Examining The Prognostic Value Of QFR-guided PCI In Patients With Coronary Artery Disease

BACKGROUN:Cardiovascular disease(CVD)is recognized worldwide as one of the greatest threats to human health.Among them,coronary heart disease(CHD)accounts for the largest proportion of cardiovascular diseases and is a serious public health problem currently affecting most Chinese people,placing a heavy burden on patients’ families,medical institutions,and society.Percutaneous coronary angioplasty(PCI)is the mainstay of treatment for coronary artery disease.Coronary angiography(CAG)is now an important test to diagnose the severity of coronary vessels.However,coronary angiography only shows the anatomy of the coronary vessels and does not provide a functional assessment of the extent to which coronary stenosis affects the myocardial blood supply.As a result,techniques to assess coronary physiology are constantly evolving,and flow reserve fraction(FFR)is currently the most widely used coronary physiological index and is considered the gold standard for assessing myocardial ischemia.However,its use is not high due to its complexity,time-consuming nature,high cost of measurement,and adverse effects of related drugs such as adenosine.Given this situation,the rapid development of medical imaging-based computational coronary physiology methods such as quantitative flow fraction(QFR),which does not require the use of pressure guidewires or the administration of vasodilators for induction,promises to greatly expand the clinical application of coronary physiology.Several studies have shown that QFR shows good agreement with FFR in the assessment of functional coronary stenosis and has good applications in clinical decision-making and clinical prognosis.In conclusion,QFR is expected to replace FFR as the "new standard" for minimally invasive and accurate assessment of coronary physiological parameters.The FAVOR Ⅲ China results published in 2021 showed that in patients undergoing PCI,a QFRguided lesion selection strategy improved 1-year clinical outcomes compared with standard angiographic guidance.Subsequent 2-year clinical outcomes follow-up of this same pilot data study showed that the QFRguided PCI lesion selection strategy improved patient clinical outcomes at 2 years compared with standard angiography-guided PCI,with increasing benefit over time.Although QFR values after PCI have been shown in previous studies to be independently predictive of prognosis in patients with coronary artery disease and to have good predictive value,QFR is a new technique,and research and exploration about it are not comprehensive enough,and its clinical application still needs to be confirmed by many studies.Among them,the predictive value of QFR after PCI is also being explored,as previous studies have focused on Western populations,and it is unclear whether the findings are entirely appropriate for the Chinese population,and the criteria for inclusion and direction of the studies are not consistent.and there are no clear guidelines on the optimal threshold value for predicting patients with coronary artery disease,which means that the optimal threshold point of QFR measured after hemodynamic reconstruction in patients with coronary artery disease is still being explored.The aim of this study was to analyse the prognostic value of patients with coronary artery disease treated with QFR-guided PCI in a Chinese population,with the aim of providing precise guidance on patient prognosis and studying indicators of factors affecting prognosis,screening patients with high postoperative VOCE event rates and influencing factors,and exploring the optimal cut-off value of QFR affecting post-PCI.OBJECTIVE:To analyze the prognostic impact of QFR values measured immediately after coronary stenting on patients and to investigate the optimal cut-off values affecting QFR after PCI.METHODS:Two hundred and twenty-two patients with coronary artery disease who underwent PCI guided by QFR and 259 vessels admitted to***People’s Hospital between June 1,2021,and December 1,2022,were included as study subjects.The patients were divided into two groups,the post-PCI QFR≥0.93 group,and the post-PCI QFR<0.93 group,based on their post-PCI QFR values,and the general data of patients in both groups were observed.Additionally,the general data,laboratory indices,procedure-related data,and patient prognosis were compared between the two groups,and the factors affecting the QFR values