Prognosis and Medical Cost of Measuring Fractional Flow Reserve in Percutaneous Coronary Intervention

Abstract

Background: There are limited data regarding comparative prognosis and medical cost between fractional flow reserve (FFR)-based and angiography-based percutaneous coronary intervention (PCI) among revascularized patients.

Objectives: This study evaluates prognosis and medical cost of FFR use in revascularized patients by PCI.

Methods: Using the National Health Insurance Service database, stable or unstable angina patients who underwent PCI from 2011 to 2017 were evaluated. Eligible patients were divided into 2 groups according to use of FFR in PCI. Primary outcome was a composite of all-cause death or spontaneous myocardial infarction (MI). Secondary outcomes included individual components of the primary outcome, unplanned revascularization, and medical costs.

Results: Among 134,613 eligible patients, PCI was performed based on angiography (n = 129,497) and FFR (n = 5,116). During the study period, both the annual number and proportion of use of FFR in PCI increased (all P for trend <0.001). The FFR group showed significantly lower risk of the primary outcome (7.0% vs 9.5%; P < 0.001), all-cause death (5.8% vs 7.7%; P = 0.001), and spontaneous MI (1.6% vs 2.2%; P = 0.022) than the angiography group. Although the FFR group showed higher medical cost during index admission than angiography group (median: $6,265.10 vs $5,385.60; P < 0.001), cumulative medical cost after index admission was significantly lower ($2,696.50 vs. $3,142.10; P < 0.001).

Conclusions: Use of FFR in PCI in stable or unstable angina patients showed significantly lower risk of all-cause death and spontaneous MI compared to angiography-based PCI. Although the FFR group had higher initial medical cost than the angiography group, cumulative medical cost after index admission was significantly lower.

Keywords: CABG, coronary artery bypass graft; FFR, fractional flow reserve; IHD, ischemic heart disease; MI, myocardial infarction; PCI, percutaneous coronary intervention; PS, propensity score; RCT, randomized controlled trial; fractional flow reserve; percutaneous coronary intervention; prognosis; stable ischemic heart disease; unstable angina.

Graphical abstract

Graphical abstract

Figure 1

Study Flow Among 134,613 patients who underwent percutaneous coronary intervention (PCI) for stable ischemic heart disease or unstable angina from January 2011 to December 2017, PCI was performed based on angiography (n = 129,497) and fractional flow reserve (FFR) (n = 5,116).AMI = acute myocardial infarction; CABG = coronary artery bypass graft NSTEMI = non–ST-segment elevation myocardial infarction; STEMI = ST-segment elevation myocardial infarction.

Figure 2

Annual Trends of Adoption Rates of FFR-Based PCI Both annual number and proportion of FFR-based PCI significantly increased during the study period. Red dots and red line indicate annual number of angiography-based PCI. Blue dots and blue line indicate annual number of FFR-based PCI. Purple boxes represent proportion of FFR-based PCI in total number of PCI. Abbreviations as in Figure 1.

Figure 3

Cumulative Incidence of Clinical Events Between Angiography and FFR-Based PCI Cumulative incidence of (A) all-cause death, (B) spontaneous myocardial infarction, (C) unplanned revascularization, and (D) death or spontaneous myocardial infarction were compared between FFR-based PCI and angiography-based PCI. Abbreviations as in Figure 1.

Figure 4

Subgroup Analysis for Death or Spontaneous Myocardial Infarction The significantly lower risk of death or spontaneous myocardial infarction in the FFR group than the angiography group was consistently observed across various subgroups. DES = drug-eluting stent; other abbreviations as in Figure 1.

Figure 5

Comparison of Cumulative Medical Cost between Angiography and FFR-Based PCI (A) Medical costs during index admission and follow-up after the index admission are compared between FFR-based PCI and angiography-based PCI. (B) There was significant interaction between FFR use during index PCI and follow-up duration (interaction P < 0.001). Mean values of medical costs were plotted and compared between angiography and FFR-based PCI. Abbreviations as in Figure 1.

Central Illustration

Prognosis and Medical Cost of Measuring FFR in PCI This study evaluated prognosis and medical cost of fractional flow reserve (FFR) use in patients undergoing percutaneous coronary intervention (PCI) for stable ischemic heart disease (IHD) or unstable angina. Among 134,613 patients from the Nationwide Korean National Health Insurance Service database, PCI was guided by angiography (n = 129,497) and FFR (n = 5,116). During the study period, both the number and proportion of FFR-based PCI increased in Korea. The FFR group showed significantly lower risk of all-cause death or spontaneous myocardial infarction than the angiography group at 4 years. Although the FFR group showed higher medical cost during index admission, cumulative medical cost after index admission was significantly lower in the FFR group than angiography group based on lower risk of adverse clinical events. These results from a nationwide cohort support the current guidelines that FFR should be used in decision-making for PCI.

Central Illustration

Prognosis and Medical Cost of Measuring FFR in PCI This study evaluated prognosis and medical cost of fractional flow reserve (FFR) use in patients undergoing percutaneous coronary intervention (PCI) for stable ischemic heart disease (IHD) or unstable angina. Among 134,613 patients from the Nationwide Korean National Health Insurance Service database, PCI was guided by angiography (n = 129,497) and FFR (n = 5,116). During the study period, both the number and proportion of FFR-based PCI increased in Korea. The FFR group showed significantly lower risk of all-cause death or spontaneous myocardial infarction than the angiography group at 4 years. Although the FFR group showed higher medical cost during index admission, cumulative medical cost after index admission was significantly lower in the FFR group than angiography group based on lower risk of adverse clinical events. These results from a nationwide cohort support the current guidelines that FFR should be used in decision-making for PCI.