Arq. Bras. Cardiol. 2018; 111(4): 551-552
To Defer or Not Defer? The Challenges of Physiology in Acute Coronary Syndromes
DOI: 10.5935/abc.20180206
This Short Editorial is referred by the Research article "Fractional Flow Reserve-Guided Strategy in Acute Coronary Syndrome. A Systematic Review and Meta-Analysis".
Conventional angiography may unreliably estimate the functional severity of coronary lesions, particularly of intermediate stenosis. It is in this context that intracoronary physiology, namely the measurement of fractional flow reserve (FFR), has been developed: to precisely differentiate stenoses that cause myocardial ischemia from those that are not significantly obstructive. Overall, FFR has been applied as a decision-making tool, helping to indicate (or defer) revascularization in intermediate or ambiguous coronary stenoses. Compared with angiography alone, the addition of FFR-derived information has been shown to improve patient outcomes and procedural cost-efficiencies, with physiology-guided coronary revascularization being currently recommended in clinical practice guidelines, on the grounds of ample scientific evidence.
Almost twenty years ago, the pivotal DEFER trial consolidated the concept that FFR-based postponement of revascularization is safe. However, numerous reasons make the translation of the DEFER trial to contemporary clinical practice outdated: i) the excessively restrictive 0.75 cutoff (as used in the study) has been supplanted by the more permissive 0.80 threshold, ii) balloon angioplasty as a stand-alone therapy has been largely replaced by drug-eluting stents, iii) more potent antiplatelet agents and other medical therapies have become available, and iv) the relation between FFR and the obstructive profile of coronary lesion is yet being questioned by some authors. Thus, the contemporary safety of deferring lesions in stable angina pectoris (SAP) and acute coronary syndrome (ACS) on the basis of FFR still deserves investigation.
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