451 Deferral of coronary revascularization in patients with reduced ejection fraction based on physiological assessment: impact on long-term survival

Abstract

Abstract Aims Deferring percutaneous coronary intervention (PCI) in patients with non-significant stenoses based on fractional flow reserve (FFR) is associated with favourable clinical outcomes up to 15 years. Whether this holds true in patients with reduced left ventricular ejection fraction (LVEF) is unclear. To investigate whether FFR provides adjunctive clinical benefit compared to coronary angiography in deferring revascularization of patients with intermediate coronary stenoses and reduced LVEF. Methods and results Consecutive patients (n = 4577) with reduced LVEF (≤50%) undergoing coronary angiography between 2002 and 2010 were screened. We eventually included patients with at least one intermediate coronary stenosis (diameter stenosis ≥40%) in whom revascularization was deferred based either on angiography plus FFR (FFR-guided) or angiography alone (angiography-guided). The primary endpoint of the study was the cumulative incidence of all-cause death at 10 years. The secondary endpoint [the incidence of major adverse cardiovascular and cerebrovascular events (MACCE)], was a composite of all-cause death, myocardial infarction, any revascularization and stroke. A total of 840 patients were included (206 in the FFR-guided and 634 in the angiography-guided group). Median clinical follow-up was 7 years [IQR: (3.22–11.08)]. After 1:1 propensity score matching, baseline characteristics between the two groups were similar. All-cause death was significantly lower in the FFR-guided group compared with the angiography-guided group [94 (45.6%) vs. 119 (57.8%), HR: 0.65 (95% CI: 0.49–0.85), P < 0.01]. The rate of major adverse cardiovascular and cerebrovascular events [(MACCE), a composite of all-cause death, myocardial infarction, any revascularization, and stroke) was lower in the FFR-guided group [123 (59.7%) vs. 139 (67.5%), HR: 0.75 (95% CI: 0.59–0.95), P = 0.02]. Conclusions In patients with reduced LVEF, deferring revascularization of intermediate coronary stenoses based on FFR is associated with a lower incidence of death and MACCE at 10 years.