Guidance on Interventional Diagnosis and Treatment of Coronary Artery Disease in 2014

Joel P Giblett; Stephen P Hoole


Interv Cardiol. 2014;6(4):353-355. 

In This Article

RIPCORD Trial: Routine Pressure Wire Assessment During Diagnostic Angiography

Evaluation of: Curzen N, Rana O, Nicholas Z et al. Does routine pressure wire assessment influence management strategy at coronary angiography for diagnosis of chest pain? The RIPCORD study. Circ. Cardiovasc. Interv. 7(2), 248–55 (2014).

Assessment of patients with a clinical history of possible angina but without objective evidence of ischemia is commonly undertaken with diagnostic angiography. Based on visual assessment of the severity of coronary artery disease, a management plan which may involve percutaneous coronary intervention (PCI) or coronary artery bypass grafts (CABG) is formulated but this assessment may be flawed. Pressure wire assessment following coronary angiography is a well-validated method for assessment of the functional severity of coronary artery disease[1] and be a more accurate gate keeper for revascularization.

A total of 200 patients listed for coronary angiography to investigate the cause of chest pains were included in the study.[2] Exclusion criteria included acute coronary syndrome at presentation, CABG and angiography within the previous 12 months. Patients underwent diagnostic angiography after which the supervising consultant was asked to formulate a management plan. Patients without significant stenosis were excluded from the study at this point. Subsequently a second interventional cardiologist performed a fractional flow reserve (FFR) study according to a standardized protocol. A reading <0.8 indicated a lesion had hemodynamic significance and merited treatment. These data were to formulate a new management plan. The primary end point was the proportion of patients in whom FFR data changed the original management plan.

Overall, the FFR data changed the management plan in 26% of patients in the study. FFR also reclassified the functional significance of 32% of the lesions assessed and in particular 18% of revascularization decisions to the left anterior descending artery, thought to be of most prognostic significance, were incorrect with angiography alone. Interestingly, of the 90 patients originally recommend for PCI, 24 (26.7%) were changed to medical therapy following FFR.

The study demonstrates the shortcomings of clinical decision making based on assessing the angiogram alone, although switching to an FFR assessment strategy may have logistical, cost and safety implications. These limitations and how proper lesion adjudication may affect clinical outcomes need to be addressed.