Prognostic Implications of Fractional Flow Reserve After Coronary Stenting : A Systematic Review and Meta-analysis

Key Points

Question

What is the clinical relevance of fractional flow reserve (FFR) after percutaneous coronary intervention (PCI) with a drug-eluting stent?

Findings

In this systematic review and individual patient-level meta-analysis, low post-PCI FFR was common and demonstrated a significant and inverse association with target vessel failure. This association remained consistent for the risk of cardiac death or target vessel myocardial infarction.

Meaning

These results support the importance of post-PCI physiologic assessment and the role of post-PCI FFR as a procedural quality metric.

Abstract

This systematic review and meta-analysis examines clinical outcomes associated with low fractional flow reserve measures after percutaneous coronary interventions with drug-eluting stents.

Abstract

Importance

Fractional flow reserve (FFR) after percutaneous coronary intervention (PCI) is generally considered to reflect residual disease. Yet the clinical relevance of post-PCI FFR after drug-eluting stent (DES) implantation remains unclear.

Objective

To evaluate the clinical relevance of post-PCI FFR measurement after DES implantation.

Data Sources

MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were searched for relevant published articles from inception to June 18, 2022.

Study Selection

Published articles that reported post-PCI FFR after DES implantation and its association with clinical outcomes were included.

Data Extraction and Synthesis

Patient-level data were collected from the corresponding authors of 17 cohorts using a standardized spreadsheet. Meta-estimates for primary and secondary outcomes were analyzed per patient and using mixed-effects Cox proportional hazard regression with registry identifiers included as a random effect. All processes followed the Preferred Reporting Items for Systematic Review and Meta-analysis of Individual Participant Data.

Main Outcomes and Measures

The primary outcome was target vessel failure (TVF) at 2 years, a composite of cardiac death, target vessel myocardial infarction (TVMI), and target vessel revascularization (TVR). The secondary outcome was a composite of cardiac death or TVMI at 2 years.

Results

Of 2268 articles identified, 29 studies met selection criteria. Of these, 28 articles from 17 cohorts provided data, including a total of 5277 patients with 5869 vessels who underwent FFR measurement after DES implantation. Mean (SD) age was 64.4 (10.1) years and 4141 patients (78.5%) were men. Median (IQR) post-PCI FFR was 0.89 (0.84-0.94) and 690 vessels (11.8%) had a post-PCI FFR of 0.80 or below. The cumulative incidence of TVF was 340 patients (7.2%), with cardiac death or TVMI occurring in 111 patients (2.4%) at 2 years. Lower post-PCI FFR significantly increased the risk of TVF (adjusted hazard ratio [HR] per 0.01 FFR decrease, 1.04; 95% CI, 1.02-1.05; P < .001). The risk of cardiac death or MI also increased inversely with post-PCI FFR (adjusted HR, 1.03; 95% CI, 1.00-1.07, P = .049). These associations were consistent regardless of age, sex, the presence of hypertension or diabetes, and clinical diagnosis.

Conclusions and Relevance

Reduced FFR after DES implantation was common and associated with the risks of TVF and of cardiac death or TVMI. These results indicate the prognostic value of post-PCI physiologic assessment after DES implantation.