Impact of Routine Invasive Physiology at Time of Angiography in Patients With Multivessel Coronary Artery Disease on Reclassification of Revascularization Strategy: Results From the DEFINE REAL Study

Eric Van Belle, Robert Gil, Volker Klauss, Mohammed Balghith, Martijn Meuwissen, Jérôme Clerc, Bernhard Witzenbichler, Miha Cercek, Marios Vlachojannis, Irene Lang, Philippe Commeau, Flavien Vincent, Luca Testa, Wojciech Wasek, Nicolas Debry, Stephan Kische, Gabriele Gabrielli, Gennaro Sardella

Research output: Contribution to journalArticle

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Abstract

Objectives: This study sought to prospectively assess the impact of routine invasive physiology at the time of angiography on reclassification of therapeutic management of multivessel disease (MVD) patients, and to assess how implementation of instantaneous wave-free ratio (iFR) alters the process. Background: Routine invasive physiology in intermediate coronary lesions at the time of diagnostic angiography, primarily in patients with single-vessel disease and using fractional flow reserve (FFR), reclassifies coronary revascularization management in 26% to 44% of patients. The role of invasive physiology in patients with MVD is unclear. Methods: In 18 centers, 484 patients undergoing diagnostic angiography disclosing MVD with lesions >40% by visual assessment were included. Investigators were asked to prospectively define their initial management strategy based on angiography and clinical information. Invasive physiology (FFR or iFR driven) was then performed and final strategy defined. Initial and final vessel, patient, procedural, and overall management were described. Reclassification was defined as the difference between initial and final strategy. Results: The majority of patients were clinically stable (82.2%). Two- and 3-vessel disease was present in 73.3% and 26.7% of patients, respectively. Lesions investigated were “intermediate” with median percent stenosis, median FFR, and median iFR at 60% (interquartile range [IQR]: 50% to 70%), 0.84 (IQR: 0.78 to 0.90), and 0.92 (IQR: 0.85 to 0.96), respectively. Vessel management was reclassified by physiology in 30.0% (249 of 828) of vessels. Patient and overall management were reclassified in 26.9% (130 of 484) and 45.7% (211 of 484) of patients, respectively. Reclassification rates were high irrespective of initial management (optimal medical therapy, percutaneous coronary intervention, or coronary artery bypass grafting), and performance and results of pre-procedural noninvasive tests. Reclassification of overall management in particular increased with the number of vessels investigated (1 vessel: 37.3%; 2 vessels: 45.0%; 3 vessels: 66.7%; p = 0.002). Incorporating iFR in the decision process was associated with investigation of more vessels (p = 0.04) and higher reclassification (p = 0.0001). Conclusions: In patients with MVD and intermediate coronary lesions, invasive physiology at time of angiography reclassifies revascularization strategy in a large proportion of cases (26.9%) and investigation of more vessels is associated with higher reclassification rates.

Original languageEnglish
Pages (from-to)354-365
Number of pages12
JournalJACC: Cardiovascular Interventions
Volume11
Issue number4
DOIs
Publication statusPublished - Feb 26 2018

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Coronary Artery Disease
Angiography
Percutaneous Coronary Intervention
Disease Management
Coronary Artery Bypass
Coronary Disease
Pathologic Constriction
Research Personnel
Therapeutics

Keywords

  • coronary stenosis
  • FFR
  • iFR
  • MVD
  • physiological assessment

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine

Cite this

Impact of Routine Invasive Physiology at Time of Angiography in Patients With Multivessel Coronary Artery Disease on Reclassification of Revascularization Strategy : Results From the DEFINE REAL Study. / Van Belle, Eric; Gil, Robert; Klauss, Volker; Balghith, Mohammed; Meuwissen, Martijn; Clerc, Jérôme; Witzenbichler, Bernhard; Cercek, Miha; Vlachojannis, Marios; Lang, Irene; Commeau, Philippe; Vincent, Flavien; Testa, Luca; Wasek, Wojciech; Debry, Nicolas; Kische, Stephan; Gabrielli, Gabriele; Sardella, Gennaro.

In: JACC: Cardiovascular Interventions, Vol. 11, No. 4, 26.02.2018, p. 354-365.