of patients after PCI were analyzed.The 259 vessels included were divided into two groups,the VOCE and non-VOCE groups,based on the presence of Vessel-oriented Composite Endpoint(VOCE)events.The procedure-related data and lesion characteristics were compared between these two groups,and the factors influencing the occurrence of VOCE events were analyzed.Multifactor logistic regression was used to analyze the factors associated with the occurrence of VOCE events.A receiver operator characteristic curve(ROC)was established to evaluate the predictive value of post-PCI QFR on the occurrence of VOCE events at 1 year and to investigate the optimal cut-off value affecting post-PCI QFR.Kaplan-Meier survival time analysis was performed based on the optimal cut-off value of QFR after PCI,and the difference in the incidence of VOCE events between the two groups of patients was compared by Log Rank test.Statistical analysis was performed using SPSS 26.0 software,and differences between groups were considered statistically significant at P<0.05.RESULTS:1.In this study,a total of 229 patients were included,of which 220(96.07%)completed the 1-year follow-up,with a mean follow-up time of 199.29±85.54 days,while 9(3.9%)were lost to follow-up.Among the patients,220 had 259 vessels included in the study,with a mean post-PCI QFR value of 0.93±0.05 for the vessels.The patients were divided into two groups,the post-PCI QFR≥0.93 group(n=145)and the post-PCI QFR<0.93 group(n=75).The mean age of the patients was 61.80±10.36 years,with 165 males and 55 females.Comparison of the general information and test indexes between the two groups after PCI showed that age,gender,body mass index,creatinine clearance,EF,lipid profile,blood glucose level,white blood cell count,hypertension,hyperlipidemia,smoking history,family history of coronary heart disease,history of previous stroke,history of previous coronary heart disease,previous PCI,location of diseased vessels,multiple coronary vessel lesions(≥2),diffuse lesions,and completely occlusive lesions were not statistically significant(P>0.05).However,the difference in the incidence of comorbid diabetes between the two groups was statistically significant(P<0.05).Specifically,the proportion of patients with coronary artery disease and comorbid diabetes was significantly higher in the group with QFR<0.93 after PCI than in the group with QFR≥0.93 after PCI(44%vs.30.3%).2.After one year of clinical prognostic follow-up,a total of 32 patients experienced a VOCE event.Among these,three had vascular-related cardiac death,12 had vascular-related myocardial infarction(MI),and 17 had target vessel revascularization(TVR).Of the total number of patients,25 were from the post-PCI QFR<0.93 group and 7 were from the post-PCI QFR≥0.93 group.The incidence of VOCE events was found to be statistically significant in both groups(P<0.001).3.By comparing the surgical data of the two groups,it was found that there were no statistically significant differences in the number of diseased vessels,the number of stents implanted per vessel,the total length of stents implanted per vessel,the total diameter of stents implanted per vessel,preoperative QFR,preoperative vascular parameters,and MLD reference lumen diameter in postoperative vascular parameters between the two groups(P>0.05).In contrast,there were statistically significant differences in post-PCI QFR,minimum lumen diameter in post-operative vascular parameters,maximum diameter stenosis rate in post-operative vascular parameters,and maximum area stenosis rate in post-operative vascular parameters(P<0.001).4.After correlation analysis of the above-mentioned six factors with statistically significant differences,the results showed that there was no correlation between QFR values and diabetes after PCI(P>0.05).However,there was a significant correlation(p<0.001)between the minimum lumen diameter and the maximum postoperative diameter stenosis rate among the postoperative vascular parameters,with a spearman correlation coefficient of 0.441 and 0.738,respectively.Moreover,there was a significant correlation(P<0.001)between the QFR value after PCI and its maximum postoperative area stenosis rate,with a pearson correlation coefficient of 0.677.The analysis also showed a significant correlation(P<0.001)with the occurrence of VOCE events,with a kendall correlation coefficient of 0.261.5.The patients’ procedure-related data were analyzed using multiple linear regression,and