Introduction

Randomized evidence suggests improved outcomes when fractional flow reserve (FFR) is used to guide coronary revascularization in well-defined patient cohorts. The frequency of elderly patients undergoing invasive coronary angiography is continuously increasing and requires evidence-based therapeutic concepts. However, the impact of FFR-guided revascularization on long-term outcomes in this high-risk subgroup is still unknown. The FLORIDA (Fractional FLOw Reserve In cardiovascular DiseAses) study sought to investigate outcomes of FFR-guided versus angiography-guided treatment strategies in a large, real-world cohort including a significant subgroup of patients ≥ 75 years.

Methods and Results

Patients enrolled into the anonymized German InGef Research Database and undergoing coronary angiography between January 2014 and December 2015 were included in the FLORIDA study. Among 64,045 patients undergoing coronary angiography for suspected coronary artery disease (CAD), 1,992 (3.11%) patients had functional lesion assessment with FFR. Using a matched cohort study design within the FLORIDA-study cohort (n=3,962) all-cause-mortality as well as major cardiovascular events (MACE: all-cause mortality, myocardial infarction and revascularization procedures) over 3-years of follow-up were analyzed for patients treated by FFR- or angiography-guided treatment respectively. For this analysis, the subgroup of patients ≥ 75 years, consisting of 736 patients (36.9 %), was investigated in detail.

Within the FFR-assessed group 13% more patients underwent revascularization by PCI/CABG compared with the angiography-only group (39.8 % vs. 35.4%). The incidence of MACE was 42.3% in the FFR-assessed group and 49.3% in the angiography-only group (p=0.0076) over 3-years of follow-up, corresponding to a 14% relative risk reduction for the use of FFR in patients ≥ 75 years. Most importantly, there was a significant difference in mortality at 3 years favoring the use of FFR (FFR: 14.9%; Angio-only: 20.1%; p=0.0076, RRR: 26%), whereas the incidence of MI and revascularization procedures (PCI/CABG) was similar (21.2% vs. 21.1%; p>0.99 and 17.7% vs. 18.5%; p=0.73 for FFR and angio-only strategies, respectively).

Conclusion

In this subgroup analysis consisting of a significant cohort of aged-patients out of the large, all-comer FLORIDA-study population, an FFR-based revascularization strategy was associated with an impressive 26% relative risk reduction for all-cause-mortality over 3 years. To our knowledge, this is the first study evidence supporting the routine use of FFR to guide revascularization therapy in elderly patients.