ABC | Volume 112, Nº1, January 2019

Original Article Quintella et al FFR-versus angiography-guided PCI in multivessel disease Arq Bras Cardiol. 2019; 112(1):40-47 Table 1 – Characteristics of the study population (overall and by group) Overall study population (%) FFR n (%) ANGIO n (%) p Number of patients 69 (100.0) 34 (49.3) 35 (50.7) – Male sex 47 (68.1) 25 (53.2) 22 (46.8) 0.342 * Female sex 22 (31.9) 9 (40.9) 13 (59.1) 0.342 * Diabetes 24 (35.8) 12 (50.0) 12 (50.0) 0.930 * Hypertension 51 (73.9) 25 (49.0) 26 (50.9) 0.943 * Dyslipidemia 50 (72.5) 24 (42.0) 26 (52.0) 0.731 * Family history 40 (57.9) 21 (52.5) 19 (47.5) 0.529 * Current smoker 19 (27.5) 10 (52.6) 9 (47.4) 0.731 * Previous AMI 15 (21.7) 8 (53.3) 7 (46.7) 0.722 * Stable angina 42 (60.8) 20 (47.6) 22 (52.3) 0.930 ‡ Acute coronary syndrome 27 (39.1) 14 (57.1) 13 (42.8) 0.930 ‡ Age (years) mean ± SD 62.0 ± 9.0 62.7 ± 8.4 59.5 ± 9.4 0.117 * LV ejection fraction (%) (mean ± SD) 67.0 ± 13.3 70.0 ± 14.0 64.0 ± 12.0 0.110 † AMI: acute myocardial infarction; FFR: fractional flow reserve group;ANGIO: coronary angiography group; SD: standard deviation; LV: left ventricle. * Pearson’s chi‑square test; † Kruskal-Wallis test; ‡ Fisher’s exact test. Table 2 – Major adverse cardiovascular events in the study population Study population (%) FFR n (%) ANGIO n (%) MACE 12 (17.3) 6 (17.6) 6 (17.1) Total deaths 3 (4.3) 2 (5.8) 1 (2.8) Deaths from cardiovascular causes 2 (2.8) 1 (2.9) 1 (2.8) Deaths from non-cardiovascular causes 1 (1.4) 1 (2.9) 0 (0.0) Angina 9 (13.0) 4 (11.7) 5 (14.2) Target lesion revascularization 6 (8.6) 2 (5.8) 4 (11.4)* FFR: fractional flow reserve group; ANGIO: coronary angiography group; MACE: major adverse cardiovascular events; * 1 patient missed second coronary angiography and was lost to follow-up. Cost-effectiveness Estimates of themain clinical outcomes and probabilities to be included in the decisionmodel were obtained from the literature, by review of randomized trials involving non‑pharmacological stents (NPS) and PCI. Procedure-index cost and, the cost of post-PCI stable stage, and other costs were expressed in Brazilian Reals (BRL) (Table 5). 10 The difference in effectiveness, costs and incremental CE ratio (ICER) were 1.8%, BRL384.61, and BRL21,156.55, respectively (Table 6). Discussion The present study shows that FFR-guided PCI is a cost‑effective strategy compared with angiographic criteria in patients with multivessel diseases, reducing the number of stenosis, stents and need for target lesion revascularization (TLR). Asymptomatic patients, even elderly patients older than 75 years, 11 with percent myocardial ischemia ≥ 10% ischemic benefit from MR. In the COURAGE trial nuclear substudy, 12 patients that achieved a reduction in ischemic myocardium from ≥10% to <5%, showed better outcomes. Reduction of risk factors is essential in medical therapy. In this regard, to reduce the extension and severity of ischemic myocardium may contribute to the improvement of patients’ quality of life, particularly among those whose medical treatment was shown to be ineffective. The correlation of coronary anatomy with ischemic parameters may provide a rational and safe basis for revascularization. The ISCHEMIA trial, 13 still under way, was designed to compensate for existing limitations in the literature. In the present study, we attempted to show a reduction in MACE with FFR-guided invasive strategy compared with optimized medical treatment, and only for patients that did not respond to medical treatment. The key point in performing or not MR is the possibility of quantifying ischemic lesions per segment in case of multiple lesions, especially when associated with moderate lesions, which represent most of the cases. In this context, the only method capable of showing this relationship is FFR. However, the method is not only an invasive strategy, but also involves higher costs. In Brazil, the reality of PCI is very 42