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• W1964255093 abstract "Coronary pressure-derived fractional flow reserve (FFR) has been used to evaluate functional severity of coronary artery stenoses. The cut-off point of 0.75 was considered to be the indication for percutaneous coronary intervention (PCI). In this study, we examined the prognosis of patients in whom PCI was deferred because the lesion was not significant by FFR (≥0.75). We measured FFR of 44 patients (50 lesions with angiographically intermediate stenoses by pressure wire between 2002 and 2009. Out of 44 patients (50 lesions), functionally non-significant stenoses with FFR ≥ 0.75 were 29 patients (33 lesions) and PCI was deferred. In the remaining 15 patients (17 lesions), FFR was <0.75 and PCI was performed. Patients were followed up for an average period of 53 months with endpoints of major adverse cardiac events (MACE; cardiac death, acute coronary syndrome, PCI, and coronary artery bypass grafting). The rate of MACE was 2/29 (6.9%) in patients with FFR ≥ 0.75 and 2/15 (13.3%) in those with FFR < 0.75, and it was not statistically different between the two groups. Since long-term clinical outcomes after deferral of PCI of intermediate coronary stenoses based on FFR were excellent (annual event rate 1.6%/year), FFR is a useful index to judge the indication of PCI and risk-stratify patients for MACE. Coronary pressure-derived fractional flow reserve (FFR) has been used to evaluate functional severity of coronary artery stenoses. The cut-off point of 0.75 was considered to be the indication for percutaneous coronary intervention (PCI). In this study, we examined the prognosis of patients in whom PCI was deferred because the lesion was not significant by FFR (≥0.75). We measured FFR of 44 patients (50 lesions with angiographically intermediate stenoses by pressure wire between 2002 and 2009. Out of 44 patients (50 lesions), functionally non-significant stenoses with FFR ≥ 0.75 were 29 patients (33 lesions) and PCI was deferred. In the remaining 15 patients (17 lesions), FFR was <0.75 and PCI was performed. Patients were followed up for an average period of 53 months with endpoints of major adverse cardiac events (MACE; cardiac death, acute coronary syndrome, PCI, and coronary artery bypass grafting). The rate of MACE was 2/29 (6.9%) in patients with FFR ≥ 0.75 and 2/15 (13.3%) in those with FFR < 0.75, and it was not statistically different between the two groups. Since long-term clinical outcomes after deferral of PCI of intermediate coronary stenoses based on FFR were excellent (annual event rate 1.6%/year), FFR is a useful index to judge the indication of PCI and risk-stratify patients for MACE. Percutaneous coronary intervention (PCI) has been widely performed to dilate stenosed or occluded coronary arteries. To determine the indication of PCI, several non-invasive modalities have been used in clinical settings such as treadmill exercise test, myocardial perfusion scintigraphy with radio-isotopes of thallium or technetium-labeled perfusion agents, echocardiography during dynamic exercise or pharmacological stress, magnetic resonance myocardial perfusion imaging, etc. Coronary pressure-derived fractional flow reserve (FFR) is an invasive index in the catheterization laboratory and has been used to evaluate functional severity of coronary artery stenoses [[1]Pijls N.H. Van Gelder B. Van der Voort P. Peels K. Bracke F.A. Bonnier H.J. el Gamal M.I. Fractional flow reserve. A useful index to evaluate the influence of an epicardial coronary stenosis on myocardial blood flow.Circulation. 