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Applying the surgical precept of complete coronary revascularization to percutaneous coronary intervention has led to the common belief that optimal results of PCI in patients with multivessel disease require revascularization of all stenotic lesions. However, little evidence supports this belief. In fact, revascularization of only the culprit lesions (those causing ischemia) might well be the most effective strategy for most contemporary PCI procedures.
Fractional flow reserve (FFR) measurement is an invasive method for identifying a culprit lesion: A pressure guidewire is placed distally to the stenosis to calculate the pressure gradient during hyperemic stress produced by adenosine-induced dilation of the microvasculature. Investigators for the manufacturer-sponsored FAME (FFR vs. Angiography for Multivessel Evaluation) study randomly assigned 1005 patients with multivessel coronary disease (mean age, 64; one quarter, women) to FFR-based PCI (revascularization only of vessels with FFR ≤80%) or to conventional PCI (guided by angiography alone).
At 1 year, the rate of death, MI, or repeat revascularization was lower in the FFR-based group than in the conventional group (13.2% vs. 18.3%; P=0.02). The mean number of coronary lesions per patient was similar in both groups (2.8 vs. 2.7), but 37% of lesions in FFR-based group were considered nonischemic (FFR >80%). Consequently, significantly fewer drug-eluting stents were used in the FFR-based group than in the conventional group (1.9 vs. 2.7, P<0.001), and the cost of materials was significantly lower (US$5332 vs. US$6007; P<0.001).
Tonino PAL et al. for the FAME Study Investigators. Fractional flow reserve versus angiography for guiding percutaneous coronary intervention. N Engl J Med 2009 Jan 15; 360:213.
Ellis SG. Refining the art and science of coronary stenting. N Engl J Med 2009 Jan 15; 360:292.
Comment
These findings indicate that the decision to treat or not to treat a coronary lesion of moderate angiographic severity with a drug-eluting stent can be refined by a simple but objective evaluation of ischemia. The message is important for the interventional cardiology community. If these results are sustained through long-term follow-up — and perhaps confirmed by a validation study — this approach might decrease complication rates and costs and enhance the beneficial effects of PCI.