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J Am Coll Cardiol, 2007; 49:2105-2111, doi:10.1016/j.jacc.2007.01.087 (Published online 11 May 2007).
© 2007 by the American College of Cardiology Foundation
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CLINICAL RESEARCH: INTERVENTIONAL CARDIOLOGY

Percutaneous Coronary Intervention of Functionally Nonsignificant Stenosis

5-Year Follow-Up of the DEFER Study

Nico H.J. Pijls, MD, PhD*,*, Pepijn van Schaardenburgh, MD*, Ganesh Manoharan, MD{dagger}, Eric Boersma, PhD{ddagger}, Jan-Willem Bech, MD, PhD*, Marcel van't Veer, MSc*, Frits Bär, MD, PhD§, Jan Hoorntje, MD, PhD||, Jacques Koolen, MD, PhD*, William Wijns, MD, PhD{dagger} and Bernard de Bruyne, MD, PhD{dagger}

* Catharina Hospital Eindhoven, Eindhoven, the Netherlands
{dagger} Cardiovascular Center Aalst, Aalst, Belgium
{ddagger} Thoraxcentrum Rotterdam, Rotterdam, the Netherlands
§ Academic Hospital Maastricht, Maastricht, the Netherlands
|| Isala Clinics Zwolle, Zwolle, the Netherlands.

Manuscript received October 4, 2006; revised manuscript received January 29, 2007, accepted January 30, 2007.

* Reprint requests and correspondence: Dr. Nico H. J. Pijls, Catharina Hospital, Department of Cardiology, Michelangelo Avenue 2, P.O. Box 1350, 5602 ZA Eindhoven, the Netherlands. (Email: nico.pijls{at}inter.nl.net).

Objectives: The purpose of this study was to investigate the appropriateness of stenting a functionally nonsignificant stenosis.

Background: Percutaneous coronary intervention (PCI) of an intermediate stenosis without evidence of ischemia is often performed, but its benefit is unproven. Coronary pressure-derived fractional flow reserve (FFR) is an invasive index used to identify a stenosis responsible for reversible ischemia.

Methods: In 325 patients scheduled for PCI of an intermediate stenosis, FFR was measured just before the planned intervention. If FFR was ≥0.75, patients were randomly assigned to deferral (Defer group; n = 91) or performance (Perform group; n = 90) of PCI. If FFR was <0.75, PCI was performed as planned (Reference group; n = 144). Clinical follow-up was 5 years.

Results: There were no differences in baseline clinical characteristics between the 3 groups. Complete follow-up was obtained in 98% of the patients. Event-free survival was not different between the Defer and Perform groups (80% and 73%, respectively; p = 0.52), but was significantly worse in the Reference group (63%; p = 0.03). The composite rate of cardiac death and acute myocardial infarction in the Defer, Perform, and Reference groups was 3.3%, 7.9%, and 15.7%, respectively (p = 0.21 for Defer vs. Perform group; p = 0.003 for the Reference vs. both other groups). The percentage of patients free from chest pain at follow-up was not different between the Defer and Perform groups.

Conclusions: Five-year outcome after deferral of PCI of an intermediate coronary stenosis based on FFR ≥0.75 is excellent. The risk of cardiac death or myocardial infarction related to this stenosis is <1% per year and not decreased by stenting.

Abbreviations and Acronyms
  AMI = acute myocardial infarction
  FFR = fractional flow reserve
  PCI = percutaneous coronary intervention
  SPECT = single-photon emission computed tomography




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K. L. Gould
Does Coronary Flow Trump Coronary Anatomy?
J. Am. Coll. Cardiol. Img., August 1, 2009; 2(8): 1009 - 1023.
[Abstract] [Full Text] [PDF]

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 J Am Coll Cardiol IntvHome page
G. Sarno, I. Decraemer, P. K. Vanhoenacker, B. De Bruyne, M. Hamilos, T. Cuisset, E. Wyffels, J. Bartunek, G. R. Heyndrickx, and W. Wijns
On the Inappropriateness of Noninvasive Multidetector Computed Tomography Coronary Angiography to Trigger Coronary Revascularization: A Comparison With Invasive Angiography
J. Am. Coll. Cardiol. Intv., June 1, 2009; 2(6): 550 - 557.
[Abstract] [Full Text] [PDF]

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 Circ Cardiovasc ImagingHome page
R. C. Hendel
Is Computed Tomography Coronary Angiography the Most Accurate and Effective Noninvasive Imaging Tool to Evaluate Patients With Acute Chest Pain in the Emergency Department?: CT Coronary Angiography Is the Most Accurate and Effective Noninvasive Imaging Tool for Evaluating Patients Presenting With Chest Pain to the Emergency Department: Antagonist Viewpoint
Circ Cardiovasc Imaging, May 1, 2009; 2(3): 264 - 275.
[Full Text] [PDF]

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 J Am Coll Cardiol ImgHome page
C. Doesch, A. Seeger, J. Doering, C. Herdeg, C. Burgstahler, C. D. Claussen, M. Gawaz, S. Miller, and A. E. May
Risk Stratification by Adenosine Stress Cardiac Magnetic Resonance in Patients With Coronary Artery Stenoses of Intermediate Angiographic Severity
J. Am. Coll. Cardiol. Img., April 1, 2009; 2(4): 424 - 433.
[Abstract] [Full Text] [PDF]