1995; 92: 3183-3193Crossref PubMed Scopus (663) Google Scholar]. FFR is defined as the ratio of the distal intracoronary pressure to the aortic pressure at the state of maximal hyperlemia. Conventionally, the cut-off point of 0.75 is recognized as the threshold of ischemia [[2]Pijls N.H. De Bruyne B. Peels K. Van Der Voort P.H. Bonnier H.J. Bartunek J. Koolen J.J. Measurement of fractional flow reserve to assess the functional severity of coronary-artery stenoses.N Engl J Med. 1996; 334: 1703-1708Crossref PubMed Scopus (1616) Google Scholar] and if the measured FFR of the stenotic lesion is less than 0.75, it is considered functionally significant. This method is profitable to decide the indication of PCI, especially in patients with angiographically intermediate stenoses. FFR measurement has been recommended class IIa in the assessment of intermediate coronary stenoses in the American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions guideline [[3]Smith Jr., S.C. Feldman T.E. Hirshfeld Jr., J.W. Jacobs A.K. Kern M.J. King 3rd, S.B. Morrison D.A. O’Neil W.W. Schaff H.V. Whitlow P.L. Williams D.O. Antman E.M. Adams C.D. Anderson J.L. Faxon D.P. et al.ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update 2001 Guidelines for Percutaneous Coronary Intervention).Circulation. 2006; 113: e166-286Crossref PubMed Scopus (630) Google Scholar]. Recently, new 2010 European Society of Cardiology guidelines for PCI have classified FFR-guided treatment as Class I with level of evidence A. This update has been driven from the Fractional Flow Reserve Versus Angiography for Multivessel Evaluation (FAME) study, which demonstrated improved outcomes at 1 year in patients with multivessel coronary disease whose coronary intervention was guided by FFR measurement rather than by angiography alone [[4]Tonino P.A. De Bruyne B. Pijls N.H. Siebert U. Ikeno F. van’t Veer M. Klauss V. Manoharan G. Engstrøm T. Oldroyd K.G. Ver Lee P.N. MacCarthy P.A. Fearon W.F. FAME Study Investigators. Fractional flow reserve versus angiography for guiding percutaneous coronary intervention.N Engl J Med. 2009; 360: 213-224Crossref PubMed Scopus (2680) Google Scholar]. It has been established to perform PCI for patients with coronary stenotic lesions which induce myocardial ischemia and successful PCI improves the outcome [[5]Davies R.F. Goldberg A.D. Forman S. Pepine C.J. Knatterud G.L. Geller N. Sopko G. Pratt C. Deanfield J. Conti C.R. Asymptomatic Cardiac Ischemia Pilot (ACIP) study two-year follow-up: outcomes of patients randomized to initial strategies of medical therapy versus revascularization.Circulation. 1997; 95: 2037-2043Crossref PubMed Scopus (384) Google Scholar]. In recent years, especially after the introduction of drug-eluting stents (DES), PCI has increased [[6]Moses J.W. Stone G.W. Nikolsky E. Mintz G.S. Dangas G. Grube E. Ellis S.G. Lansky A.J. Weisz G. Fahy M. Na Y. Russell M.E. Donohoe D. Leon M.B. Mehran R. Drug-eluting stents in the treatment of intermediate lesions: pooled analysis from four randomized trials.J Am Coll Cardiol. 2006; 47: 2164-2171Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar] and tends to be performed on angiographically intermediate stenotic lesions which may not be proven as real myocardial ischemia. However, it is unclear whether stenting to non-significant coronary stenoses improve patients’ prognosis, and whether optimal medical therapy such as antiplatelets and statins is effective for stable coronary disease [[7]Boden W.E. O’Rourke R.A. Teo K.K. Hartigan P.M. Maron D.J. Kostuk W.J. Knudtson M. Dada M. Casperson P. Harris C.L. Chaitman B.R. Shaw L. Gosselin G. Nawaz S. Title L.M. et al.Optimal medical therapy with or without PCI for stable coronary disease.N Engl J Med. 2007; 356: 1503-1516Crossref PubMed Scopus (3373) Google Scholar]. In real world clinical practice, we often meet equivocal angiographical intermediate stenoses of coronary lesions. It is sometimes difficult to decide whether those lesions are necessary for performing PCI or not. Therefore, if the stenotic lesion could be proven non-significant by FFR measurement, the patient could avoid unnecessary coronary stenting. The purpose of the present study was to evaluate the long-term prognosis of patients in whom PCI was deferred because the lesions were assessed to be functionally non-significant stenosis by FFR measurement in Japanese population. In the present study, 44 consecutive patients (50 lesions) with angiographically intermediate stenoses and evaluated by FFR measurement from January 2002 to May 2009 in our institution were enrolled. There were 35 males and 9 females with mean age of 66 years (Table 1). All subjects had stable angina pectoris and we excluded