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With growing use of invasive diagnostic tools to improve lesion assessment and optimize interventional procedures, the Society for Cardiovascular Angiography and Intervention (SCAI) has published an expert consensus statement outlining how to leverage each modality to achieve the best outcomes based on recent research. The guidance was published online November 13, 2013, ahead of print in Catheterization and Cardiovascular Interventions.
Lloyd W. Klein, MD, of Rush Medical College (Chicago, IL), and colleagues on the SCAI writing committee sought to fill a gap in recommendations since the American College of Cardiology Foundation/American Heart Association/SCAI PCI guidelines were last updated in 2011. “The purpose of this consensus statement is to review recent studies, to develop a consensus of how these procedures are best utilized in practice, and to support their incorporation into guideline and appropriate use documents,” they write.
Each Technique Has a Role
The SCAI report focuses specifically on the benefits of 3 modalities—FFR, IVUS, and OCT (table 1).
Table 1. Recommendations for Use of FFR, IVUS, and OCT
FFR-guided PCI improves outcomes vs. PCI guided by angiography alone in patients with multivessel disease.
In 3-vessel disease, measurement helps guide decisions on whether to perform PCI or surgery and whether a patient needs urgent care vs. medication alone.
Can determine optimal stent deployment and the size of the vessel undergoing stent implantation, ensuring proper fit.
Could appraise the significance of LM stenosis and assess whether or not revascularization is warranted.
Could determine optimal stent deployment with improved resolution compared with IVUS.
The concern that “we’re overutilizing stents can be completely handled by increasing the use of objective measures of ischemia,” Dr. Klein told TCTMD in a telephone interview. “The whole question of FFR has progressed in a substantial way” since the FAME 1 and FAME 2 trials were published, he added.
In lesions of between 50% and 90% stenosis, FFR is going to play an increasingly pivotal role, Dr. Klein continued. “FFR needs to become part of every interventional cardiologist’s armamentarium,” he said. “I think FFR is totally underused and will have a major impact in the future.”
OCT is more in its “adolescence,” he observed. While it has certain advantages over IVUS, there have not been any studies of whether it improves outcomes or when it can be used other than as an adjunct to a stenting procedure. However, OCT “has a lot of potential” going forward, he said.
“IVUS is the opposite, having been [available] for 20 years,” Dr. Klein explained. “I think the question with IVUS is whether or not compared to FFR and OCT it’s going to have a role going forward. Right now it’s still a very easy and useful technique in the left main, but [there are limitations] in non-left main lesions. So I’m not sure where it’s going to go.”
‘Functional Angioplasty’ the Way of the Future
Dr. Klein said that although he is unaware of any plans for updated PCI guidelines, he hopes this paper will be used as a significant part of the guidelines writing committee’s evaluation. “We consciously tried not to write [the paper] in the way you’d write guidelines because we’re not writing guidelines,” he explained. “But we do want there to be a sense that certainly when it comes to FFR, there definitely needs to be a change in the guidelines and how doctors are using them. Perhaps also for IVUS as well.”
So-called functional angioplasty will also play a more prominent role in the future, he observed. “Functional angioplasty differs from what we currently do--make a visual assessment angiographically of the severity of the stenosis and correlate that with stress testing,” Dr. Klein commented. In the future, “the percentage of stenosis that we’re guestimating from the angiogram [will be] a starting point, but proving physiologic significance is what is going to determine in many patients whether or not they should have a stent.”
Dr. Klein also emphasized the importance of third-party payers supporting the use of diagnostic tools. “If you want to have less overutilization and better use of stenting, then you’ve got to be willing to pay for these tests so that we can connect the dots,” he concluded. “If they don’t pay substantially for it and it’s not worth people’s time to do it, nobody’s going to do it and then that doesn’t move us forward.”
Note: Study coauthor Roxana Mehran, MD, of Mount Sinai School of Medicine (New York, NY), is a faculty member of the Cardiovascular Research Foundation, which owns and operates TCTMD.
Dr. Klein reports no relevant conflicts of interest.