Clinical Relevance of Impaired Physiological Assessment After Percutaneous Coronary Intervention: A Meta-analysis

Abstract

Background: Despite the optimal angiographic result of percutaneous coronary intervention (PCI), residual disease at the site of the culprit lesion can lead to major adverse cardiac events. Post-PCI physiological assessment can identify residual stenosis. This meta-analysis aims to investigate data of studies examining post-PCI physiological assessment in relation to long-term outcomes.

Methods: Studies were included in the meta-analysis after performing a systematic literature search on July 1, 2022. The primary end point was the incidence of major adverse cardiac events, vessel-orientated cardiac events, or target vessel failure.

Results: Low post-PCI fractional flow reserve, reported in 7 studies with fractional flow reserve cutoff values between 0.84 and 0.90, including 4017 patients, was associated with an increased rate of the primary end point (hazard ratio [HR], 2.06; 95% CI, 1.37-3.08). One study reported about impaired post-PCI instantaneous wave-free ratio with instantaneous wave-free ratio cutoff value of 0.95 in relation to major adverse cardiac events, showing a significant association (HR, 3.38; 95% CI, 0.99-11.6; P = .04). Low post-PCI quantitative flow ratio, reported in 3 studies with quantitative flow ratio cutoff value between 0.89 and 0.91, including 1181 patients, was associated with an increased rate of vessel-orientated cardiac events (HR, 3.01; 95% CI, 2.10-4.32). Combining data of all modalities, impaired physiological assessment showed an increased rate of the primary end point (HR, 2.32; 95% CI, 1.71-3.16) and secondary end points, including death (HR, 1.41; 95% CI, 1.04-1.89), myocardial infarction (HR, 2.70; 95% CI, 1.34-5.42) and target vessel revascularization (HR, 2.88; 95% CI, 1.91-4.35).

Conclusions: Impaired post-PCI physiological assessment is associated with increased adverse cardiac events and individual end points, including death, myocardial infarction, and target vessel revascularization. Therefore, prospective studies are awaited on whether physiology-based optimization of PCI results in better clinical outcomes.

Keywords: fractional flow reserve; instantaneous wave-free ratio; major adverse cardiac events; percutaneous coronary intervention; physiological assessment; quantitative flow ratio.

Post-PCIphysiologicalassessment andadversecardiacevents. Forest plots of hazard ratios (HR) of post-PCI physiological assessment and adverse cardiac events, including MACE, VOCE and TVF, defined according to the included studies. Markers represent point estimates of HRs. Marker size represents study weight. Horizontal bars indicate 95% CIs. FFR, fractional flow reserve; iFR, instantaneous wave-free ratio; MACE, major adverse cardiac events; PCI, percutaneous coronary intervention; QFR, quantitative flow ratio; TVF, target vessel failure; VOCE, vessel-orientated cardiac events.

Figure 1

Literature search strategy on post-percutaneous coronary interventionphysiological assessment. FFR, fractional flow reserve; iFR, instantaneous wave-free ratio; QFR, quantitative flow ratio.

Figure 2

Ratio between adverse cardiac events and impaired physiological assessment. The plot of absolute numbers of adverse cardiac events related to the number of impaired physiological assessments categorized for each study. FFR, fractional flow reserve; iFR, instantaneous wave-free ratio; MACE, major adverse cardiovascular events; QFR, quantitative flow ratio.

Figure 3

Post-PCI FFR and adverse cardiac events. Forest plots of hazard ratios (HR) of post-PCI FFR and adverse cardiac events, including MACE, VOCE, and TVF, are defined according to the included studies. Markers represent point estimates of HRs. Marker size represents study weight. Horizontal bars indicate 95% CIs. FFR, fractional flow reserve; MACE, major adverse cardiovascular events; PCI, percutaneous coronary intervention; TVF, target vessel failure; VOCE, vessel-orientated cardiac events.

Figure 4

Post-PCI QFR and adverse cardiac events. Forest plots of hazard ratios (HRs) of post-PCI QFR and adverse cardiac events, including VOCE, defined according to the included studies. Markers represent point estimates of HRs. Marker size represents study weight. Horizontal bars indicate 95% CIs. PCI, percutaneous coronary intervention; QFR: quantitative flow ratio; VOCE, vessel-orientated cardiac events.

Central Illustration

Post-PCI physiological assessment and adverse cardiac events. Forest plots of hazard ratios (HR) of post-PCI physiological assessment and adverse cardiac events, including MACE, VOCE, and TVF, defined according to the included studies. Markers represent point estimates of HRs. Marker size represents study weight. Horizontal bars indicate 95% CIs. FFR, fractional flow reserve; iFR, instantaneous wave-free ratio; MACE, major adverse cardiovascular events; PCI, percutaneous coronary intervention; QFR, quantitative flow ratio; TVF, target vessel failure; VOCE, vessel-orientated cardiac events.

Figure 5

Post-PCI physiological assessment and secondary end points. Forest plots of hazard ratios (HRs) of post-PCI physiological assessment and (A) death, (B) myocardial infarction, and (C) target vessel revascularization. Markers represent point estimates of HRs. Marker size represents study weight. Horizontal bars indicate 95% CIs. PCI, percutaneous coronary intervention.