External Validation of the FREEDOM Score for Individualized Decision Making Between CABG and PCI

Outcomes After CABG Compared With FFR-Guided PCI in Patients Presenting With Acute Coronary Syndrome

BACKGROUND

There are limited data comparing coronary artery bypass grafting (CABG) with percutaneous coronary intervention (PCI) in patients presenting with non-ST-segment elevation acute coronary syndrome (NSTE-ACS).

OBJECTIVES

The aim of this study was to evaluate differences in outcomes in patients presenting with or without NSTE-ACS after CABG compared with fractional flow reserve (FFR)-guided PCI using current generation drug-eluting stents.

METHODS

The FAME 3 trial (Fractional flow reserve versus Angiography for Multivessel Evaluation; NCT02100722) was an investigator-initiated, randomized controlled trial to attest noninferiority of FFR-guided PCI using the current-generation drug-eluting stents to CABG with respect to the primary endpoint, defined as a composite of death, myocardial infarction (MI), stroke, or repeat revascularization at 1 year, in 1,500 patients with 3-vessel coronary artery disease. The prespecified key secondary endpoint was a composite of death, MI, or stroke at 3 years.

RESULTS

Of 1,500 patients enrolled, 587 (39.2%) presented with NSTE-ACS. Patients were followed up for a median of 1,080 days (Q1-Q3: 1,080-1,080 days). At 3 years, the risk of the composite of death, MI, or stroke was similar between patients presenting with NSTE-ACS and with chronic coronary syndrome (CCS) (11.8% vs 10.0%; adjusted HR [aHR]: 1.20; 95% CI: 0.81-1.77; P = 0.37). Patients presenting with NSTE-ACS had a similar risk of death, MI, or stroke at 3 years after CABG as compared with PCI (aHR: 0.98; 95% CI: 0.60-1.60; P = 0.94), whereas patients presenting with CCS had a significantly reduced risk after CABG compared with PCI (aHR: 0.58; 95% CI: 0.38-0.90; P = 0.02; Pinteraction = 0.11), which was driven by a lower risk of MI (aHR: 0.32; 95% CI: 0.15-0.64; P = 0.002; Pinteraction = 0.01).

CONCLUSIONS

The risk of death, MI, or stroke at 3 years was similar after CABG compared with FFR-guided PCI in patients presenting with NSTE-ACS, but reduced by CABG in patients presenting with CCS. (Fractional flow reserve versus Angiography for Multivessel Evaluation [FAME 3]; NCT02100722).

FFR-Guided Percutaneous Coronary Intervention vs Coronary Artery Bypass Grafting in Patients With Diabetes

Importance

Outcomes in patients with diabetes after fractional flow reserve (FFR)-guided percutaneous coronary intervention (PCI) using current-generation drug-eluting stents (DES) compared with coronary artery bypass grafting (CABG) are unknown.

Objectives

To investigate the relative treatment effect of PCI vs CABG according to diabetes status with respect to major adverse cardiac and cerebrovascular events (MACCE) at 3 years and to evaluate the impact of the SYNTAX score.

Design, Setting, and Participants

This is a prespecified subgroup analysis of the FAME (Fractional Flow Reserve vs Angiography for Multivessel Evaluation) 3 trial, an investigator-initiated, randomized clinical trial conducted at 48 centers worldwide. The FAME 3 trial enrolled patients with 3-vessel coronary artery disease not involving the left main undergoing coronary revascularization between August 2014 and December 2019. Data analysis was conducted in August 2023. Clinical follow-up was performed at hospital discharge and at 1 month, 6 months, 1 year, 2 years, and 3 years after randomization.

Intervention

Either FFR-guided PCI with current-generation DES or CABG.

Main Outcomes and Measures

The primary end point was MACCE, defined as the composite of all-cause death, myocardial infarction, stroke, or repeat revascularization at 3 years.

