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 4 – Mean fractional flow reserve before and after percutaneous coronary intervention n FFR (mean ± SD) p Before PCI 87 0.74 ± 0.15 0.290* Post-PCI 39 0.90 ± 0.06 0.290* FFR: fractional flow reserve; PCI: percutaneous coronary intervention; SD: standard deviation; * Pearson’s chi-square test. Table 5 – Estimates for the model: procedure and outpatient service costs Procedures Costs (BRL) ANGIO FFR Procedure-index 1,503.00 1,503.00 28 ( Stent and FFR – mean cost) 2,034.50 2,517.25 Restenosis management (ICP + c/ SF*) 7,904.01 29 Revascularization surgery – elective 7,620.60 29 - emergency 8,950.50 28 AMI-index 2,716.95 29 One year without events following ICP or stable MRS 1,383.00 28 Cardiac catheterization 539.00 28 Mean PCI 5,386.76 29 PCI with balloon 1,599.02 29 Death for CAD 2,577.00 28 PCI: percutaneous coronary intervention;AMI: acute myocardial infarction; CAD: coronary artery disease; MRS: myocardial revascularization surgery;ANGIO: coronary angiography group; FFR: fractional flow reserve group. * Management of restenosis with percutaneous coronary intervention + covered stent. Table 6 – Results of cost-effectiveness analysis: coronary angiography (ANGIO) group versus fractional flow reserve (FFR) group Strategy One-year effectiveness Difference in effectiveness Cost (BRL) Cost difference (BRL) ICER ANGIO 78.52% – 5,045.97 – – FFR 80.34% 1.82% 5,430.60 384.62 21.156.55 ICER: incremental cost-effectiveness ratio; ANGIO: coronary angiography group; FFR: fractional flow reserve. from FAME, that used a cut-off of 0.80. The choice for a lower cut-off point was justified by a 100% 16 predictive value for a FFR value of 0.75. A cut-off of 0.75 would hence represent a lower chance of restenosis, since it would be expected a higher incidence of restenosis with the use of NPS. Li et al. 17 evaluated more than 7,300 patients, 1,090 of them undergoing FFR-guided PCI, 30% with NPS. After the exclusion of patients with FFR > 0.75 and < 0.80, there was a decrease in the rates of AMI and in the composite of AMI and death. In patients with FFR > 0.80, a conservative approach was used. Clinical data Although the increment of 1.45% in mortality in the FFR group was not statistically significant, the result contrasts with the literature, although we attributed this finding to the small number of randomized patients. 17-19 Zhang et al. 20 showed in a meta-analysis including nearly 50,000 patients that FFR reduced the absolute risk of late mortality by 7.7%. 20 The frequency of MACE in our study group was 17.3%, with similar distribution between the groups, in accordance with the FAME study. 15 The incidence of angina in the FFR group was identical between the groups. In the present study, 9 (13.0) patients had angina and/or ischemia according to ergometric test, 4 (44.4%) in the FFR group and 5 (55.6%) in the ANGIO group. In the ANGIO group, one patient was lost to follow-up before reassessment. All the four patients reassessed were treated for intra-stent stenosis defined by angiographic criteria, whereas in the FFR group, functional analysis indicated that 2 of these 4 patients required treatment. When we evaluated the need for new revascularization considering the presence of clinical restenosis (angina/ischemia) and functional reassessment, only half of patients in the FFR group was subjected to another PCI for intra-stent restenosis. In the ANGIO group, according to angiographic criteria, 12 vessels with restenosis were identified, which were later treated. In the FFR group, 8 vessels were reassessed, and only 2 required treatment. Thus, in the former group, the number of treated vessels was six times greater, with twice the number of TLR compared with the latter group. 44