Korean Circ J.  2024 Aug;54(8):485-496. 10.4070/kcj.2024.0046.

Discordance Between Angiographic Assessment and Fractional Flow Reserve or Intravascular Ultrasound in Intermediate Coronary Lesions: A Post-hoc Analysis of the FLAVOUR Trial

• Lee JH
• Ahn SG
• Jeon HS
• Lee JW
• Youn YJ
• Zhang J
• Hu X
• Wang J
• Lee JM
• Hahn JY
• Nam CW
• Doh JH
• Lee BK
• Kim W
• Huang J
• Jiang F
• Zhou H
• Chen P
• Tang L
• Jiang W
• Chen X
• He W
• Yoon MH
• Tahk SJ
• Kim U
• Ki YJ
• Shin ES
• Hwang D
• Kang J
• Kim HS
• Koo BK

• KMID: 2558540
• DOI: http://doi.org/10.4070/kcj.2024.0046

Abstract

Background and Objectives
Angiographic assessment of coronary stenosis severity using quantitative coronary angiography (QCA) is often inconsistent with that based on fractional flow reserve (FFR) or intravascular ultrasound (IVUS). We investigated the incidence of discrepancies between QCA and FFR or IVUS, and the outcomes of FFR- and IVUS-guided strategies in discordant coronary lesions.
Methods
This study was a post-hoc analysis of the FLAVOUR study. We used a QCA-derived diameter stenosis (DS) of 60% or greater, the highest tertile, to classify coronary lesions as concordant or discordant with FFR or IVUS criteria for percutaneous coronary intervention (PCI). The patient-oriented composite outcome (POCO) was defined as a composite of death, myocardial infarction, or revascularization at 24 months.
Results
The discordance rate between QCA and FFR or IVUS was 30.2% (n=551). The QCAFFR discordance rate was numerically lower than the QCA-IVUS discordance rate (28.2% vs. 32.4%, p=0.050). In 200 patients with ≥60% DS, PCI was deferred according to negative FFR (n=141) and negative IVUS (n=59) (15.3% vs. 6.5%, p<0.001). The POCO incidence was comparable between the FFR- and IVUS-guided deferral strategies (5.9% vs. 3.4%, p=0.479). Conversely, 351 patients with DS <60% underwent PCI according to positive FFR (n=118) and positive IVUS (n=233) (12.8% vs. 25.9%, p<0.001). FFR- and IVUS-guided PCI did not differ in the incidence of POCO (9.5% vs. 6.5%, p=0.294).
Conclusions
The proportion of QCA-FFR or IVUS discordance was approximately one third for intermediate coronary lesions. FFR- or IVUS-guided strategies for these lesions were comparable with respect to POCO at 24 months.

Keyword

Fractional flow reserve, myocardial; Ultrasonography, interventional; Percutaneous coronary intervention; Treatment outcome

Figure

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  Figure 1 Study flow. The highest tertile (60%) DS by QCA was used to categorize lesions discordant with the FFR or IVUS criteria. PCI was deferred in 200 patients with ≥60% DS (141 with FFR and 59 with IVUS), whereas 351 patients with DS <60% underwent PCI (118 with FFR and 233 with IVUS).DS = diameter stenosis; FFR = fractional flow reserve; IVUS = intravascular ultrasound; QCA = quantitative coronary angiography.

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  Figure 2 Correlation between DS and FFR or IVUS minimum lumen area. There is an inverse correlation between %DS and FFR (A) or the minimum lumen area on IVUS (B). The proportions of discordance between QCA and FFR or IVUS were 28.2% and 32.4%, respectively (p=0.050). In the FFR group, 141 vessels (15.3%) had lesions with DS ≥60% but were FFR negative, and 118 vessels (12.8%) showed DS <60% but were FFR positive. In the IVUS group, 59 vessels (6.5%) showed IVUS negativity among lesions with DS ≥60%, and 233 vessels (25.9%) showed IVUS positivity among lesions with DS <60%.DS = diameter stenosis; FFR = fractional flow reserve; IVUS = intravascular ultrasound; QCA = quantitative coronary angiography.

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  Figure 3 Cumulative 2-year clinical outcomes based on FFR- or IVUS-guided decision making. The 2-year cumulative event POCO was matched between the FFR and IVUS arms in deferred lesions with DS ≥60% but FFR- or IVUS-negative (A), and (B) in PCI lesions with DS <60% but FFR- or IVUS-positive. POCO was defined as a composite of all-cause death, myocardial infarction, and revascularization.CI = confidence interval; DS = diameter stenosis; FFR = fractional flow reserve; HR = hazard ratio; IVUS = intravascular ultrasound; PCI = percutaneous coronary intervention; POCO = patient-oriented composite outcome; QCA = quantitative coronary angiography.

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