Results

Of 1500 total patients enrolled, mean (SD) patient age was 65.1 (8.4) years, and 265 patients (17.7%) were female. The FAME 3 trial included 428 patients with diabetes (28.5%). Patients with diabetes, especially those receiving insulin, had a higher risk of MACCE at 3 years compared with those without diabetes. Regarding relative treatment effect, the risk of MACCE was higher after FFR-guided PCI compared with CABG in both patients with diabetes (hazard ratio [HR], 1.44; 95% CI, 0.91-2.28; P = .12) and those without diabetes (HR, 1.50; 95% CI, 1.08-2.07; P = .02), with no significant interaction (P for interaction = .94). In patients with a low SYNTAX score (<23), there was no significant difference in MACCE between PCI and CABG, while in patients with an intermediate to high SYNTAX score (≥23), PCI had a higher risk of MACCE than CABG, regardless of diabetes status.

Conclusions and Relevance

In this subgroup analysis of the FAME 3 randomized clinical trial, the relative benefit of CABG compared with FFR-guided PCI was similar among patients with and without diabetes.

Trial Registration

ClinicalTrials.gov Identifier: NCT02100722.

Sex Differences in Patients Undergoing FFR-Guided PCI or CABG in the FAME 3 Trial

BACKGROUND

Outcomes in women after fractional flow reserve (FFR)-guided percutaneous coronary intervention (PCI) using current-generation drug-eluting stents (DES) compared with coronary artery bypass grafting (CABG) are unknown.

OBJECTIVES

This study sought to evaluate differences in clinical outcomes according to sex after FFR-guided PCI with current generation DES compared with CABG.

METHODS

The FAME 3 (Fractional Flow Reserve Versus Angiography for Multivessel Evaluation) trial was an investigator-initiated, randomized controlled trial, comparing FFR-guided PCI with current generation DES or CABG in patients with 3-vessel coronary artery disease. This prespecified subgroup analysis compared the incidence of major adverse cardiac and cerebrovascular events (MACCE) according to sex, defined as the composite of all-cause death, myocardial infarction, stroke, or repeat revascularization at 3 years.

RESULTS

Of 1,500 patients included in the FAME 3 trial, 265 (17.7%) were women. Women had a significantly higher risk of MACCE at 3 years compared with men after CABG (18.1% vs 11.7%; adjusted HR: 2.07; 95% CI: 1.19-3.60), whereas women had a similar risk of MACCE at 3 years compared with men after PCI (18.2% vs 19.1%; adjusted HR: 1.27; 95% CI: 0.79-2.03). Regarding treatment effects by sex, women undergoing PCI had a similar risk of MACCE at 3 years compared with CABG (adjusted HR: 1.15; 95% CI: 0.62-2.11). By contrast, men undergoing PCI had a higher risk of MACCE at 3 years compared with CABG (adjusted HR: 1.68; 95% CI: 1.25-2.25; Pinteraction = 0.142), which was mainly driven by a higher risk of myocardial infarction (adjusted HR: 2.11; 95% CI: 1.26-3.56; Pinteraction = 0.102) and repeat revascularization (adjusted HR: 2.26; 95% CI: 1.47-3.47; Pinteraction = 0.071).

CONCLUSIONS

In the FAME 3 trial, at 3 years, women had similar outcomes with FFR-guided PCI compared with CABG, whereas men had improved outcomes with CABG. (A Comparison of Fractional Flow Reserve-Guided Percutaneous Coronary Intervention and Coronary Artery Bypass Graft Surgery in Patients With Multivessel Coronary Artery Disease [FAME 3]; NCT02100722).

Chest Pain at Rest With Unremarkable ECG and Cardiac Enzymes: Case Study Emphasising the Importance of Clinical Suspicion in the Diagnosis of Coronary Artery Disease

BACKGROUND

Coronary artery disease (CAD), primarily caused by atherosclerosis, is a leading cause of death, presenting as angina or myocardial infarction. Advances in cardiac imaging, angiography, and procedures like percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) surgery have improved early detection and management of this condition. This report presents the case of a man who experienced worsening exertional chest pain and discomfort while at rest.

