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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/cdn\/css\/http\/css_Xg7z6oCTVgud_Q0huYz9x9iiD5H_2YPSJ5z2ZViSWdY.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EThis article discusses the use of fractional flow reserve (FFR) with angiography for detecting significant coronary artery stenosis. FFR is the only functional index that has been validated against a true gold standard. All studies performed in a wide range of clinical and angiographic conditions found an FFR threshold of 0.75 to 0.80 to detect significant stenosis, with a sensitivity of 90% and specificity of 100% [Pijls NHJ et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 1996].\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003ECardiology Clinical Trials\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ECoronary Artery Disease\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EInterventional Techniques \u0026amp; Devices\u003C\/li\u003E\u003C\/ul\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EFractional Flow Reserve and FAME-Trials\u003C\/h2\u003E\n         \u003Cp id=\u0022p-2\u0022\u003EMohamed Sadaka, MD, Alexandria University, Alexandria, Egypt, discussed the use of fractional flow reserve (FFR) with angiography for detecting significant coronary artery stenosis. FFR is the only functional index that has been validated against a true gold standard. All studies performed in a wide range of clinical and angiographic conditions found an FFR threshold of 0.75 to 0.80 to detect significant stenosis, with a sensitivity of 90% and specificity of 100% [Pijls NHJ et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 1996].\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-2\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EFractional Flow Reserve in Single-Vessel Disease\u003C\/h2\u003E\n         \u003Cp id=\u0022p-3\u0022\u003EThe Deferral of Percutaneous Coronary Intervention [DEFER] study assessed the safety of deferring percutaneous coronary intervention (PCI) for stenoses in patients without proof of ischemia scheduled for 1-vessel PCI (n=325) [Pijls NHJ et al. \u003Cem\u003EJ Am Coll Cardiol\u003C\/em\u003E 2007]. Patients who had an FFR \u22650.75 were randomized to medical therapy (Defer group) versus PCI (Perform group). PCI was performed in patients with FFR \u0026lt;0.75 (Reference group). After 5 years, the rates of death or myocardial infarction (MI) were 3.3% in the Defer group, 7.9% in the Perform group, and 15.7% in the Reference group. The event-free survival rates were 80%, 73%, 63% for the 3 groups, respectively. These results showed that the annual death rate is low (\u223c1% per year) and PCI does not improve prognosis in patients with coronary artery disease (CAD) without ischemia.\u003C\/p\u003E\n         \u003Cp id=\u0022p-4\u0022\u003EHamilos et al. [\u003Cem\u003ECirculation\u003C\/em\u003E 2009] performed FFR and quantitative coronary angiography in 274 patients with equivocal left main coronary artery stenosis. Patients with FFR \u22650.80 were treated medically and those with FFR \u0026lt;0.80 were treated with coronary artery bypass graft. The results showed no significant difference in 5-year survival rates between the 2 groups. In a study of FFR-guided decision-making in patients with proximal left anterior descending artery stenosis, patients with FFR \u22650.80 versus FFR \u0026lt;0.80 had significantly lower rates of major adverse cardiac events (MACE; p=0.0019) and mortality (p=0.0479) [Muller O et al. AHA 2009].\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-3\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EFractional Flow Reserve in Multivessel Disease\u003C\/h2\u003E\n         \u003Cp id=\u0022p-5\u0022\u003EThe Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation [COURAGE] trial showed that reducing ischemia prevents death and MI in patients with multivessel disease (MVD) [Shaw LJ et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2008]. Patients with a \u22655% reduction in ischemia from baseline (n=82) had a lower unadjusted risk of death or MI compared with those with no significant reduction in ischemia (n=232; p=0.037; risk-adjusted p=0.26). The difference was even greater in the subgroup of patients with moderate to severe baseline ischemia (p=0.001; risk-adjusted p=0.08). The mean percentage of ischemic myocardium in patients treated with optimal medical therapy (OMT; n=155) changed from 8.6% before therapy to 8.1% at 6 to 18 months (mean change, \u22120.5%; 95% CI, \u22121.6 to 0.6; p=0.63). In patients treated with PCI plus OMT, the pretreatment ischemia percentage of 8.2% was reduced to 5.5% at 6 to 18 months (mean change, \u22122.7%; 95% CI, \u22121.7 to \u22123.8; p\u0026lt;0.001; PCI+OMT vs OMT; p\u0026lt;0.0001).