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QFR-Guided PCI Benefits Build Over Time: FAVOR III China

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Percutaneous coronary intervention (PCI) guided by quantitative flow rate (QFR) rather than angiography improves clinical outcomes at two years, according to new results from the FAVOR III study in China.

“A QFR-guided lesion selection strategy for PCI improved clinical outcomes at 2 years compared to standard angiography guidance, with incrementally increasing benefit over time,” said Lei Song, MD, Fuwai Hospital, National Center for Cardiovascular Disease , Chinese Academy of Medical Sciences and Beijing Union Medical College, Beijing.

The results were presented in a late-breaking session at Transcatheter Cardiovascular Therapeutics (TCT) 2022 and published simultaneously in the Journal of the American College of Cardiology.

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As previously reported at TCT 2021, the results 1 year after the sham-controlled study showed that PCI was successful in approximately 95% of cases with both strategies, but the QFR assessment was associated with less serious adverse cardiac events (MACE) and procedural complications was and implanted stents.

Patients with stable or unstable angina or a myocardial infarction (MI) at least 72 hours prior to screening were included in the study if they had at least one coronary lesion with a stenosis diameter of 50% to 90% and a reference vessel diameter of at least 2.5 mm .

In the QFR group, QFR was measured in all coronary arteries with a lesion, but PCI was only performed for lesions with a QFR of at least 0.80 or a stenosis diameter of more than 90%.

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At 2 years, the primary outcome of MACE—a composite of all-cause death, myocardial infarction, or ischemia-related revascularization—occurred in 8.5% of the QFR group and 12.5% ​​of the angiography group (hazard ratio [HR], 0.66; P<0.0001).

This was caused by fewer MIs (4.0% vs. 6.8%) and ischemia-related revascularization (4.2% vs. 5.8%). The key secondary endpoint of MACE without periprocedural myocardial infarction was also significantly lower with QFR (5.8% vs. 8.8%).

All-cause death (1.1%) and cardiovascular death (0.6%) were identical in both groups.

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The QFR group had significantly lower rates of periprocedural MI (2.9% vs 4.2%), nonprocedural MI (1.1% vs 2.8%), and any revascularization (5.7% vs 7, 3%). Target vessel revascularization (2.4% vs. 3.5%) and stent thrombosis (0.3% vs. 0.5%) tended to be lower.

More pronounced benefits

Among the 3825 randomly assigned participants, post-random assignment revascularization strategy was changed in 23.3% of patients in the QFR-guided group and 6.2% of patients in the angiography-guided group.

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This was due to treatment delay in at least one vessel originally intended for PCI in 19.6% vs. 5.2% and unplanned PCI in at least one vessel intended for PCI in 4.4% vs. 1.5% was not originally intended for treatment.

The reduction in MACE was most pronounced in patients whose preplanned PCI strategy was modified by QFR and in patients who received QFR-concordant treatment, Song observed via video.

The 2-year MACE rate was 8.8% with QFR guidance and 23.5% with angiographic guidance in patients with a change in PCI strategy and 8.4% vs. 11.7% in patients without a plan change ( P for interaction = 0.009 ).

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MACE occurred in 8.8% of patients with QFR-concordant pre-PCI treatment versus 17.2% with non-concordant treatment. MACE without periprocedural MI occurred in 6.1% and 11.9%, respectively (p for both < 0.0001).

In landmark analyses, the absolute risk reduction for MACE with QFR guidance vs. angiography guidance was 3.0% and 1.6% within the first year and between the first and second years (HR 0.65 in each period).

Professor Carlo Di Mario, MD, Careggi University Hospital, Florence, Italy told theheart.org | Medscape Cardiology said the data are interesting and that QFR use is increasing in Italy, but that “we must fully agree that this technique can replace more invasive measurements of the functional severity of the lesion.”

He noted that FFR and IFR are already being used to overcome the limitations of angiography in detecting lesion severity, but that it is unclear from the data whether QFR, the latest iteration, can really overcome this limitation. “The periprocedural myocardial infarction is excluded here. However, the biggest benefit seems to be in the first 30 days, so it’s difficult for me to understand what really drives him.”

Commenting for theheart.org | Medscape Cardiology, Eric A. Cohen, MD, Sunnybrook Health Sciences Center, Toronto, Canada, said that QFR has “tremendous appeal and opportunity,” but expressed concern that it may be beginning to at least increase belief in the need for careful engineering dislodge-guided angiography.

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“It automates the process, maybe a little too much,” Cohen said. “At least that’s one of the concerns – taking the operator out of the equation, much like over-reliance on the autopilot in the cockpit.”

Gary S. Mintz, MD, program director for TCT, also commented on the results, emphasizing that an “event surge” after one year in the angiography arm “is typical of what we’re seeing for the self-fulfilling prophecy of angiogram driving the.” Events. This used to be called the oculo-stenotic reflex.”

After the formal presentation, panelist Davide Capodanno, MD, PhD, Azienda Ospedaliero Universitaria Policlinico–Vittorio Emanuele, Catania, Italy, also noted that there was an accumulation of events at 12 months and said this suggests that there is a Breaking the blinding in the sham-controlled study.

“I don’t have a clear explanation for this, but if you know what’s going on, you’re obviously prone to revascularization, and that’s a likely explanation for this increase in the number of events in the control group,” he said.

The study was supported by grants from the Beijing Municipal Science and Technology Commission, the Chinese Academy of Medical Sciences and the National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital. Song reviews without relevant disclosures. Cohen reports grant support and research contract with Abbott Vascular, and consulting fees/speaker office participation with Abbott Vascular, Medtronic and Baylis. Mintz reports on consulting fees/fees/speaker office participation at Boston Scientific, Medtronic, and Abiomed. Capodanno reports on consulting fees/fees/speaker office participation at Amgen, Arena, Daiichi-Sankyo/Eli Lilly, Sanofi-Aventis, Terumo Medical and Medtronic.

Transcatheter Cardiovascular Therapeutics 2022. Presented September 19, 2022.

J Am Coll Cardiol. Published September 19, 2022. Full text

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