I am Francisco Hidalgo from the Department of Cardiology
of the Reina Sofia Hospital from Cordoba in Spain.
It is a great pleasure for me to
be with the
Radcliffe interview.
So it's a big pleasure for me.
Yes, well as you know the use of physiological assessment
is our routine practice in the contemporary cath labs,
the IFR presents the advantage
of far quicker evaluation and the absence
of side effects derived from other nursing administration
However, the evidence supporting their use
in acute coronary syndrome is scarce,
and derived from a sub-analysis of the main trials
with already 222 patients until one month follow up.
But the association between acute coronary syndrome
and the presence of other non-culprit lesions
is very frequent in daily practice
and require of PCI decision making available.
But our group has been using the IFR to determine
the need for revascularization of non-culprit lesions.
For this reason we decided to study the usefulness, safety
and efficacy of a physiological evaluation with IFR
of non-culprit lesions in patients
with acute coronary syndrome
with successful revascularization of the culprit vessel.
Yeah, we performed a multicenter registry where
we included 356 patients with acute coronary syndrome
STEMI.
And NSTEMI in whom the IFR was used to guide the need
for revascularization of nonculprit lesions
between January 2017 and December 2019
in four high volume PCI centres of Spain.
The total of
of nonculprit lesions included, were 472 lesions.
The cutoff value was then established
in the main trial, 0.89.
We excluded from the analysis patients
with severe left or right
ventricular dysfunction, cardiogenic shock,
and the of the non-consecution of an optimal result
of the culprit vessel during the index procedure.
Patients were
66 years old and
77% were male
37% had a personal history of diabetes.
And the clinical presentation was NSTEMI
in 66% of the patients, and STEMI in 34%.
The main left ventricular ejection fraction was 55%,
and the radial access
was the choice access in more than 90%
of the patients who presented a mean syntax score of 15.
The most frequent
culprit vessel was the right coronary artery following
by the LAD artery.
That was the most frequent non-culprit vessel analysed.
The primary endpoint of the study was the incidence
of MACE at follow-up, and the secondary endpoint
we established the following.
First, to analyse the components
of the primary endpoint separately.
Two,
to explore predictive factors for MACE.
Three, to calculate the risk of MACE
depending on the clinical scenario, STEMI
versus NSTEMI and to calculate the rates of MACE
according to the IFR obtained during the procedure, a mean.
Patients in whom at least one lesion presenting an IFR
higher than 0.89 and patients in whom
of the lesion analysed presenting an IFR
lower than 0.89%, who were
revascularized.
Yes, we observed a total incidence of MACE of 9%
patients with this strategy
presented at 22 months follow up, incidence of cardiac death
of 1.4% and incidence of myocardial infarction 3.4%
and stent thrombosis of 0.3% and a need for repeat
revascularisation of 3.9%. Regarding secondary endpoints,
we observed that there were no differences in terms of MACE
between patients who presented with STEMI and NSTEMI.
And finally, for me, the most important finding
of the study, we observed that patients
with at least a nonculprit lesion
with a baseline IFR higher than 0.89%, deferred for PCI
a total of 251 patients presented that similar incidence
of MACE, regarding patients in whom or the lesion
analysed presenting an IFR lower than 0.89%
underwent complete revascularization.
A total of 105 patients.
We observed
that the only predictor of a higher incidence
of MACE at follow-up was the presence of a personal history
of prior coronary revascularization, but not for example
the presence of nonculprit lesions
without physiological significance deferred for PCI,
or the type of nonculprit vessel deferred
for revascularisation.
An important point is that, although the main type
of lesion analysed was angiographically
moderate lesions,
the 42% of the lesions can be considered
as a complex lesion, diffuse disease, sequential lesions
bifurcation lesions, in-stent restenosis
coronary revascularisation, etc.
Yeah, I think that the main conclusions are, first,
that IFR guided PCI strategy in nonculprit vessels
in patients with acute coronary syndrome seems to be safe
With an acceptable percentage
of MACE at the mid-term follow-up.
And second, that patients with PCI deferral
of lesions without physiological significance
and patients undergoing complete revascularization show
with a similar rate of cardiac adverse events at follow-up.
Yeah, I think
that the take-home message is that it is feasible to
guide PCI decision-making with the use
of IFR in patients who present an acute coronary syndrome,
a STEMI and NSTEMI with several revascularization
and other nonculprit lesions. Using the same
cut-off value that they established in the main trial,
we know that the probability of suffering MACE
during the followup is similar in patients in whom
at least one of the lesions evaluated
present an IFR higher than 0.89%,
and those patients with complete revascularization.
Yes, I think
that this study can be considered as a hypothesis generator.
I think that isn't necessarily
on a specific randomised clinical trial to confirm
this result, but until we have a specific study
I think that the results are very useful
for the interventional cardiologists who have to
take decision-making in these clinical scenarios
on the daily.