Functional Assessment by Virtual Online Reconstruction. The FAVOR III Europe Japan Study

Patients at high risk of having one or more coronary stenosis are evaluated routinely by invasive coronary angiography (CAG). Lesions are often quantified by visual assessment of the angiogram, but physiological assessment of the functional significance by fractional flow reserve has been shown to improve clinical outcome, to reduce number of stents implanted, and has obtained the highest recommendation in European guidelines. FFR is assessed during CAG by advancing a wire with a pressure transducer towards the stenosis and measure the ratio in pressure between the two sides of the stenosis during medical induced maximum blood flow (hyperaemia). The solid evidence for FFR evaluation of coronary stenosis and the relative simplicity in performing the measurements have supported adoption of an FFR based strategy but the need for interrogating the stenosis by a pressure wire, the small risks associated hereto, the cost of the wire, and the drug inducing hyperaemia has limited more widespread adoption. Quantitative Flow Ratio is a novel method for evaluating the functional significance of coronary stenosis by calculation of the pressure drop in the vessel based on computation of two angiographic projections. Two multi‐center studies, the FAVOR II Europe‐Japan and China studies evaluated the feasibility and diagnostic performance of in‐procedure QFR, showing very good agreement between QFR and FFR. The purpose of the FAVOR III Europe Japan study is to investigate if a QFR‐based diagnostic strategy yields non‐inferior 12‐month clinical outcome compared to a standard pressure‐wire guided strategy in evaluation of patients with stable angina pectoris and intermediate coronary stenosis. Primary hypothesis: A QFR based diagnostic strategy results in non‐inferior clinical outcome, assessed by a composite endpoint of all cause death, non‐fatal myocardial infarction (MI) and unplanned revascularization after one year, compared to a strategy of pressure wire‐based FFR for assessment of physiological significance of intermediate coronary artery stenosis. Methods: Investigator initiated, 1:1 randomized, prospective, clinical outcome, non‐inferiority, multi‐center trial performed at up to 40 international sites with inclusion of 2000 patients. Patients with stable angina pectoris or need for evaluation of non‐culprit lesions after acute MI are enrolled. At least two angiographic projections are acquired during resting conditions. If the angiographic criteria are met, the patient is randomized to either a QFR‐ or an FFR‐based diagnostic strategy. Revascularization is performed according to best standard by percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). Patient follow‐up is continued until 24 months.