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Original Investigation |

Long-term Survival in Patients Undergoing Percutaneous Interventions With or Without Intracoronary Pressure Wire Guidance or Intracoronary Ultrasonographic Imaging:  A Large Cohort Study

Georg M. Fröhlich, MD1; Simon Redwood, MD2; Roby Rakhit, MD3; Philip A. MacCarthy, MD4; Pitt Lim, MD5; Tom Crake, MD1; Steven K. White, MD1; Charles J. Knight, MD6; Christoph Kustosz, MSc7; Guido Knapp, PhD7; Miles C. Dalby, MD8; Iqbal S. Mali, MD9; Andrew Archbold, MD6; Andrew Wragg, MD6; Adam D. Timmis, MD6; Pascal Meier, MD1
[+] Author Affiliations
1Department of Cardiology, The Heart Hospital, University College London Hospital, London, England
2Department of Cardiology, Guy’s and St Thomas’ Hospital, London, England
3Department of Cardiology, Royal Free Hampstead National Health Service Trust, London, England
4Department of Cardiology, King’s College Hospital, London, England
5Department of Cardiology, St George’s Hospital, London, England
6Department of Cardiology, Barts Health National Health Service Trust, London, England
7Department of Statistics, Technische Universität Dortmund, Dortmund, Germany
8Department of Cardiology, Harefield Hospital, London, England
9Department of Cardiology, Imperial College Healthcare National Health Service Trust, London, England
JAMA Intern Med. 2014;174(8):1360-1366. doi:10.1001/jamainternmed.2014.1595.
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Importance  Intracoronary pressure wire–derived measurements of fractional flow reserve (FFR) and intravascular ultrasonography (IVUS) provide functional and anatomical information that can be used to guide coronary stent implantation. Although these devices are widely used and recommended by guidelines, limited data exist about their effect on clinical end points.

Objective  To determine the effect on long-term survival of using FFR and IVUS during percutaneous coronary intervention (PCI).

Design and Setting  Cohort study based on the pan-London (United Kingdom) PCI registry. In total, 64 232 patients are included in this registry covering the London, England, area.

Participants  All patients (n = 41 688) who underwent elective or urgent PCI in National Health Service hospitals in London between January 1, 2004, and July 31, 2011, were included. Patients with ST-segment elevation myocardial infarction (n = 11 370) were excluded.

Interventions  Patients underwent PCI guided by angiography (visual lesion assessment) alone, PCI guided by FFR, or IVUS-guided PCI.

Main Outcomes and Measures  The primary end point was all-cause mortality at a median of 3.3 years.

Results  Fractional flow reserve was used in 2767 patients (6.6%) and IVUS was used in 1831 patients (4.4%). No difference in mortality was observed between patients who underwent angiography-guided PCI compared with patients who underwent FFR-guided PCI (hazard ratio, 0.88; 95% CI, 0.67-1.16; P = .37). Patients who underwent IVUS had a slightly higher adjusted mortality (hazard ratio, 1.39; 95% CI, 1.09-1.78; P = .009) compared with patients who underwent angiography-guided PCI. However, this difference was no longer statistically significant in a propensity score–based analysis (hazard ratio, 1.33; 95% CI, 0.85-2.09; P = .25). The mean (SD) number of implanted stents was lower in the FFR group (1.1 [1.2] stents) compared with the IVUS group (1.6 [1.3]) and the angiography-guided group (1.7 [1.1]) (P < .001).

Conclusions and Relevance  In this large observational study, FFR-guided PCI and IVUS-guided PCI were not associated with improved long-term survival compared with standard angiography-guided PCI. The use of FFR was associated with the implantation of fewer stents.

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Figure.
Kaplan-Meier Survival Plots Based on Propensity Score–Matched Patients

A, Fractional flow reserve (FFR)–guided vs angiography-guided percutaneous coronary intervention. B, Intravascular ultrasonography (IVUS)–guided vs angiography-guided percutaneous coronary intervention.

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