CASE REPORT

A 66-year-old man with a history of neurogenic syncope and asthma presented at the same-day emergency care (SDEC) unit with worsening exertional chest pain and discomfort whilst at rest. Despite normal ECG and cardiac enzyme results, further cardiac computed tomography angiography (CTCA) revealed significant CAD with moderate stenosis in the right coronary artery (RCA) and severe stenosis at the left anterior descending artery (LAD) bifurcation, leading to CABG surgery. Echocardiography showed a left ventricular ejection fraction of 50-54% with mid-inferior and basal to mid-inferoseptal hypokinesia. The cardiology-cardiothoracic multidisciplinary team concluded that CABG surgery would provide the most durable long-term outcome.

CONCLUSION

This case demonstrates the high importance of clinical suspicion of CAD despite normal initial investigations in the early identification and timely investigation as well as the role multidisciplinary teams and CABG can play in the timely management of complex CAD, ultimately leading to improved patient outcomes.

Impact of quantitative flow ratio on graft function in patients undergoing coronary artery bypass grafting

Recent studies showed that preoperative functional assessment with fractional flow reserve (FFR) could predict a long-term patency of arterial bypass grafts in patients with coronary artery bypass grafting (CABG). Quantitative flow ratio (QFR) is a novel angiography-based approach to estimate FFR. This study aimed to investigate whether preoperative QFR could discriminate arterial bypass function at 1 year after surgery. The PRIDE-METAL registry was a prospective, multicenter observational study that enrolled 54 patients with multivessel coronary artery disease. By protocol, left coronary stenoses were revascularized by CABG with arterial grafts, whereas right coronary stenoses were treated with coronary stenting. Follow-up angiography at 1 year after surgery was scheduled to assess arterial graft patency. QFR was performed using index angiography by certified analysts, blinded to bypass graft function. The primary end point of this sub-study was the discriminative ability of QFR for arterial graft function, as assessed by receiver-operating characteristic curve. Among 54 patients enrolled in the PRIDE-METAL registry, index and follow-up angiography was available in 41 patients with 97 anastomoses. QFR were analyzed in 35 patients (71 anastomoses) with an analyzability of 85.5% (71/83). Five bypass grafts were found to be non-functional at 1 year. The diagnostic performance of QFR was substantial (area under the curve: 0.89; 95% confidence interval: 0.83 to 0.96) with an optimal cutoff of 0.76 to predict functionality of bypass grafts. Preoperative QFR is highly discriminative for predicting postoperative arterial graft function.Trial registration: Clinical.gov reference: NCT02894255.

Cardiac scoring systems, coronary artery disease and major adverse cardiovascular events: A scoping review

BACKGROUND

In 2019, the World Health Organization (WHO) declared coronary artery disease (CAD) as the leading cause of death globally for the last 20 years. Early screening and detection (primary prevention) and intervention (secondary prevention) are necessary to curb CAD and major adverse cardiovascular event (MACE) prevalence. A scoping review to assess the current literature on using cardiac scoring systems to predict CAD and MACE was performed.

METHODS

The research question 'What is the literature on using cardiac scoring systems to predict CAD and MACE?' was addressed. The updated Arksey and O'Malley and the Preferred Reporting Items for Systematic reviews and Meta-Analyses Extension for Scoping Reviews methodologies were used. The search terms 'coronary artery disease' and 'cardiac scoring systems' and 'major adverse cardiovascular events' were used in the Boolean search on PubMed, ScienceDirect, MedLine and Cochrane Library.

RESULTS

The final list consisted of 19 published English results after the year 2000. There were six results without participants (four clinical guidelines, one review article and one ongoing clinical trial). Scoring systems were cardiovascular risk estimation systems focusing on the primary prevention of CAD; MACE was discussed but not scored. There were 13 robust results published from completed multinational clinical trials with participants. These results focused on a scoring system for the secondary prevention of CAD and MACE.

CONCLUSION

Scoring systems remain an objective method for primary and secondary prevention of CAD and MACE.Contribution: Scoring systems may be helpful with clinical uncertainty or to standardise patient results for comparison in research.