Prognostic value of fractional flow reserve: linking physiologic severity to clinical outcomes.
In this manuscript, the authors use meta-analysis techniques to evaluate the relationship between measured coronary fractional flow reserve (FFR) and patients’ outcomes. They demonstrate that FFR provides a continuous and independent marker of subsequent MACE as modulated by treatment (medical therapy vs revascularization) in a broad range of clinical scenarios. Lesions with lower FFR values receive larger absolute benefits from PCI or CABG. When FFR values are high, we can do harm by proceeding with revascularization. The cut-point for determining revascularization strategy using this statistical analysis remains in the 0.75-0.80 range, which is in keeping with previous reports on this subject. According to the findings, the authors conclude that an FFR-guided revascularization strategy significantly reduces MACE and increases freedom from angina with less PCI or CABG than an anatomy-based strategy.
a classic error to assume that CABG and PCI are equivalent when analysisng FFR. If I am interpreting the meta- analysis correctly virtually no patient had CABG and yet the authors have extrapolated the data to assume all revascularisation strategies are equivalent. It would seem the concept of burdon of disease and distal vessel grafting protecting against future disease will be dismissed as cardiologists use FFR to downgrade the number of diseased vessels to justify limited PCI revascularisation. Perhaps another interpretation is that FFR results demonstrate as many have long suspected that cardiologists are not as good as they think at picking the “culprit” lesion and therefore have suffered worse results as a result of the incomplete revascularisation.