RIPCORD Study: FFR Results Change Path of Patient Management

PARIS, France—Routine assessment of fractional flow reserve (FFR) at the time of diagnostic angiography could change the course of treatment for more than a quarter of patients with stable angina, according to findings presented Thursday, May 23 at EuroPCR 2013.

For the RIPCORD trial, Nick Curzen, PhD, of University Hospital Southampton (Southampton, United Kingdom), and colleagues enrolled 200 patients with chest pain who were being evaluated for suspected CAD at 10 centers. The protocol involved several steps:

• Cardiologist 1 (typically a noninterventionalist) performed a diagnostic coronary angiogram and then decided on a treatment plan involving medical therapy, PCI, CABG, or further evaluation
• Cardiologist 2 (an interventionalist) performed FFR of all patent vessels of at least 2.25 mm diameter
• The results were then shown to Cardiologist 1, who did or did not revise the treatment plan based on the updated information

One-Quarter of Patients Affected

The treatment plan based on angiography remained the same after FFR in only 145 out of 200 cases (74%). In the remaining 26% of cases, FFR changed the course of patient management.

The overall shift in treatment plans based on imaging results achieved statistical significance (P < 0.0001). Using angiography alone, 36% of patients were slated for medical therapy, 45% for PCI, 11.5% for CABG, and 7.5% for further evaluation. With the addition of FFR, the distribution shifted to 44.5% medical therapy, 40% PCI, 15% CABG, and 0.5% further evaluation.

In the end, 63 of the 72 cases (87.5%) originally selected for medical therapy based on angiography saw no change in their treatment plan after FFR, while 64 of 90 cases (71.1%) slated for PCI and 19 of 23 cases (82.6%) headed toward CABG kept on the same course.

A secondary analysis looking at the number of vessels with significant lesions on angiography and FFR found that in 64 of 200 cases (32%), FFR led to a change in judgment.

“These results have potentially important implications for clinical practice,” Dr. Curzen noted. “The management of patients with stable angina by angiogram alone is probably flawed [and] would be improved by routine use of FFR at the diagnostic stage.”

However, he stressed that the current study offers only “proof of principle” and must be confirmed by a large randomized trial.

Defining the Role of FFR for Suspected CAD

After the presentation, an audience member asked Dr. Curzen whether he thought the disparity between FFR and angiography would exceed differences in interpretation by 2 cardiologists.

“That’s a smart question,” he replied, relating a plan to ask groups of interventionalists, general cardiologists, and surgeons each to interpret the same set of 200 angiograms and FFR measurements and come to a consensus. “My prediction is that the 3 groups based on the angiogram would have really quite different assessments of what should happen to the patients. But I think they would come much closer together when they’ve seen the FFR data.”

Another person raised the issue of whether noninvasive testing prior to angiography might have influenced decisions. About 30% of patients underwent such testing in the current study, Dr. Curzen noted, though he emphasized that as clinical outcomes were not investigated, the issue was not relevant.

Only a randomized trial can truly compare the clinical impact of the 2 approaches, he said. Cost is also a consideration. “Obviously there would be concern about using [an expensive] pressure wire in every angiogram,” Dr. Curzen added, noting that the cost-effectiveness of FFR has thus far only been demonstrated in patients slated for multivessel stenting.

Panel co-chair Rodney H. Stables, MD, of Imperial College London (London, United Kingdom) took issue with the idea that noninvasive testing would not affect treatment decisions in this scenario.

“I accept that,” Dr. Curzen said, but he noted that exercise stress testing, the most common choice in the United Kingdom, does not help localize ischemia, to which Dr. Stables agreed.

 

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Source:
Curzen N. Does routine pressure wire assessment influence management of coronary angiography for diagnosis of chest pain? The RIPCORD study. Presented at: EuroPCR. May 23, 2013. Paris, France.

 

 

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