patients with acute coronary syndrome (ACS). These lesions were de novo stenoses in native coronary artery including multivessel disease and left main trunk disease, and were not documented as ischemia in other non-invasive tests. Lesions with restenosis and bypass graft were excluded.Table 1Baseline characteristics of the two groups.FFR ≥ 0.75 (n = 29)FFR < 0.75 (n = 15)p-ValueAge (years)66.4 ± 11.065.5 ± 8.0n.s.Gender (%)n.s. Male22 (75.9)13 (86.7) Female7 (24.1)2 (13.3)Risk factors (%) Hypertension22 (75.9)11 (73.3)n.s. Dyslipidemia18 (62.1)8 (53.3)n.s. Diabetes15 (51.7)5 (33.3)n.s. Smoking14 (48.3)6 (40.0)n.s. Obesity (BMI ≥ 25)12 (41.3)2 (13.3)n.s. Familial history4 (13.8)1 (6.7)n.s.Use of medications (%) ACE inhibitor2 (6.9)0 (0)n.s. ARB18 (62.1)10 (67.7)n.s. β-Blockers8 (27.6)1 (6.6)n.s. Calcium channel blockers18 (62.1)8 (53.3)n.s. Nitrates and other coronary vasodilators22 (75.9)11 (73.3)n.s. Aspirin23 (79.3)15 (100)n.s. Antiplatelet agents other than aspirin17 (58.6)11 (73.3)n.s. Statins18 (62.1)9 (60.0)n.s.Diseased vesselsn.s. 1 vessel20 (69.0)11 (73.3) 2 vessels5 (17.2)3 (20.0) 3 vessels3 (10.4)1 (6.7) Left main trunk1 (3.4)0 (0)FFR, fractional flow reserve; BMI, body mass index; ACE, angiotensin-converting enzyme; ARB, angiotensin II receptor blocker. Open table in a new tab FFR, fractional flow reserve; BMI, body mass index; ACE, angiotensin-converting enzyme; ARB, angiotensin II receptor blocker. The FFR was measured by using a 0.014-in. pressure guidewire (Smart Wire II, Volcano, Rancho Cordova, CA, USA) after intracoronary bolus injection of papaverine hydrochloride (12 mg in the left coronary artery and 8 mg in the right coronary artery) to induce maximum hyperemia. In all 50 lesions, there were 33 lesions with FFR ≥ 0.75 and 17 lesions with FFR < 0.75 as shown in Fig. 1. In 33 lesions with FFR > 0.75, PCI was deferred. In the remaining 17 lesions with FFR < 0.75, PCI was performed. The strategies of PCI were dependent on diseased lesions including plain old balloon angioplasty (POBA), 4 lesions; directional coronary atherectomy (DCA), 3 lesions; bare metal stent (BMS), 4 lesions; and DES, 6 lesions. Quantitative coronary angiography (QCA) analysis was performed using QAngio XA version 7 (Medis, Leiden, the Netherlands) and diameter stenosis, reference diameter, and minimal lumen diameter were measured. Patients were followed up with the end points of major adverse cardiac event (MACE), cardiac death, ACS, PCI, and coronary artery bypass surgery, with a mean follow-up period of 53 months. All values are expressed as mean ± SD. A p-value less than 0.05 was considered statistically significant. Patients’ event-free curves for MACE were constructed according to the Kaplan–Meier analysis and compared by the log-rank test. Significance between two groups was determined by unpaired t test for continuous variables and chi-square test for discrete variables. Baseline clinical characteristics of the two groups are summarized in Table 1. Age, gender, risk factors, the use of medications, and diseased vessels were not different between the two groups. In angiography, target vessel and reference diameters were similar, but angiographic stenosis such as diameter stenosis and minimal lumen diameter were more severe in the FFR < 0.75 group compared to the FFR ≥ 0.75 group (Table 2).Table 2Angiographical characteristics of the two groups.FFR ≥ 0.75 (n = 33)FFR < 0.75 (n = 17)p-ValueTarget vessel (%)n.s. Left main trunk1 (3.0)0 (0) Left anterior descending artery14 (42.4)9 (52.9) Left circumflex14 (42.4)5 (29.4) Right coronary artery4 (12.1)3 (17.6)Quantitative coronary angiography Diameter stenosis (%)49.8 ± 9.558.8 ± 13.7<0.05 Reference diameter (mm)2.52 ± 0.532.45 ± 0.49n.s. Minimal lumen diameter (mm)1.24 ± 0.310.94 ± 0.22<0.001 FFR0.86 ± 0.060.64 ± 0.10<0.001FFR, fractional flow reserve. Open table in a new tab FFR, fractional flow reserve. Patients were followed up by clinical visits for mean follow-up periods of 53 months. There were 4 MACE (ACS and PCI) during the follow-up period (Table 3). No death occurred in subjects enrolled. In FFR ≥ 0.75 group (n = 33), the events of ACS (1) and PCI (1) occurred