Research output: Contribution to journalArticle

Van Belle, E, Gil, R, Klauss, V, Balghith, M, Meuwissen, M, Clerc, J, Witzenbichler, B, Cercek, M, Vlachojannis, M, Lang, I, Commeau, P, Vincent, F, Testa, L, Wasek, W, Debry, N, Kische, S, Gabrielli, G & Sardella, G 2018, 'Impact of Routine Invasive Physiology at Time of Angiography in Patients With Multivessel Coronary Artery Disease on Reclassification of Revascularization Strategy: Results From the DEFINE REAL Study', JACC: Cardiovascular Interventions, vol. 11, no. 4, pp. 354-365. https://doi.org/10.1016/j.jcin.2017.11.030
Van Belle, Eric ; Gil, Robert ; Klauss, Volker ; Balghith, Mohammed ; Meuwissen, Martijn ; Clerc, Jérôme ; Witzenbichler, Bernhard ; Cercek, Miha ; Vlachojannis, Marios ; Lang, Irene ; Commeau, Philippe ; Vincent, Flavien ; Testa, Luca ; Wasek, Wojciech ; Debry, Nicolas ; Kische, Stephan ; Gabrielli, Gabriele ; Sardella, Gennaro. / Impact of Routine Invasive Physiology at Time of Angiography in Patients With Multivessel Coronary Artery Disease on Reclassification of Revascularization Strategy : Results From the DEFINE REAL Study. In: JACC: Cardiovascular Interventions. 2018 ; Vol. 11, No. 4. pp. 354-365.
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abstract = "Objectives: This study sought to prospectively assess the impact of routine invasive physiology at the time of angiography on reclassification of therapeutic management of multivessel disease (MVD) patients, and to assess how implementation of instantaneous wave-free ratio (iFR) alters the process. Background: Routine invasive physiology in intermediate coronary lesions at the time of diagnostic angiography, primarily in patients with single-vessel disease and using fractional flow reserve (FFR), reclassifies coronary revascularization management in 26{\%} to 44{\%} of patients. The role of invasive physiology in patients with MVD is unclear. Methods: In 18 centers, 484 patients undergoing diagnostic angiography disclosing MVD with lesions >40{\%} by visual assessment were included. Investigators were asked to prospectively define their initial management strategy based on angiography and clinical information. Invasive physiology (FFR or iFR driven) was then performed and final strategy defined. Initial and final vessel, patient, procedural, and overall management were described. Reclassification was defined as the difference between initial and final strategy. Results: The majority of patients were clinically stable (82.2{\%}). Two- and 3-vessel disease was present in 73.3{\%} and 26.7{\%} of patients, respectively. Lesions investigated were “intermediate” with median percent stenosis, median FFR, and median iFR at 60{\%} (interquartile range [IQR]: 50{\%} to 70{\%}), 0.84 (IQR: 0.78 to 0.90), and 0.92 (IQR: 0.85 to 0.96), respectively. Vessel management was reclassified by physiology in 30.0{\%} (249 of 828) of vessels. Patient and overall management were reclassified in 26.9{\%} (130 of 484) and 45.7{\%} (211 of 484) of patients, respectively. Reclassification rates were high irrespective of initial management (optimal medical therapy, percutaneous coronary intervention, or coronary artery bypass grafting), and performance and results of pre-procedural noninvasive tests. Reclassification of overall management in particular increased with the number of vessels investigated (1 vessel: 37.3{\%}; 2 vessels: 45.0{\%}; 3 vessels: 66.7{\%}; p = 0.002). Incorporating iFR in the decision process was associated with investigation of more vessels (p = 0.04) and higher reclassification (p = 0.0001). Conclusions: In patients with MVD and intermediate coronary lesions, invasive physiology at time of angiography reclassifies revascularization strategy in a large proportion of cases (26.9{\%}) and investigation of more vessels is associated with higher reclassification rates.",
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TY - JOUR

T1 - Impact of Routine Invasive Physiology at Time of Angiography in Patients With Multivessel Coronary Artery Disease on Reclassification of Revascularization Strategy

