensity score matched analyses.  

The FFR group used fewer stents compared with IVUS and angiography (1.1 vs. 1.6 vs. 1.7 stents, respectively).

“It is perhaps too optimistic to expect a survival advantage from the use of a purely diagnostic procedure,” they wrote of FFR. But FFR was associated with fewer periprocedural complications and the use of fewer stents, which could offer other benefits such as lower costs and less risk of bleeding and in-stent thrombosis.

IVUS also may provide value beyond survivability in some cases because it allows interventional cardiologists to better characterize lesions, identify potential complications, size vessels and plan a procedure. Fröhlich et al added that they could not tell through the registry data if IVUS was performed before or after PCI, though.