06 FFR Curzen N aimradial2016 - clinical judgment
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This document discusses the use of fractional flow reserve (FFR) measurements to guide clinical decision making for patients undergoing diagnostic coronary angiography. It notes that multiple studies have found that FFR assessment changes the treatment plan in around 30% of cases compared to angiography alone, as FFR can more accurately determine whether a lesion is functionally significant. The document advocates for the routine use of FFR during angiography to improve patient management and outcomes. It concludes by highlighting the need for a large randomized trial like RIPCORD 2 to further establish the benefits of FFR-guided assessment.
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06 FFR Curzen N aimradial2016 - clinical judgment
- 1. Nick Curzen BM(Hons) PhD FRCP Professor of Interventional Cardiology University Hospital Southampton NHS FT UK FFR assessment: how it affects clinical judgement 4 October 2016
- 2. 4 October 2016 Potential Conflicts of Interest Unrestricted research grant for RIPCORD St Jude Medical Speakers Fees Unrestricted research grant for FFRCT RIPCORD HeartFlow Speaker Fees Unrestricted research grant for RIPCORD 2 Boston Scientific Speaker Fees Unrestricted education grant Volcano-Phillips
- 3. 4-Oct-16 CAD present? Benefit from aspirin/statin/ramipril? Symptoms due to this CAD? Needs revasc? ? ?
- 4. 04/10/2016 Physiology versus anatomy Despite the data we hardly use FFR Can this be done non-invasively? Decision-making Revascularisation vs no revasc? PCI vs CABG? Which vessel(s) for PCI/CABG?
- 5. 4-Oct-16 Current practice for assessment & management of angina is fundamentally flawed.......
- 6. 4-Oct-16 Patient with chest pain Test for evidence of reversible ischaemia Diagnostic Angiogram OMT PCI CABG
- 7. 4-Oct-16 Multivessel Disease..... Stents or Surgery? The problem is…. You can’t tell from the angiogram whether the lesion is ischaemic or not… 4 October 2016
- 8. FFR 50mcg adenosine LAD 0.54 OM 0.99 CX 0.89 FFR 50mcg adenosine RCA 0.90 4-Oct-16 Multivessel Disease..... Stents or Surgery?
- 9. You cannot rely on what you see at angiography if your currency is “significance”
- 10. 4-Oct-16 Our current practice for assessment & management of angina is flawed & confused....... We get patient-level & lesion-specific ischaemia wrong in about 30%!!
- 11. 4-Oct-16 Have we really exploited the value of FFR in routine practice yet? Angiogram Tree
- 12. 4-Oct-16 Patient with chest pain Test for evidence of reversible ischaemia Diagnostic Angiogram OMT PCI CABG ? ?DEFER FAME FAME 2
- 13. Non-randomised…….. “prospectively allocated” 137 patients (312 vessels) FFR-PCI 57 patients, 128 vessels……. 48 patients, 53 vessels Conventional PCI: 80 patients, 184 vessels Am J Cardiol 2005;96:877-884 4 October 2016
- 14. 4 October 2016
- 16. Method 04/10/2016 The RIPCORD Study Diagnostic Coronary Angiogram by Cardiologist 1 Patient being investigated for chest pain TREATMENT PLAN 1 Medical/PCI/CABG/more info FFR* of all patent vessels of stentable (>2.25mm) diameter by Cardiologist 2 TREATMENT PLAN 2 Medical/PCI/CABG/more info Primary endpoint based upon the difference between Plan 1 and Plan 2 *FFR<0.8 Cardiologist 1 shown FFR results n=200
- 18. 4-Oct-16 Results: PRIMARY ENDPOINT Management of population by angiogram versus FFR Fishers exact test p<0.0001 Summary Agreement about category of management in 147 out of 200 (74%) ie after FFR management change in 26% of cases FFR The RIPCORD Study ANGIO PLAN 1 PLAN 2
- 19. 4-Oct-16 Limitations No clinical outcome High denominator… selection of cases… CTOs not part of this trial Already VERY unpopular with non-interventional cardiologists! The RIPCORD Study But, even so, the message that FFR makes a more accurate diagnosis & therefore leads to the patient getting more accurate treatment is spookily consistent with other evidence…….
- 20. Toth et al EHJ 2014Curzen et al Circ Interven 2014 Tonino et al JACC 2010 4-Oct-16 Berry et al Eur Heart J 2014
- 21. 4-Oct-16 The RIPCORD Study No matter how experienced you are… No matter how “tight” the lesion looks… You will be wrong on the angio in about 30% of lesions!
- 22. 4-Oct-16 IMPLICATIONS These results have potentially important implications for clinical practice: - management of patients with stable angina by angiogram alone is flawed - management of patients would be improved by routine use of FFR at the diagnostic stage A large scale randomised trial of angiographic- versus FFR-guided assessment & management of patients undergoing diagnostic angiography with stable angina is now warranted The RIPCORD Study RIPCORD 2
- 23. 4-Oct-16 Circulation 2014 -n=1075 consecutive patients undergoing diagnostic angiography including an FFR Investigation -Patients had to have at least 1 angiographically ambiguous lesion -Primary objective was to describe the rate of reclassification of the patient’s coronary revascularisation strategy by an intention to use FFR in patients referred for coronary angiography
- 24. 4-Oct-16
- 25. 4-Oct-16
- 27. 4-Oct-164 October 2016 Circulation Cardiov Interven 2016 • Multicentre registry • Non-selected patients undergoing angiography in whom at least 1 lesion underwent FFR • n=918 patients with 1293 lesions • FFR-determined change in management cf angio alone • Endpoint = MACE at 1 year (CV death + MI + unplanned revasc)
- 32. Cardiovasc Inter & Ther 2014 Am J Cardiol 2007 Eurointervention 2016 Circulation Cardiov Interv 2014 Eur Heart J 2014 Circulation 2014 Circulation Cardiov Interv 2016
- 33. 4-Oct-164 October 2016 Study Year No. Patients Setting FFR Limit Stenosis Limit Change in management Lesion Change Sant'Anna et al 2007 250 Elective 0.75 >50% 48% 32% RIPCORD 2014 200 Elective 0.8 >30% 26% 32% CVIT-DEFER Registry 2014 3093 Elective & ACS 0.8 50-90% 39% FAMOUS 2014 350 ACS 0.8 >30% 22% FFR-R3F 2014 1075 Elective & ACS 0.8 35-65% 43% POST-IT 2016 918 Elective & ACS 0.75-0.8 Intermediate 44% 45% Danish Registry 2016 1,716 Elective 0.8 50-89% 31% 48% FFRCT RIPCORD 2016 200 Elective 0.8 >30% 36%
- 34. 4-Oct-164 October 2016 Conclusion: FFR assessment – how it affects clinical judgement A discrepancy exists between anatomical (angiographic) and physiological (FFR) assessment of lesion “significance” It has been repeatedly shown that in around 30% of lesions, it is not possible to predict whether they are ischaemic based on the angogram alone As a result, there is a consistent difference in the angio-directed management of patients and the management derived from FFR data …. Specifically, in between 22-48% of cases, the management changes when FFR is available There is a already strong case to use FFR routinely at diagnostic angiography…. Difficult to justify not using FFR! RIPCORD 2
- 35. 4 October 2016
- 36. FFR 50mcg adenosine LAD after 3x24 DES = 0.73 FFR 50mcg adenosine LAD after 3x12 DES = 0.76 Only after 3.5 NC balloon in top stent FFR 50mcg adenosine = 0.90 4-Oct-16