T2 - Results From the DEFINE REAL Study

AU - Van Belle, Eric

AU - Gil, Robert

AU - Klauss, Volker

AU - Balghith, Mohammed

AU - Meuwissen, Martijn

AU - Clerc, Jérôme

AU - Witzenbichler, Bernhard

AU - Cercek, Miha

AU - Vlachojannis, Marios

AU - Lang, Irene

AU - Commeau, Philippe

AU - Vincent, Flavien

AU - Testa, Luca

AU - Wasek, Wojciech

AU - Debry, Nicolas

AU - Kische, Stephan

AU - Gabrielli, Gabriele

AU - Sardella, Gennaro

PY - 2018/2/26

Y1 - 2018/2/26

N2 - Objectives: This study sought to prospectively assess the impact of routine invasive physiology at the time of angiography on reclassification of therapeutic management of multivessel disease (MVD) patients, and to assess how implementation of instantaneous wave-free ratio (iFR) alters the process. Background: Routine invasive physiology in intermediate coronary lesions at the time of diagnostic angiography, primarily in patients with single-vessel disease and using fractional flow reserve (FFR), reclassifies coronary revascularization management in 26% to 44% of patients. The role of invasive physiology in patients with MVD is unclear. Methods: In 18 centers, 484 patients undergoing diagnostic angiography disclosing MVD with lesions >40% by visual assessment were included. Investigators were asked to prospectively define their initial management strategy based on angiography and clinical information. Invasive physiology (FFR or iFR driven) was then performed and final strategy defined. Initial and final vessel, patient, procedural, and overall management were described. Reclassification was defined as the difference between initial and final strategy. Results: The majority of patients were clinically stable (82.2%). Two- and 3-vessel disease was present in 73.3% and 26.7% of patients, respectively. Lesions investigated were “intermediate” with median percent stenosis, median FFR, and median iFR at 60% (interquartile range [IQR]: 50% to 70%), 0.84 (IQR: 0.78 to 0.90), and 0.92 (IQR: 0.85 to 0.96), respectively. Vessel management was reclassified by physiology in 30.0% (249 of 828) of vessels. Patient and overall management were reclassified in 26.9% (130 of 484) and 45.7% (211 of 484) of patients, respectively. Reclassification rates were high irrespective of initial management (optimal medical therapy, percutaneous coronary intervention, or coronary artery bypass grafting), and performance and results of pre-procedural noninvasive tests. Reclassification of overall management in particular increased with the number of vessels investigated (1 vessel: 37.3%; 2 vessels: 45.0%; 3 vessels: 66.7%; p = 0.002). Incorporating iFR in the decision process was associated with investigation of more vessels (p = 0.04) and higher reclassification (p = 0.0001). Conclusions: In patients with MVD and intermediate coronary lesions, invasive physiology at time of angiography reclassifies revascularization strategy in a large proportion of cases (26.9%) and investigation of more vessels is associated with higher reclassification rates.

AB - Objectives: This study sought to prospectively assess the impact of routine invasive physiology at the time of angiography on reclassification of therapeutic management of multivessel disease (MVD) patients, and to assess how implementation of instantaneous wave-free ratio (iFR) alters the process. Background: Routine invasive physiology in intermediate coronary lesions at the time of diagnostic angiography, primarily in patients with single-vessel disease and using fractional flow reserve (FFR), reclassifies coronary revascularization management in 26% to 44% of patients. The role of invasive physiology in patients with MVD is unclear. Methods: In 18 centers, 484 patients undergoing diagnostic angiography disclosing MVD with lesions >40% by visual assessment were included. Investigators were asked to prospectively define their initial management strategy based on angiography and clinical information. Invasive physiology (FFR or iFR driven) was then performed and final strategy defined. Initial and final vessel, patient, procedural, and overall management were described. Reclassification was defined as the difference between initial and final strategy. Results: The majority of patients were clinically stable (82.2%). Two- and 3-vessel disease was present in 73.3% and 26.7% of patients, respectively. Lesions investigated were “intermediate” with median percent stenosis, median FFR, and median iFR at 60% (interquartile range [IQR]: 50% to 70%), 0.84 (IQR: 0.78 to 0.90), and 0.92 (IQR: 0.85 to 0.96), respectively. Vessel management was reclassified by physiology in 30.0% (249 of 828) of vessels. Patient and overall management were reclassified in 26.9% (130 of 484) and 45.7% (211 of 484) of patients, respectively. Reclassification rates were high irrespective of initial management (optimal medical therapy, percutaneous coronary intervention, or coronary artery bypass grafting), and performance and results of pre-procedural noninvasive tests. Reclassification of overall management in particular increased with the number of vessels investigated (1 vessel: 37.3%; 2 vessels: 45.0%; 3 vessels: 66.7%; p = 0.002). Incorporating iFR in the decision process was associated with investigation of more vessels (p = 0.04) and higher reclassification (p = 0.0001). Conclusions: In patients with MVD and intermediate coronary lesions, invasive physiology at time of angiography reclassifies revascularization strategy in a large proportion of cases (26.9%) and investigation of more vessels is associated with higher reclassification rates.

KW - coronary stenosis

KW - FFR

KW - iFR

KW - MVD

KW - physiological assessment

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