in 2 patients. The details of MACE in 2 patients with FFR ≥ 0.75 are shown in Table 4. A 75-year-old male suffered from unstable angina at 32 months in the same lesion and underwent BMS implantation. A 69-year-old male had a progressed lesion with the lower FFR value of 0.62 in the same lesion at 52 months and he underwent DES implantation. On the other hand, in the FFR < 0.75 group (n = 17), 2 patients underwent PCI because of restenoses. As the Kaplan–Meier curve shown in Fig. 2, event-free survival rate was 93.1% in FFR ≥ 0.75 group and 86.7% in FFR < 0.75 group, and the rate of MACE in the two groups was not statistically different (log-rank test; p = 0.50).Table 3Comparisons of clinical outcomes between the two groups.FFR ≥ 0.75 (n = 29)FFR < 0.75 (n = 15)p-ValueFollow up (months)50.9 ± 25.150.6 ± 26.2n.s.MACE (%)2 (6.9)2 (13.3)n.s.Death00ACS10PCI12CABG00FFR, fractional flow reserve; MACE, major adverse cardiac events; ACS, acute coronary syndrome; PCI, percutaneous coronary intervention; CABG, coronary artery bypass graft. Open table in a new tab Table 4Details of the MACE in 2 patients with FFR ≥ 0.75.AgeGenderVesselFFRMACEFollow up (months)DS (%)RD (mm)MLD (mm)75MaleLCX0.81ACS32482.31.1869MaleLAD0.92PCI52552.61.17MACE, major adverse cardiac events; FFR, fractional flow reserve; DS, diameter stenosis; RD, reference diameter; MLD, minimal lumen diameter; LCX, left circumflex artery; LAD, left anterior descending artery; ACS, acute coronary syndrome; PCI, percutaneous coronary intervention. Open table in a new tab FFR, fractional flow reserve; MACE, major adverse cardiac events; ACS, acute coronary syndrome; PCI, percutaneous coronary intervention; CABG, coronary artery bypass graft. MACE, major adverse cardiac events; FFR, fractional flow reserve; DS, diameter stenosis; RD, reference diameter; MLD, minimal lumen diameter; LCX, left circumflex artery; LAD, left anterior descending artery; ACS, acute coronary syndrome; PCI, percutaneous coronary intervention. In addition, in patients with multivessel disease, there were 4 patients in FFR ≥ 0.75 group and 2 patients in FFR < 0.75 group, in whom FFR was measured to 2 vessels at the same time. Among these patients, only 1 patient with FFR ≥ 0.75 had a cardiac event of ACS in the deferred lesion. Furthermore, 1 patient with stenosis of left main trunk and FFR ≥ 0.75 had no cardiac event during follow-up period of 6 years. In the present study, we examined functional severity of 50 coronary artery lesions with angiographically intermediate stenoses by FFR. When FFR was ≥ 0.75, PCI was deferred (n = 33) and then if FFR was <0.75, PCI was performed (n = 17). Patients were followed-up for MACE with an average period of 53 months. The rate of MACE in the two groups was not statistically different (6.9% vs. 13.3%), suggesting that our strategy using FFR was reasonable to decide the indication of PCI. After deferral of PCI based on FFR ≥ 0.75, MACE occurred in only 2 (6.9%) out of 29 patients (33 lesions) in about 4 years. This result was favorable compared to other studies from Western countries [8Pijls N.H. van Schaardenburgh P. Manoharan G. Boersma E. Bech J.W. van’t Veer M. Bär F. Hoorntje J. Koolen J. Wijns W. de Bruyne B. Percutaneous coronary intervention of functionally nonsignificant stenosis: 5-year follow-up of the DEFER Study.J Am Coll Cardiol. 2007; 49: 2105-2111Abstract Full Text Full Text PDF PubMed Scopus (1125) Google Scholar, 9Bech G.J. De Bruyne B. Bonnier H.J. Bartunek J. Wijns W. Peels K. Heyndrickx G.R. Koolen J.J. Pijls N.H. Long-term follow-up after deferral of percutaneous transluminal coronary angioplasty of intermediate stenosis on the basis of coronary pressure measurement.J Am Coll Cardiol. 1998; 31: 841-847Abstract Full Text Full Text PDF PubMed Scopus (158) Google Scholar]. Pijls et al. demonstrated in the DEFER study that the rate of cardiac death or myocardial infarction related to functionally non-significant stenoses based on FFR > 0.75 was 3.3% for 5-year follow-up periods and not decreased by PCI with coronary stents [[8]Pijls N.H. van Schaardenburgh P. Manoharan G. Boersma E. Bech J.W. van’t Veer M. Bär F. Hoorntje J. Koolen J. Wijns W. de Bruyne B. Percutaneous coronary intervention of functionally nonsignificant stenosis: 5-year follow-up of the DEFER Study.J Am Coll Cardiol. 