J Am Heart Assoc. 2018;7(4):JAHA.117.008055.

Clinical Relevance of Functionally Insignificant Moderate Coronary Artery Stenosis Assessed by 3-Vessel Fractional Flow Reserve Measurement.

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제1저자 박종한 · 교신저자 구본권

PMID 29449274 PMC5850206 DOI 10.1161/JAHA.117.008055 IF 6 순환기내과

소속 (17)

Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea.
Department of Internal Medicine, Naju National Hospital, Naju, Korea.
Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Seoul, Korea.
Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea bkkoo@snu.ac.kr.
Institute on Aging, Seoul National University, Seoul, Korea.
Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, South Korea.
Division of Cardiology, Dietrich Bonhoeffer Hospital, Academic Teaching Hospital of University of Greifswald, Greifswald, Germany.
Department of Medicine, Keimyung University Dongsan Medical Center, Daegu, South Korea.
Department of Medicine, Inje University Ilsan Paik Hospital, Goyang, South Korea.
Department of Cardiology, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.
Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China.
Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China.
Department of Cardiology, Tokyo Medical University, Tokyo, Japan.
Kokura Memorial Hospital, Kitakyuku, Japan.
Department of Cardiology, Gifu Heart Center, Gifu, Japan.
Department of Cardiology, Aichi Medical University, Nagakute, Japan.
Wakayama Medical University, Wakayama, Japan.

Abstract

BACKGROUND Understanding of the risk conferred by functionally insignificant lesions in multiple coronary vessels is limited. We investigated the prognostic implications of coronary artery disease (CAD) based on 3-vessel fractional flow reserve (FFR).

METHODS AND RESULTS A total of 1,136 patients underwent FFR measurement in the 3 major epicardial arteries. We defined vessels with "Moderate CAD" as vessels with FFR, 0.81 to 0.87. Patients were classified into Group 1: No apparent CAD (FFR>0.87 in all 3-vessels); Group 2: Single-vessel moderate CAD; Group 3: Multivessel moderate CAD; and Group 4: Functionally significant CAD (FFR≤0.80) in any vessel. The primary end point was 2-year major adverse cardiac events, a composite of cardiac death, myocardial infarction, and ischemia-driven revascularization. Forty-three percent of patients had moderate CAD (Group 2: 403/1136, 35.5%; Group 3: 84/1136, 7.4%). The 2-year risk of major adverse cardiac events was not significantly different between patients with single-vessel moderate CAD and no apparent CAD (2.6 versus 2.6%; HR, 1.1; 95% confidence interval, 0.4%-2.8%; P=0.89). However, patients with multivessel moderate CAD were at significantly higher risk than Group 1 (7.4 versus 2.6%; hazard ratio, 3.3; 95% confidence interval, 1.1%-9.8%; P=0.03). The risk of major adverse cardiac events in patients with multivessel moderate CAD was comparable to that of patients with functionally significant CAD (hazard ratio, 1.2; 95% confidence interval, 0.5%-3.0%; P=0.67). In a multivariable regression model, multivessel moderate CAD was an independent predictor of greater risk of 2-year major adverse cardiac events.

CONCLUSIONS Global physiologic assessment with FFR measurement of 3 vessels can identify multivessel moderate CAD. The prognostic implication of multivessel moderate CAD appears comparable to that of functionally significant CAD.

CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT01621438.

Keywords

coronary artery diseasefractional flow reservemultivessel coronary artery diseasephysiology/functionprognosis

Figures

**Figure 1** Distribution of per‐vessel fractional flow reserve. The histogram depicts the frequency of vessels by FFR values. Among the total 3298 vessels, 12.3% were functionally significant (FFR ≤0.80, yellow bars). The functionally insignificant vessels (87.7%, 2891/3298) are further categorized into quartiles and depicted as bars filled with graded saturation (blue). The darkest blue bars represent vessels in the lowest quartile (FFR 0.81–0.87) defined as moderate CAD in this study. CAD indicates coronary artery disease; FFR, fractional flow reserve.

**Figure 2** Distribution of SYNTAX score among the 4 patient groups. The box plots with whiskers depict distribution of SYNTAX score among the 4 patient groups including interquartile range, median, and minimum to maximum values, within 1.5 times the interquartile range. *P<0.05 for between‐group comparisons; n.s. indicates not significant; SYNTAX, synergy between percutaneous coronary intervention with taxus and cardiac surgery.

**Figure 3** Comparison of 2‐year MACE among the 4 groups. Cumulative incidence of (MACE) in each group is shown. CAD indicates coronary artery disease; FFR, fractional flow reserve; MACE, major adverse cardiac events.

**Figure 4** Comparison of 2‐year MACE among the 4 groups, restricted to subgroups. The clinical outcomes of 4 patient groups are compared in patient subgroups with (A) clinically high‐risk (diabetes mellitus or acute coronary syndrome) and (B) anatomically nonobstructive CAD with all coronary vessels % DS <50%. Cumulative incidences of major adverse cardiac events (MACE) patients are presented. CAD indicates coronary artery disease; DS, diameter stenosis; FFR, fractional flow reserve.

그림 출처: PubMed Central 공개 논문 (PMC5850206)

Comment · 정정

Comment in J Thorac Dis. 2018 Sep;10(Suppl 26):S3078-S3080. doi: 10.21037/jtd.2018.07.129.

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