Measuring fractional flow reserve (FFR) has been available as a diagnostic tool for over a decade, but many cardiologists are only now starting to realize the full value of the technique.
FFR involves inserting a coronary pressure guidewire into an artery to measure blood flow. This allows physicians to determine whether any apparent narrowing is severe enough to merit angioplasty or stenting. The FAME (FFR vs. Angiography for Multivessel Evaluation) study, published earlier this year in the New England Journal of Medicine, compared angiography-guided treatment to FFR-guided PCI (PressureWire Certus, St. Jude Medical). Researchers found that the use of FFR resulted in a 30 percent reduction in major adverse cardiac events after one year. In addition, the FFR method cut the per-patient cost of PCI by an average of $675 without prolonging the procedure. The results of the FAME study demonstrate a rare chance to cut costs without cutting corners in patient care.
One of the initial reactions to the FAME data is that FFR only stands to reduce costs by lowering the number of stents used. But FFR isn’t simply about stenting less. FFR is about stenting the right areas and performing bypass in the right situations.
We have been using and advocating FFR since pressure guidewire technology first came to the U.S. in 1998. At Emory, we are sometimes asked to reevaluate patients who have been slated for CABG surgery at another hospital where recommendations are made based on angiography alone. When we evaluate these cases using FFR, we are sometimes able to recommend courses of treatment that involve fewer stents or even medical therapy. Occasionally, based on FFR data, we send our patients for an endoscopic or “minimally invasive” bypass and stent the remaining narrowings.
In addition, FFR has helped reduce the number of multi-vessel PCIs performed. Patients who might have received stents in three vessels after angiography alone would likely receive stents in only one or two vessels after FFR-guided analysis. Among patients with single-vessel disease, FFR often has allowed us to recommend medical treatment in lieu of stenting. Implanting fewer stents also means using less contrast agent and fewer materials, which lowers the expenses involved in treatment.
With greater use of FFR in patients with stenosis (particularly between 30 and 80 percent), treatment will be directed only to narrowings that are flow limiting, thus reducing unnecessary bypass surgeries and stenting procedures. This should result in significant cost savings to the U.S. healthcare system.
For some patients, the capacity of FFR-guided treatment to curb unnecessary stenting and bypass surgery may push the pendulum of cardiac care more toward the conservative side, shifting the emphasis toward more intense medical therapy. However, at the same time, approximately 30 to 40 percent of FFR procedures show severe arterial narrowings that would have been passed over during angiography despite seriously restricting blood flow. When this happens, FFR will lead us to stent or even bypass areas that would have otherwise gone untreated. In these cases, the cost of an individual patient’s treatment may increase, but so does quality of care.
Since the results of the FAME study were announced, I have noticed increased use and interest in FFR from our fellows and colleagues at Emory. Cardiologists are starting to see how the method’s cost-saving potential goes hand-in-hand with the ultimate goal of improving clinical outcomes for patients with multi-vessel disease. This is a rare type of win-win opportunity for both heart disease patients and their healthcare providers. It’s time for FFR to become standard practice for evaluation of a substantial portion of our patients.
Dr. Samady is associate professor of medicine, division of Cardiology, Emory University School of Medicine, Atlanta.