Clinical Relevance of Discordance Between Physiology- and Imaging- Guided PCI Strategies in Intermediate Coronary Stenosis

초록

BACKGROUND Recent randomized clinical trials have demonstrated the benefits of intravascular imaging (IVI)-guided percutaneous coronary intervention (PCI) over angiography-guided PCI. However, the role of angiography-based physiological assessment during IVI-guided PCI remains unclear. OBJECTIVES This study aimed to explore the discrepancies and significance of angiography-based physiological assessments in IVI-guided PCI. METHODS In the international multicenter randomized FLAVOUR (Fractional Flow Reserve and Intravascular Ultrasound for Clinical Outcomes in Patients With Intermediate Stenosis) trial, angiography-based physiological assessment was retrospectively performed using the Murray law-based quantitative flow ratio (mu QFR). In this post hoc analysis, patients were categorized based on intravascular ultrasound (IVUS)-guided treatment decisions (PCI or deferral) and mu QFR as follows: negative mu QFR with deferral of PCI (DEFER), negative mu QFR with PCI (PERFORM), and positive mu QFR with PCI (REFERENCE). The primary outcome was major adverse cardiovascular events, defined as a composite of death, myocardial infarction, and target vessel revascularization at the 24-month follow-up. RESULTS Of the 784 patients, 34.4% (270/784), 29.3% (230/784), and 31.5% (247/784) were categorized into the DEFER, PERFORM, and REFERENCE groups, respectively. Physiological assessment led to substantial reclassification, encompassing 48.2% (230/477) of patients who underwent IVUS-guided PCI. The REFERENCE group showed a higher risk for major adverse cardiovascular events at 2 years compared with the PERFORM group (adjusted HR: 2.46; 95% CI: 1.13-5.35; P = 0.023). However, the primary outcomes in the DEFER and PERFORM groups were similar (adjusted HR: 0.88; 95% CI: 0.37-2.11; P = 0.779). The quality of life at 2 years was comparable among the 3 groups (P = 0.198). CONCLUSIONS Angiography-based physiological assessments can offer additional prognostic insights for patients undergoing IVI-guided PCI. IVUS-guided PCI may not be advantageous in patients with functionally insignificant lesions. (JACC Cardiovasc Interv. 2025;18:145-153) (c) 2025 by the American College of Cardiology Foundation.

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