2007; 49: 2105-2111Abstract Full Text Full Text PDF PubMed Scopus (1125) Google Scholar]. These data suggested that FFR was a useful index to identify patients who do not need immediate PCI. In predicting the prognosis, myocardial perfusion single photon emission computed tomography (SPECT) was a reliable and noninvasive method. The patients with normal scan of perfusion SPECT had low risk (0.5%/year) of myocardial infarction and cardiac death [[10]Tanaka H. Chikamori T. Tanaka N. Hida S. Shindo N. Igarashi Y. Yamashina A. A flow-limiting stenosis is the major determinant of exercise-induced myocardial stunning in patients with coronary artery disease.J Cardiol. 2010; 55: 337-344Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar]. Importantly, normal scan of SPECT included not only intermediate coronary stenoses but also mild stenoses and normal coronary arteries. In contrast, the target lesions of our study were intermediate stenoses, which had diameter stenosis of 49.8 ± 9.5% and FFR was a reliable tool in such intermediate stenoses. In this study, we focused on de novo stenoses in native coronary arteries including multivessel disease and left main disease. The usefulness of FFR measurement has been documented in multivessel disease [[11]Hachamovitch R. Berman D.S. Shaw L.J. Kiat H. Cohen I. Cabico J.A. Friedman J. Diamond G.A. Incremental prognostic value of myocardial perfusion single photon emission computed tomography for the prediction of cardiac death: differential stratification for risk of cardiac death and myocardial infarction.Circulation. 1998; 97: 535-543Crossref PubMed Scopus (1008) Google Scholar], left main disease [[12]Berger A. Botman K.J. MacCarthy P.A. Wijns W. Bartunek J. Heyndrickx G.R. Pijls N.H. De Bruyne B. Long-term clinical outcome after fractional flow reserve-guided percutaneous coronary intervention in patients with multivessel disease.J Am Coll Cardiol. 2005; 46: 438-442Abstract Full Text Full Text PDF PubMed Scopus (156) Google Scholar], restenosis [[13]Hamilos M. Muller O. Cuisset T. Ntalianis A. Chlouverakis G. Sarno G. Nelis O. Bartunek J. Vanderheyden M. Wyffels E. Barbato E. Heyndrickx G.R. Wijns W. De Bruyne B. Long-term clinical outcome after fractional flow reserve-guided treatment in patients with angiographically equivocal left main coronary artery stenosis.Circulation. 2009; 120: 1505-1512Crossref PubMed Scopus (273) Google Scholar], as well as single-intermediate stenoses [[7]Boden W.E. O’Rourke R.A. Teo K.K. Hartigan P.M. Maron D.J. Kostuk W.J. Knudtson M. Dada M. Casperson P. Harris C.L. Chaitman B.R. Shaw L. Gosselin G. Nawaz S. Title L.M. et al.Optimal medical therapy with or without PCI for stable coronary disease.N Engl J Med. 2007; 356: 1503-1516Crossref PubMed Scopus (3373) Google Scholar]. The FFR measurement between 0.75 and 0.80 has been recognized as gray zone [[14]Kobori Y. Tanaka N. Takazawa K. Yamashina A. Usefulness of fractional flow reserve in determining the indication of target lesion revascularization.Catheter Cardiovasc Interv. 2005; 65: 355-360Crossref PubMed Scopus (16) Google Scholar], although we have used the cut-off point of 0.75 in our study. Recently, several studies have chosen the cut-off value of 0.80 for the indication of PCI and demonstrated a higher rate of cardiac events in patients with gray zone [15Kern M.J. Lerman A. Bech J.W. De Bruyne B. Eeckhout E. Fearon W.F. Higano S.T. Lim M.J. Meuwissen M. Piek J.J. Pijls N.H. Siebes M. Spaan J.A. American Heart Association Committee on Diagnostic and Interventional Cardiac Catheterization, Council on Clinical Cardiology. Physiological assessment of coronary artery disease in the cardiac catheterization laboratory: a scientific statement from the American Heart Association Committee on Diagnostic and Interventional Cardiac Catheterization. Council on Clinical Cardiology.Circulation. 