Deferred versus performed revascularisation according to hyperaemic and nonhyperaemic physiological indexes in acute coronary syndrome: insights from the IRIS-FFR Registry

Background/Introduction Physiology-guided PCI in the ACS setting remains debatable. Purpose We aimed to determine the long-term prognostic utility of fractional flow reserve (FFR)- or resting distal coronary pressure to aortic pressure ratio (Pd/Pa)-directed percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS) cases. Methods This study included 11,415 coronary stenoses in 7945 patients, including 1668 ACS cases who underwent FFR and resting Pd/Pa. The primary endpoint was the rate of a composite of cardiac death, spontaneous myocardial infarction (MI), and repeat revascularisation. Results During a median follow-up of 3.9 years (IQR: 2.0–4.9), 108 events (12 cardiac deaths, 9 MIs, and 100 revascularisations) of the primary endpoint occurred in 101 patients. In the deferred lesions with FFR >0.80 or Pd/Pa >0.91, the primary endpoint rate was higher in ACS patients than those with stable ischaemic heart disease (SIHD) (adjusted HR 1.87, 95% CI 1.37–2.55 for FFR; adjusted HR 1.78, 95% CI 1.34–2.38 for Pd/Pa). Among ACS patients with FFR ≤0.8 or Pd/Pa ≤0.91, performed revascularisation was associated with a lower rate of the primary endpoint compared to deferred PCI. (6.0% vs. 15.4%, adjusted HR 0.42, 95% CI 0.23–0.77 for FFR; 4.3% vs. 14%, adjusted HR 0.33–0.71, 95% CI 0.33–0.71 for Pd/Pa). However, performed and deferred groups had similar outcome rates in ACS patients with FFR >0.80 or Pd/Pa >0.91. Conclusion ACS patients who deferred revascularisation based on physiology had higher cardiovascular events than did those with SIHD. FFR- and resting Pd/Pa-directed decision-making for PCI is likely useful even in the ACS setting. Funding Acknowledgement Type of funding source: None