the results revealed that the preoperative QFR value,minimum lumen diameter,MLD reference lumen diameter in the postoperative vascular parameters,and occurrence of VOCE events had a significant and positive influence on the predicted QFR value after PCI(P<0.05).Additionally,the study depicted the proportion of the vascular distribution of VOCE events at the vascular level through a histogram using the stratification of post-PCI QFR values per 0.05 unit point as the horizontal axis and the post-PCI QFR predicting the rate of VOCE events at 1 year as the vertical axis.This showed that,except for the post-PCI QFR values in the range of 0.96-1.0,the proportion of VOCE events at the vascular level at the 1-year follow-up decreased over time with increasing QFR values after PCI.6.Two hundred and twenty patients completed the 1-year follow-up,and 32(14.55%)patients,with 37 vessels(14.29%),had a VOCE event.The patients were divided into two groups,VOCE and no VOCE groups,based on the presence or absence of a VOCE event.The results showed that there was a significant difference in lesion vessel location,multiple coronary lesions(≥2),diffuse lesions,number of lesion vessels,number of stents implanted per vessel,total length of stents implanted per vessel,total diameter of stents implanted per vessel,pre-procedure QFR,minimum lumen diameter in pre-procedure vascular parameters,maximum diameter stenosis rate in pre-procedure vascular parameters,maximum area stenosis rate in pre-procedure vascular parameters,between both groups,but these differences were not statistically significant(P>0.05).However,statistically significant differences were found in combined complete occlusion,pre-procedure QFR,MLD reference lumen diameter in pre-procedure vascular parameters,post-procedure QFR,minimum lumen diameter in post-procedure vascular parameters,maximum diameter stenosis rate in post-procedure vascular parameters,and maximum area stenosis rate in post-procedure vascular parameters after PCI(P<0.05).7.Binary multifactorial logistic regression analysis affecting the occurrence of VOCE events showed that after correcting for the effects of other factors,pre-procedure QFR values,post-PCI QFR values,and patients with combined complete occlusion were independent risk factors for the occurrence of VOCE events(P<0.05).8.The results of establishing ROC curve analysis showed that the best cut-off value for predicting 1-year VOCE event occurrence by QFR value after PCI in patients with coronary artery disease was 0.93,AUC:0.753(95%CI:0.647-0.858,P<0.001),which had a high predictive value with a sensitivity of 75.7%and specificity of 73.9%.Similarly,in coronary heart disease patients with combined diabetes,the best cutoff value for predicting the occurrence of 1-year VOCE events after PCI was also found to be 0.93 with an AUC of 0.895(95%CI:0.826-0.964,P<0.001),and had high predictive value with a sensitivity of 100%and specificity of 68.4%.9.The optimal cut-off value obtained by ROC curve analysis was 0.93.Kaplan-Meier survival analysis was conducted for both the post-PCI QFR<0.93 group and the post-PCI QFR≥0.93 group.The results showed that the mean time to VOCE events during follow-up was significantly later for patients in the post-PCI QFR≥0.93 group,with a statistically significant difference of P<0.001 by Log Rank test.10.Based on the optimal cut-off value of QFR after PCI determined by the ROC curve,we divided the patients into two groups:those with QFR≥0.93 after PCI and those with QFR<0.93 after PCI.We then compared the occurrence of VOCE events between the two groups during the follow-up period.The results showed that the 1-year VOCE event rate was significantly higher in the group with QFR<0.93 after PCI than in the group with QFR≥0.93 after PCI(OR:8.797,95%CI:4.031-19.196,P<0.001).In a further subgroup analysis at the vascular level,we found a statistically significant difference between the two groups in terms of MI and TVR(P<0.001).CONCLUSION:1.QFR has predictive value for the prognosis of patients undergoing PCI under its guidance.2.QFR values after PCI have predictive value for the occurrence of VOCE events 1 year after stenting in patients,and patients with lower post-PCI QFR values have a higher risk of VOCE events.3.Post-PCI QFR is an independent predictor of adverse events in patients who undergo PCI,and a QFR value of 0.93 or lower is the optimal threshold for predicting the occurrence of VOCE events within one year.