FFR IN MULTIVESSEL DISEASE Sample Clauses

FFR IN MULTIVESSEL DISEASE. The FAME trial (90) demonstrated that stenting in multivessel disease with FFR guidance results in fewer adverse events (death, non fatal MI and repeat revascularisation) than with angiography guidance. It has been suggested that this is likely to be due to a reduction in stent usage leading to a reduction in events, due to less side branch occlusion or embolisation and stent thrombosis. Although this suggests that an FFR guided strategy is superior to an angiography guided strategy the utility of stenting in multivessel disease needs to be examined more closely. One of the advantages of FFR is that it allows precise localisation of the lesion causing ischaemia, which is thought to be superior to the spatial resolution of non-invasive imaging. Every artery or segment is analysed separately, and potential masking of one ischaemic area by another, more severely ischaemic zone is avoided. However, the utility of FFR to guide complete revascularisation as opposed to a “targeted revascularisation” approach needs to be considered. The COURAGE trial(67) failed to show a benefit for revascularisation when compared with optimal medical therapy, albeit in a low risk population with non-complex CAD. PCI was only beneficial in terms of ischaemia reduction in patients with significant ischaemia at the start. Thus there is an emerging concept that a favourable prognosis results from substantial ischaemia reduction rather than complete anatomical revascularisation. In the FAME trial (90), the main difference between the angiography and the FFR guided groups was a difference in the primary endpoint of mortality and myocardial infarction with no significant difference in angina reduction between the two groups (76% vs 80% free form angina at two years) (91). As alluded to earlier, the higher rate of death and myocardial infarction may be related to the increased number of stents used in the angiography guided vs FFR guided strategy (2.7 vs 1.9 stents per patient respectively). Although there is clear demonstration that an FFR guided strategy is better than an angiographic strategy as it reduces the amount of excessive stent usage, there is no evidence that stenting in itself leads to symptomatic improvement or improved prognosis. Thus, it is possible that targeting revascularisation of lesions with a high ischaemic burden further, both within the multi-vessel and single vessel cohort could be beneficial in terms of symptom reduction as well as further reducing stent utilis...