ABC | Volume 112, Nº1, January 2019

Original Article Clinical Outcomes and Cost-Effectiveness Analysis of FFR Compared with Angiography in Multivessel Disease Patient Edgard Freitas Quintella, 1,2 Esmeralci Ferreira, 1 Vitor Manuel Pereira Azevedo, 3,4 Denizar V. Araujo, 1 Fernando Mendes Sant`Anna, 1 Bernardo Amorim, 2 Denilson Campos de Albuquerque 1 Hospital Universitário Pedro Ernesto - Universidade Estadual do Rio de Janeiro (UERJ), 1 Rio de Janeiro, RJ – Brazil Instituto Estadual de Cardiologia Aloysio de Castro (IECAC), 2 Rio de Janeiro, RJ – Brazil Cardiology Department. Hospital Clínico Universitario, INCLIVA. Universitat de València, 3 Valencia – Spain Instituto Nacional de Cardiologia Laranjeiras (INCL), 4 Rio de Janeiro, RJ – Brazil Mailing Address: Edgard Freitas Quintella • Rua dos Jacarandás 300, Bloco 5 Apto 1206. Postal Code 22776-050, Barra da Tijuca, RJ – Brazil E-mail: e.quintella@gmail.com Manuscript received April 04, 2018, revised manuscript July 23, 2018, accepted July 23, 2018 DOI: 10.5935/abc.20180262 Abstract Background: In multivessel disease patients with moderate stenosis, fractional flow reserve (FFR) allows the analysis of the lesions and guides treatment, and could contribute to the cost-effectiveness (CE) of non-pharmacological stents (NPS). Objectives: To evaluate CE and clinical impact of FFR-guided versus angiography-guided angioplasty (ANGIO) in multivessel patients using NPS. Methods: Multivessel disease patients were prospectively randomized to FFR or ANGIO groups during a 5 year-period and followed for < 12 months. Outcomes measures were major adverse cardiac events (MACE), restenosis and CE. Results: We studied 69 patients, 47 (68.1%) men, aged 62.0 ± 9.0 years, 34 (49.2%) in FFR group and 53 (50.7%) in ANGIO group, with stable angina or acute coronary syndrome. In FFR, there were 26 patients with biarterial disease (76.5%) and 8 (23.5%) with triarterial disease, and in ANGIO, 24 (68.6%) with biarterial and 11 (31.4%) with triarterial disease. Twelve MACEs were observed – 3 deaths: 2 (5.8%) in FFR and 1 (2.8%) in ANGIO, 9 (13.0%) angina: 4(11.7%) in FFR and 5(14.2%) in ANGIO, 6 restenosis: 2(5.8%) in FFR and 4 (11.4%) in ANGIO. Angiography detected 87(53.0%) lesions in FFR, 39(23.7%) with PCI and 48(29.3%) with medical treatment; and 77 (47.0%) lesions in ANGIO, all treated with angioplasty. Thirty-nine (33.3%) stents were registered in FFR (0.45 ± 0.50 stents/lesion) and 78 (1.05 ± 0.22 stents/lesion) in ANGIO (p = 0.0001), 51.4% greater in ANGIO than FFR. CE analysis revealed a cost of BRL 5,045.97 BRL 5,430.60 in ANGIO and FFR, respectively. The difference of effectiveness was of 1.82%. Conclusion: FFR reduced the number of lesions treated and stents, and the need for target-lesion revascularization, with a CE comparable with that of angiography. (Arq Bras Cardiol. 2019; 112(1):40-47) Keywords: Fractional Flow Reserve, Myocardial; Cost-Benefit Analysis; Coronary Artery Disease/economics; Angioplasty, Balloon, Coronary; Stents. Introduction In stable coronary artery disease (CAD), angiographic lesions that would benefit most from myocardial revascularization (MR) are those associated with ischemia. 1 Non-invasive tests (NITs) for ischemia may yield conflicting results, which make it difficult to identify culprit lesions based on symptoms, and consequently to make better therapeutic decisions. 2 In multivessel coronary disease patients, angiography may fail to evaluate the prognosis, especially in those with moderate stenosis (50-70%). 3 FAME-2 4 trial compared the use of fractional flow reserve (FFR) and angiography alone to identify coronary stenosis that required treatment. The study could be discontinued earlier due to the superiority of FFR-guided revascularization. Although most percutaneous coronary interventions (PCIs) are still performedwithout NITs, 70%of patients referred for PCI have multivessel diseases, and 80%havemoderate lesions. 5 However, it is estimated that 40-50% of these lesions are ischemic. FFR is the best method to associate obstruction with ischemia. A FFR < 0.75 is considered to be associated with ischemia, with sensitivity, specificity, positive and negative predictive values greater than 90%. 6,7 PCI for ischemic lesions is cost-effective and decreases the occurrence of major adverse cardiac events (MACE). 8 Fearon et al. 9 showed that FFR-guided PCI in patients with one-vessel CAD was superior to other therapeutic strategies based on angiography or scintigraphy. Our study aims to add to the knowledge of the cost‑effectiveness (CE) of FFR-guided PCI in patients with multivessel CAD. 40