\u003C\/p\u003E\n         \u003Cp id=\u0022p-6\u0022\u003EA meta-analysis of the Asymptomatic Cardiac Ischemia Pilot [ACIP], COURAGE SI, and Swiss Interventional Study on Silent Ischemia Type II [SWISSI-II] trials showed that mortality was significantly lower with PCI plus OMT (3.5%) versus OMT (9.4%) in patients with silent myocardial ischemia (n=619; risk ratio, 0.34; 95% CI, 0.20 to 0.60; p=0.0002) [Boden WE. ACC 2009].\u003C\/p\u003E\n         \u003Cp id=\u0022p-7\u0022\u003EThe objective of the Fractional Flow Reserve Versus Angiography for Multivessel Evaluation [FAME] study was to compare revascularization using angiography plus FFR with angiography only in patients with MVD. The primary endpoint was mortality, MI, or repeat revascularization at 1 year [Tonino PA et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2009]. In the FFR-guided group, PCI was performed in patients with FFR \u22640.80. PCI was performed on indicated lesions in the angiography-guided group.\u003C\/p\u003E\n         \u003Cp id=\u0022p-8\u0022\u003EAt 1 year, the primary endpoint occurred in 13.2% of the FFR group versus 18.3% of the angiography group (p=0.02). The number of drug-eluting stents (DES) per patient was 1.9\u00b11.3 in the FFR group versus 2.7\u00b11.2 in the angiography group (p\u0026lt;0.001). Less contrast agent was used in the FFR group (272\u00b1133 mL) versus the angiography group (302\u00b1127 mL; p\u0026lt;0.001). The rate of MACE was lower in the FFR versus angiography group by 2.9% at 30 days, 3.8% at 90 days, 4.9% at 180 days, and 5.3% at 360 days.\u003C\/p\u003E\n         \u003Cp id=\u0022p-9\u0022\u003EAt 2 years, among 509 FFR-guided patients with 513 deferred lesions, there were 31 MIs, of which 22 were periprocedural; 9 were late MIs, 8 due to a new lesion or stent-related, and 1 (0.2%) due to an originally deferred lesion [Pijls NHJ et al. \u003Cem\u003EJ Am Coll Cardiol\u003C\/em\u003E 2010]. In this group, there also were 53 repeat revascularizations (37 in a new lesion and\/or a restenotic lesion); 16 of these were in originally deferred lesions (6 without FFR or despite FFR \u0026gt;0.80), 10 of which showed clear progression.\u003C\/p\u003E\n         \u003Cp id=\u0022p-10\u0022\u003EThis study showed that, in patients with MVD, revascularization based on angiography plus FFR compared with angiography alone reduces MACE and death\/MI rate by about 30%, despite using fewer stents and less contrast medium. FAME challenges the definition of MVD and the concept of completeness of revascularization.\u003C\/p\u003E\n         \u003Cp id=\u0022p-11\u0022\u003EThe FAME 2 study evaluated FFR-guided PCI plus OMT versus OMT alone in patients with stable CAD in randomized and registry cohorts [De Bruyne B et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2012]. Stable patients scheduled for 1, 2, or 3 vessel DES stenting had FFR in all target lesions. In the randomized cohort, patients with at least 1 stenosis with FFR \u22640.80 were randomized to PCI plus OMT or OMT. In the registry cohort, patients with all FFR \u0026gt;0.80 were treated with OMT. The independent data and safety monitoring board recommended halting patient recruitment due to a significantly increased risk of MACE among patients randomized to OMT alone compared with patients randomized to OMT plus FFR-guided PCI.\u003C\/p\u003E\n         \u003Cp id=\u0022p-12\u0022\u003EThe primary endpoint, a composite of death, MI, or urgent revascularization, occurred in 4.3% in the PCI plus OMT group and 12.7% in the OMT group (HR with PCI, 0.32; 95% CI, 0.19 to 0.53; p\u0026lt;0.001). This difference was driven by a reduction in revascularization (1.7% vs 12.1%; HR, 7.63; 95% CI, 3.24 to 18.0; p\u0026lt;0.0001). The harder endpoints of death or MI were not reduced with PCI plus OMT (3.4% vs 3.9%; HR, 0.61; 95% CI, 0.28 to 1.35; p=0.22). There was no significant difference in revascularization rates between the randomized PCI plus OMT group and the registry OMT group (p=0.54).\u003C\/p\u003E\n         \u003Cp id=\u0022p-13\u0022\u003EBased on the DEFER and FAME studies, the European Society of Cardiology\/European Association for Cardio-Thoracic Surgery Guidelines on myocardial revascularization [Wijns W et al. \u003Cem\u003EEur Heart J\u003C\/em\u003E 2010] recommend FFR-guided PCI for detection of ischemia-related lesions when objective evidence of vessel-related ischemia is not available. According to the 2011 American College of Cardiology Foundation\/American Heart Association\/Society for Cardiovascular Angiography and Interventions Guideline for percutaneous coronary intervention [Levine GN et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2011], FFR is reasonable to assess angiographic intermediate coronary lesions (50% to 70% diameter stenosis) and can be useful in guiding revascularization decisions in patients with stable ischemic heart disease.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2012 MD Conference Express\u00ae\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/12\/8\/8.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzna41\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}