February 10th, 2011
What’s Keeping Us from Using FFR?
Richard A. Lange, MD, MBA and L. David Hillis, MD
A recent study of PCI in subjects with multivessel CAD showed that procedure costs were lower when a management strategy based on the results of fractional flow reserve (FFR) measurements was employed. The FFR-based strategy resulted in fewer stents used, which more than offset the cost of the FFR pressure wire.
Even though FFR-guided PCI has been shown to improve outcomes, it appears to be underutilized. We want to know how often you use FFR when angiography demonstrates a coronary stenosis of “intermediate” severity (i.e., < 75% narrowing).
If you don’t use FFR in most cases, is it because FFR (1) prolongs the procedure, (2) is of questionable benefit, or (3) is too costly? Or, do you have another reason and if so, what is it?
4 Responses to “What’s Keeping Us from Using FFR?”
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In Japan, we can get pressurewire cost when cathe goes into PTCA procedure, but not in only angio and FFR examination. In DPC senario, the more exams the more we lose. I think “too costly” is the main problem.
This physiologic adjunct, with its consistent robust outcomes data, is the single most meaningful innovation assisting decisionmaking regarding appropriateness of PCI in nonACS. But, one need be rigorous to understand the limitations and pitfalls of patient selection and anatomic subsets(eg, the influence of downstream disease on accuracy).
My understanding of DEFER and FAME are that FFR tells you that it is safe to not stent lesions with an FFR greater than 0.8 in single vessel or multivessel disease. As far as I can tell, it doesn’t instruct us on whether we reduce MACCE events other than revascularization in patients with FFR <0.8. The original 1996 NEJM paper by Dr. Pijls and Dr. De Bruyne demonstrated that an FFR <0.75 correlated very well with an abnormal stress test, but whether MACE rates changed is unclear. My understanding is that Dr. Pijls and Dr. De Bruyne are working on a randomized trial for those with FFR < 0.8, but that recruitment has been slow.
So we end up using FFR quite frequently in the angina patient who hasn't received a stress test, or in the patient with an atypical chest discomfort presentation and a borderline stress test. In patients who presents with angina and a strongly positive stress test, we tend to treat intermediate lesions.
Competing interests pertaining specifically to this post, comment, or both:
No conflicts
It’s a great tool, no question about it. There’s a “grey” area (FFR between 0.75 and 0.8) in that when you get an FFR of, say, 0.78 you’re OK to stent based on FAME but not according to DEFER but in the majority of cases the numbers are pretty clear cut. Furthermore, it never ceases to amaze me how wrong our eyes can sometimes be in assessing functional significance of lesions – how the seemingly “tight” lesion on an angiogram isn’t so bad by FFR and a long moderate lesion subtending a large amount of myocardium (eg in an LAD) ends up with an FFR of 0.6
The larger problem is costs. In Asia, patients bear a significant proportion of the costs as an out-of-pocket expense. The pressure wire is a pretty hefty incremental cost and when you factor that into decision making, sometimes it’s cheaper to go ahead and implant a stent and get it over with. I don’t think it prolongs the procedure substantially.