Usefulness of fractional flow reserve guided percutaneous coronary intervention in decision making and cost effectiveness: a real world scenario from developing country

Objective: This study was devised in view of the real life application of FFR in catheterisation laboratory from a developing world country and to evaluate the cost effectiveness of the same. Background: FFR has been proved to be superior to angiographic ally driven PCI in various studies also it has been proven to be economically beneficial. However there is difference between trials and real life situation. Considering this we conducted this study and evaluated clinical outcome and cost effectiveness associated with use of FFR. Methods: We conducted a retrospective study which included all patients who underwent FFR in our hospital. Coronary angiograms of these patients were retrospectively analysed by two interventional cardiologists and decision regarding the lesion were made. The proposed decisions and their associated costs were compared with the actual procedure and costs incurred with the use of FFR. Also patients were evaluated for any adverse outcome after the procedure to the time of analysis. Results: 38 patients underwent FFR in our hospital. 12 patients had SVD, 13 patients had DVD, 3 patients had TVD and 2 patients had LMCA disease. Mean FFR value in our study was 0.84±0.09 and 36.8% of all lesions had FFR≤0.80 and 16.2% had FFR 0.75-0.80. LAD was the most common vessel interrogated (27 patients). Total 42 lesions were analysed in 38 patients. Concordance between cardiologist opinion and FFR results were seen in 47.6% lesions. On basis of angiography alone intervention cardiologists decided 22 lesions to be stented but after estimation of FFR, 16 lesions were stented. Overall in 22 lesions decision was changed of which 14 lesions were deferred and 8 lesions were those which underwent PCI. On evaluation total cost of procedures as per decision of intervention cardiologist was found to be Rs 2603254 and actual total cost was Rs 2887954 with a difference of Rs 284700, which was not significant statistically. If further it was considered that FFR wire was used as guide wire for the patients who later underwent PCI after FFR, and cost of guide wire was reduced from the actual cost then Rs 207900 was the difference. Out of 38 patients we were able to contact 32 patients only. Mean duration of follow up was 12.7±7.14 mths. Amongst the 32 patients only 2 patients complained of class II angina. One patient later underwent CABG and was asymptomatic on follow up. Conclusion: Despite few number of patients this study reinforces that clinical trials don’t represent real life scenario and cost effective analysis may not be achieved in each set of situations. However, despite the increased cost we support the use of FFR for guiding revascularisation in intermediate severity lesions as it helps to classify these lesions correctly into significant or non significant. More so deferring of insignificant lesions and attending to significant lesions both are important to improve outcome.