Reviwer: Dr. Serhat Sığırcı

Name of the Study: Does Routine Pressure Wire Assessment Influence Management Strategy at Coronary Angiography for Diagnosis of Chest Pain? – RIPCORD 2

Published Congress: ESC 2021

Background: 

The traditional approach to angina is based on either assessment of the coronary anatomy by angiography or noninvasive testing for reversible ischemia.

Invasive pressure wire evaluation during angiography provides essential information about both anatomy and physiology. Fractional flow reserve (FFR) guided percutaneous coronary intervention is associated with less resource use and better clinical outcome than angiographic evaluation alone. However, routine evaluation of all major coronary arteries by FFR during diagnostic angiography has not been demonstrated in a randomized trial despite convincing observational data. A practical change to the routine FFR evaluation of all major vessels during diagnostic angiography requires evidence of not only clinical benefit but also cost-effectiveness.This randomized trial aims to test that strategy.
Objectives: The RIPCORD2 trial, as the first study in this area, aims to evaluate whether systematic FFR assessment of all relevant coronary arteries at the diagnostic angiography stage can provide superiority in resource utilization, quality of life, and clinical outcomes compared to angiographic assessment alone.

Methods:

1100 patients scheduled to undergo diagnostic coronary angiography for stable angina or non-ST elevation myocardial infarction at 17 UK centers were randomized into this study. Significant coronary artery disease was defined as any stenosis >30% in lumen diameter by visual estimation in at least one vessel (approximately 2.25 mm diameter).

Patients were randomized to either angiographic evaluation alone (ONLY ANGIO) or FFR evaluation of all epicardial vessels (ANGIO+FFR) sufficient for stenting or grafting. The primary economic endpoint is a comparison of 1-year health care costs. The primary quality of life endpoint was a comparison of patient-reported quality of life scores at one year. Secondary endpoints included clinical events at one year, management strategy (optimal medical therapy with or without revascularization), and angina status at one year according to Canadian Cardiovascular Society angina grade.

Results:

There was no difference in health care costs at one year between the ONLY ANGIO and ANGIO+FFR groups (£4,136 and £4,510, respectively. P: 0.137). There was no improvement in patients' quality of life or angina status at one year with routine use of FFR.
Routine FFR use was associated with longer procedures, more radiation and contrast use, and a higher complication rate.
Conclusions: Routine, systematic evaluation of FFR during diagnostic angiography is cost-neutral compared to angiographic guidance alone.
It is not associated with significant differences in quality of life or angiography status at one year. Thus, this strategy has no overall advantage over angiography alone.