Takashi Akasaka

BACKGROUND: The clinical utility of physiology-guided revascularization for decision-making in patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD) remains uncertain. The aim of this study is to evaluate the diagnostic performance and prognostic significance of fractional flow reserve (FFR) and nonhyperemic pressure ratios (NHPRs) according to the severity of CKD. METHODS: This subanalysis of the J-PRIDE registry, a prospective multicenter study conducted at 20 Japanese centers between September 2019 and February 2021, included 4296 lesions from 3194 patients who underwent both FFR and NHPR assessment. Patients were categorized by estimated glomerular filtration rate into non-CKD (≥60 mL/min per 1.73 m ² ; n=1639), CKD (15–59; n=1321), and ESRD (P P =0.001). The NHPR cutoff predicting FFR ≤0.80 was lower in ESRD compared with CKD and non-CKD (0.85 versus 0.89 versus 0.89). Although the overall prevalence of FFR/NHPR discordance was comparable (23.6%, 19.7%, and 19.7%; P =0.24), FFR−/NHPR+ discordance predominated in ESRD (18.6% versus 9.3% versus 7.0%; P <0.001). FFR−/NHPR+ lesions in the ESRD group exhibited an excess risk compared with other lesions. Revascularization was beneficial in non-CKD patients with FFR+/NHPR− lesions, whereas no clear benefit was observed in patients with CKD and ESRD. CONCLUSIONS: Patients with ESRD exhibited distinct physiological characteristics and substantially worse outcomes, highlighting the need for tailored coronary revascularization strategies in this population. REGISTRATION: URL: https://www.umin.ac.jp/ctr ; Unique identifier: UMIN000038403.

BACKGROUND: Limited large-scale, real-world data exist on the prevalence and clinical impact of discordance between fractional flow reserve (FFR) and nonhyperemic pressure ratios (NHPRs). METHODS: The J-PRIDE registry (Clinical Outcomes of Japanese Patients With Coronary Artery Disease Assessed by Resting Indices and Fractional Flow Reserve: A Prospective Multicenter Registry) prospectively enrolled 4304 lesions in 3200 patients from 20 Japanese centers. The lesions were classified into FFR+/NHPR−, FFR−/NHPR+, FFR+/NHPR+, or FFR−/NHPR groups according to cutoff values of 0.89 for NHPRs and 0.80 for FFR. The primary study end point was the cumulative 1-year incidence of target vessel failure (a composite of cardiac death, target vessel–related myocardial infarction, and clinically driven target vessel revascularization) on a lesion basis. RESULTS: An NHPR cutoff value of 0.89, determined using online software, predicted an FFR of 0.80 across various NHPR types. Discordance between FFR and NHPRs was observed in 20% of lesions (FFR+/NHPR−, 11.2%; FFR−/NHPRs+, 8.8%). Revascularization was deferred in 42.9% and 88.4% of the FFR+/NHPR− and FFR−/NHPR+ groups, respectively. In deferred vessels, the FFR+/NHPR− and FFR−/NHPR+ groups showed a higher 1-year incidence of target vessel failure compared with the FFR−/NHPR− group (7.9% versus 5.5% versus 1.7%; for FFR+/NHPR−, adjusted hazard ratio [aHR], 4.89 [95% CI, 2.68–8.91]; P P P =0.17), although with similar outcomes between the FFR+/NHPR− and FFR+/NHPR+ groups (2.3% versus 3.4%; aHR, 0.96 [95% CI, 0.37–2.38]; P =0.93). The FFR+/NHPR− group benefited from revascularization compared with medical treatment (aHR, 0.26 [95% CI, 0.08–0.86]; P =0.027); the FFR−/NHPR+ group did not (aHR, 2.39 [95% CI, 0.62–9.21]; P =0.20). CONCLUSIONS: Discordance between FFR and NHPRs was noted in 20% of lesions, and discordant deferred lesions resulted in worse outcomes than concordant negative lesions. Although the outcomes after deferring revascularization were comparable between the FFR+/NHPR− and FFR−/NHPR+ lesions, only FFR+/NHPR− lesions showed a benefit from revascularization compared with medical treatment, suggesting that an FFR-guided strategy is superior to an NHPR-guided strategy in discordant lesions. REGISTRATION: URL: https://www.umin.ac.jp ; Unique identifier: UMIN000038403.