Editors' ChoiceCardiovascular Medicine

Translational Tectonics for Stents

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Science Translational Medicine  08 Oct 2014:
Vol. 6, Issue 257, pp. 257ec171
DOI: 10.1126/scitranslmed.3010420

In stable coronary heart disease, blockages of the arteries that supply the heart limit blood flow and cause a predictable and unchanging pattern of chest pain. This is in contrast to patients with unpredictable, accelerating patterns of chest pain or frank heart attack. Dominant thinking holds that rather than opening blockages with, for example, a stent, medical therapy alone (intense use of aspirin, statins, β-blockers, and angiotensin-converting-enzyme (ACE) inhibitors) is likely sufficient for preventing death and heart attack in patients with stable coronary heart disease. New findings show that placing stents with guidance from measurements of the functional pressure drop across the lesion may offer an even better avenue for treatment.

De Bruyne et al. used fractional flow reserve (FFR) to guide stent placement and compared this approach with medical therapy alone. The FFR-stent combination reduced death, heart attack, or urgent revascularization by 19.5% after 2 years (to 8.1%). The fact that this sizeable benefit was largely driven by urgent revascularization prompted debate as to whether the effect was clinically meaningful. But the subset of patients experiencing death or heart attack only was reduced from 8 to 4.6% in the 8 days to 2 years after treatment, lending confidence in the results.

These data should prompt clinicians to reconsider the optimal treatment for their patients, especially if FFR can be measured more efficiently. FFR is typically invasive and time-consuming, but computed tomography FFR already exists and permits noninvasive global FFR measurements. Such tools have long processing times that limit their utility in time-critical settings but could have newfound value in stable patients. If FFR guidance can reliably reduce the relative risk of death or heart attack by nearly 50%, then the millions of people with stable coronary heart disease will profit from these technologies.

B. De Bruyne et al., Fractional flow reserve–guided PCI for stable coronary artery disease. N. Engl. J. Med. 371, 1208–1217 (2014). [Abstract]

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