2006; 114: 1321-1341Crossref PubMed Scopus (394) Google Scholar, 16Legalery P. Schiele F. Seronde M.F. Meneveau N. Wei H. Didier K. Blonde M.C. Caulfield F. Bassand J.P. One-year outcome of patients submitted to routine fractional flow reserve assessment to determine the need for angioplasty.Eur Heart J. 2005; 26: 2623-2629Crossref PubMed Scopus (87) Google Scholar]. However, in our study, the stenotic lesions with gray zone were 8 (24%) out of all 33 lesions with FFR > 0.75, but none of them had cardiac events during the follow-up period. Therefore, we should consider gray zone in individuals and diseased lesions by clinical judgment. During the follow-up period, cardiac events occurred in 2 patients and both patients had developed lesions where FFR was evaluated. It was reported that the occlusion of coronary artery causing myocardial infarction most frequently evolved from mild to moderate stenoses [[17]Courtis J. Rodes-Cabau J. Larose E. Dery J.P. Nguyen C.M. Proulx G. Gleeton O. Roy L. Barbeau G. Noël B. DeLarochellière R. Bertrand O.F. Comparison of medical treatment and coronary revascularization in patients with moderate coronary lesions and borderline fractional flow reserve measurements.Catheter Cardiovasc Interv. 2008; 71: 541-548PubMed Google Scholar], and that coronary plaque disruption and subsequent thrombus formation which recognized “vulnerable plaques” lead to ACS from stable coronary artery disease [[18]Falk E. Shah P.K. Fuster V. Coronary plaque disruption.Circulation. 1995; 92: 657-671Crossref PubMed Scopus (3029) Google Scholar]. Therefore, it is important to consider the characteristics of plaques, and the vulnerable plaque is characterized as a large lipid pool covered by a thin fibrous cap. To evaluate the morphology of plaques, other modalities such as intravascular ultrasound (IVUS), angioscopy, optical coherence tomography (OCT), and multidetector-row computed tomography (MDCT) might be necessary [19Schaar J.A. Muller J.E. Falk E. Virmani R. Fuster V. Serruys P.W. Colombo A. Stefanadis C. Ward Casscells S. Moreno P.R. Maseri A. van der Steen A.F. Terminology for high-risk and vulnerable coronary artery plaques. Report of a meeting on the vulnerable plaque, June 17 and 18, 2003, Santorini, Greece.Eur Heart J. 2004; 25: 1077-1082Crossref PubMed Scopus (418) Google Scholar, 20Matter C.M. Stuber M. Nahrendorf M. Imaging of the unstable plaque: how far have we got?.Eur Heart J. 2009; 30: 2566-2574Crossref PubMed Scopus (78) Google Scholar, 21Tanaka S. Noda T. Segawa T. Iwama M. Minagawa T. Watanabe S. Minatoguchi S. Relation between functional stenosis and tissue characterization of intermediate coronary plaques in patients with stable coronary heart disease.J Cardiol. 2010; 55: 296-302Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar]. In order to prevent plaque rupture and ACS in the stenoses with deferral of PCI, the stabilization of coronary plaques was important and lipid-lowering therapy by statins was considered useful [[22]Kodama K. Komatsu S. Ueda Y. Takayama T. Yajima J. Nanto S. Matsuoka H. Saito S. Hirayama A. Stabilization and regression of coronary plaques treated with pitavastatin proven by angioscopy and intravascular ultrasound—the TOGETHAR trial.Circ J. 2010; 74: 1922-1928Crossref PubMed Scopus (42) Google Scholar]. This study has several limitations. The first limitation is that the study population was small in a single institution in Japan. Second, several strategies of PCI (POBA, DCA, BMS, and DES) were used in patients with FFR < 0.75. The MACE occurred in 2 patients with FFR < 0.75 because of restenosis and their strategies of PCI were POBA and DCA. These facts might influence the rate of MACE because the restenosis rate varied among each strategy. Long-term clinical outcomes after deferral of PCI of intermediate coronary stenoses based on FFR were excellent. These data suggest that FFR is a useful index to judge the indication of PCI and risk-stratification of patients for MACE." @default.
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• W1964255093 title "Long-term clinical outcomes after deferral of percutaneous coronary intervention of intermediate coronary stenoses based on coronary pressure-derived fractional flow reserve" @default.
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