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 J Am Coll Cardiol ImgHome page
E. Nagel
Taking the Last Hurdles: Magnetic Resonance Myocardial Perfusion Imaging
J. Am. Coll. Cardiol. Img., April 1, 2009; 2(4): 434 - 436.
[Full Text] [PDF]

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 J Am Coll Cardiol IntvHome page
M. A. Leesar
Baseline Fractional Flow Reserve and Stent Diameter Predict Event Rates After Stenting: A Further Step, But Still Much to Learn
J. Am. Coll. Cardiol. Intv., April 1, 2009; 2(4): 364 - 365.
[Full Text] [PDF]

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 JAMAHome page
G. A. Lin, D. J. Malenka, and R. F. Redberg
Documenting Ischemia Prior to Elective Percutaneous Coronary Intervention--Reply
JAMA, March 11, 2009; 301(10): 1018 - 1019.
[Full Text] [PDF]

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 ESC Textbook of Cardiovascular MedicineHome page
C. Di Mario, G. R. Heyndrickx, F. Prati, and N. H.J. Pijls
CHAPTER 8 Invasive Imaging and Haemodynamics
ESC Textbook of Cardiovascular Medicine, January 1, 2009; 2(1): med-9780199566990-chapter - med-9780199566990-chapter.
[Abstract] [Full Text] [PDF]

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 J Am Coll CardiolHome page
D. G. Katritsis and B. Meier
Percutaneous Coronary Intervention for Stable Coronary Artery Disease
J. Am. Coll. Cardiol., September 9, 2008; 52(11): 889 - 893.
[Abstract] [Full Text] [PDF]

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 J Am Coll CardiolHome page
M. J. Kern
Limitations of Angiographic Predictors of Bypass Graft Patency
J. Am. Coll. Cardiol., September 2, 2008; 52(10): 886 - 887.
[Full Text] [PDF]

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 Circ Cardiovasc Qual OutcomesHome page
A. J. Kirtane and D. J. Cohen
When Is Better Not Good Enough?: Insights From the COURAGE Economic Study
Circ Cardiovasc Qual Outcomes, September 1, 2008; 1(1): 4 - 6.
[Full Text] [PDF]

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 J Am Coll CardiolHome page
W. B. Meijboom, C. A.G. Van Mieghem, N. van Pelt, A. Weustink, F. Pugliese, N. R. Mollet, E. Boersma, E. Regar, R. J. van Geuns, P. J. de Jaegere, et al.
Comprehensive Assessment of Coronary Artery Stenoses: Computed Tomography Coronary Angiography Versus Conventional Coronary Angiography and Correlation With Fractional Flow Reserve in Patients With Stable Angina
J. Am. Coll. Cardiol., August 19, 2008; 52(8): 636 - 643.
[Abstract] [Full Text] [PDF]

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 HeartHome page
B De Bruyne and J Sarma
Fractional flow reserve: a review
Heart, July 1, 2008; 94(7): 949 - 959.
[Full Text] [PDF]

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 J Am Coll CardiolHome page
S. R. Dixon, C. L. Grines, and W. W. O'Neill
The Year in Interventional Cardiology
J. Am. Coll. Cardiol., June 17, 2008; 51(24): 2355 - 2369.
[Full Text] [PDF]

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 J Am Coll CardiolHome page
U. C. Rangasetty and C. Y. Lui
Fractional Flow Reserve-Guided Intervention of Angiographically Nonsignificant Coronary Stenoses
J. Am. Coll. Cardiol., March 18, 2008; 51(11): 1123 - 1123.
[Full Text] [PDF]

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 J Am Coll CardiolHome page
N. H.J. Pijls, P. van Schaardenburg, G. Manoharan, E. Boersma, J.-W. Bech, M. van't Veer, F. Bar, J. Hoorntje, J. Koolen, W. Wijns, et al.
Reply
J. Am. Coll. Cardiol., March 18, 2008; 51(11): 1123 - 1124.
[Full Text] [PDF]

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 Eur Heart JHome page
E. S. Brilakis and P. B. Berger
Treatment of coronary bifurcations: might less be more?
Eur. Heart J., March 2, 2008; 29(6): 704 - 706.
[Full Text] [PDF]

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 J Am Coll CardiolHome page
A. N. DeMaria, J. J. Bax, O. Ben-Yehuda, P. Clopton, G. K. Feld, G. S. Ginsburg, B. H. Greenberg, J. D. Knoke, W. Y.W. Lew, J. A.C. Lima, et al.
Highlights of the Year in JACC 2007
J. Am. Coll. Cardiol., January 29, 2008; 51(4): 490 - 512.
[Full Text] [PDF]

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 J Am Coll CardiolHome page
K. L. Gould
Not All Randomized Trials Are Equal
J. Am. Coll. Cardiol., November 13, 2007; 50(20): 2013 - 2015.
[Full Text] [PDF]


 
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