Angiography-based physiological assessments can offer additional prognostic insights for patients undergoing intravascular ultrasound (IVUS)-guided percutaneous coronary intervention (PCI), according to a post-hoc analysis of the FLAVOUR trial. However, the new analysis concluded that, for patients with functionally insignificant lesions, “even IVUS-guided PCI may not be advantageous”. The findings were published Monday online in JACC: Cardiovascular Interventions, led by Jinlong Zhang, MD, PhD, from the Second Affiliated Hospital of Zhejiang University School of Medicine, China, and Wei Yu, PhD, Shanghai Jiao Tong University, China. Superior clinical outcomes with intravascular imaging (IVI)-guided PCI strategies versus angiography-guided approaches have been “widely demonstrated,” the researchers noted. Yet, the FLAVOUR (Fractional Flow Reserve and Intravascular Ultrasound for Clinical Outcomes in Patients With Intermediate Stenosis) trial showed that a physiology-guided PCI strategy had equal effectiveness to IVI-guided approaches, with fewer stents. Angiography-based physiological assessment represents a wire-free approach in the catheterization laboratory to simplify physiological assessment, the researchers added. And while the clinical value of angiography-based physiological assessments in the context of IVI-guided PCI remains unclear. “Angiography-based physiological assessment could be an alternative option in this combination,” the authors wrote. The current study therefore set out to explore angiography-based physiological assessments in IVI-guided PCI through an analysis of the 784 patients in the multicenter FLAVOUR study. This study used angiography-based physiological assessments retrospectively,using the Murray law–based quantitative flow ratio (μQFR). Patients were categorized based on IVUS-guided treatment decisions (PCI or deferral) and μQFR status including: negative with deferral of PCI (DEFER – 34.4% of patients), negative μQFR with PCI (PERFORM – 29.3 μQFR %), and positive μQFR with PCI (REFERENCE – 31.5%). “Physiological assessment led to substantial reclassification, encompassing 48.2% (230/477) of patients who underwent IVUS-guided PCI,” the researchers noted, adding that there was a 36.2% discordance in disease significance as assessed by IVUS and μQFR. The reclassification rate meant that “almost one-half of patients could avoid being subjected to PCI,” the researchers highlighted. At baseline, there were no statistically significant differences in patient characteristics among the 3 groups except for the initial diagnosis. The REFERENCE group had a higher angiographic diameter stenosis, smaller minimal lumen area (MLA), more plaque burden, and lower μQFR than the other 2 groups. After PCI, the minimal stent area was not different between the PERFORM group and the REFERENCE group (7.1 ± 2.2 mm2 vs 6.8 ± 2.1 mm2 ; P = 0.127), whereas μQFR was higher in the PERFORM group (0.94 ± 0.04 vs 0.92 ± 0.05; P < 0.001). When compared with the PERFORM group, the REFERENCE group showed a higher risk for the primary outcome measure of major adverse cardiovascular events at 2 years – a composite of death, myocardial infarction, and target vessel revascularization (adjusted hazard ratio [HR]: 2.46; 95% confidence interval [CI]: 1.13-5.35; P = 0.023). However, the primary outcomes in the DEFER and PERFORM groups were similar (adjusted HR: 0.88; 95% CI: 0.37-2.11; P = 0.779). Quality of life scores as assessed by the Seattle Angina Questionnaire were comparable among the 3 groups at 2 years (DEFER: 66.5 ± 11 vs. PERFORM: 64.4 ± 13.5 vs. REFERENCE: 64.7 ± 15; P = 0.198). The researchers added that functionally negative stenoses assessed by μQFR, no differences were observed in terms of major adverse cardiovascular events (MACE_ and quality of life between PCI guided by IVUS and deferral of PCI. In an accompanying editorial, Damien Collison, MB, BCh, MD, from the Golden Jubilee National Hospital, UK, marked the study as “thought provoking” and called for additional studies to deterring whether combining physiology-guided decision making and imaging-guided PCI can “give us the best of both worlds and further enhance clinical outcomes for patients with coronary artery disease.” Sources: Zhang J, Yu Wei, Hu X, et al. Clinical Relevance of Discordance Between Physiology- and ImagingGuided PCI Strategies in Intermediate Coronary Stenosis. JACC: Cardiovasc Interv 2024; DOI: 10.1016/j.jcin.2024.09.045. Collison D. The Best of Both Worlds: Intracoronary Imaging and Physiology, Together in Perfect Harmony? JACC: Cardiovasc Interv 2024; DOI: 10.1016/j.jcin.2024.09.074. Image Credit: andrey_orlov – stock.adobe.com