FFR assessment: how it affects clinical judgment - Nick Curzen

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

15. 4-Oct-16
Circulation: Cardiovasc Interven 2014

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

17. 4-Oct-16
The RIPCORD Study

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

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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)

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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%

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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

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