1. Ref. NEJM Vol 360, No 3, pp 213-224. Slides courtesy Nico H J Pijls. The New England Journal of Medicine January 15, 2009. Vol. 360, No.3. pp. 213-224. Nico H.J.Pijls, MD, PhD Catharina Hospital, Eindhoven The Netherlands, The Netherlands, on behalf of the FAME investigators FRACTIONAL FLOW RESERVE versus ANGIOGRAPHY versus ANGIOGRAPHY FOR GUIDING PCI IN PATIENTS WITH FOR GUIDING PCI IN PATIENTS WITH MULTIVESSEL CORONARY ARTERY DISEASE

2. Ref. NEJM Vol 360, No 3, pp 213-224. Slides courtesy Nico H J Pijls. FAME study: disclosure To perform the FAME study, an unrestricted institutional research grant was obtained from RADI Medical Systems I have no further conflict of interest to declare

3. Ref. NEJM Vol 360, No 3, pp 213-224. Slides courtesy Nico H J Pijls. F ractional Flow Reserve versus versus A ngiography for M ultivessel E valuation FRACTIONAL FLOW RESERVE FRACTIONAL FLOW RESERVE versus ANGIOGRAPHY versus ANGIOGRAPHY FOR GUIDING PCI IN PATIENTS WITH FOR GUIDING PCI IN PATIENTS WITH MULTIVESSEL CORONARY ARTERY DISEASE MULTIVESSEL CORONARY ARTERY DISEASE

4. Ref. NEJM Vol 360, No 3, pp 213-224. Slides courtesy Nico H J Pijls. FAME study: BACKGROUND (1) Stenting of non-ischemic stenoses has no benefit Stenting of non-ischemic stenoses has no benefit compared to medical treatment only compared to medical treatment only Stenting of ischemia-related stenoses improves Stenting of ischemia-related stenoses improves symptoms and outcome symptoms and outcome In multivessel coronary disease (MVD), identifying In multivessel coronary disease (MVD), identifying which stenoses cause ischemia is difficult: which stenoses cause ischemia is difficult: Non-invasive tests are often unreliable in MVD and Non-invasive tests are often unreliable in MVD and coronary angiography often results in both under- coronary angiography often results in both under- or overestimation of functional stenosis severity or overestimation of functional stenosis severity

5. Ref. NEJM Vol 360, No 3, pp 213-224. Slides courtesy Nico H J Pijls. FAME study: BACKGROUND (2) Fractional Flow Reserve (FFR), is the most accurate Fractional Flow Reserve (FFR), is the most accurate and selective index to indicate whether a particular and selective index to indicate whether a particular stenosis is responsible for inducible ischemia stenosis is responsible for inducible ischemia FFR can be easily determined in the cathlab FFR can be easily determined in the cathlab just prior to stenting just prior to stentingTherefore: FFR guidance of PCI in patients with FFR guidance of PCI in patients with multivessel disease may improve outcome multivessel disease may improve outcome

6. Ref. NEJM Vol 360, No 3, pp 213-224. Slides courtesy Nico H J Pijls. FAME study: HYPOTHESIS FFR – guided Percutaneous Coronary FFR – guided Percutaneous Coronary Intervention (PCI) in multivessel disease, is superior to current is superior to current angiography – guided PCI angiography – guided PCI

7. Ref. NEJM Vol 360, No 3, pp 213-224. Slides courtesy Nico H J Pijls. FAME study: DESIGN Randomized multicenter study in 1000 patients undergoing DES-stenting for multivessel disease in 20 US and European centers Multivessel disease: Stenoses of > 50% in at least 2 of the 3 major coronary arteries independent core-lab independent core-lab independent data analysis independent data analysis blinded adverse event committee blinded adverse event committee

8. Ref. NEJM Vol 360, No 3, pp 213-224. Slides courtesy Nico H J Pijls. Participating Centers USA (6) Stanford University (William F. Fearon) Northeast Cardiology, Bangor, Maine (Peter N. Ver Lee) University of Louisville (Massoud Leesar) St Louis University (Michael Lim) University Hospital Virginia (Michael Ragosta) University of South Carolina (Eric Powers) EUROPE (14) King´s College Hospital, London) (Ph.MacCarthy) Cardiovascular Center Aalst (B. De Bruyne) Catharina Hospital Eindhoven (N.Pijls) Rigshospitalet, Copenhagen (T.Engstrom) Klinikum der Universitat Munchen(V.Klauss) Aarhus University Hospital (Ole Frobert) University Hospital Bergmannsheil (Waldemar Bojara) Sodersjukhhuset, Stockholm (I Herzfeld) Helsingborgs Lasarett (F Schersten) Klinikum Darmstadt (Gerald Werner) Bristol Royal Infirmary (A.Baumbach) Staedt. Krankenhaus, Bogenhausen (G.Riess) Glasgow Western Infirmary (Keith Oldroyd) Royal Victoria Hospital, Belfast (Ganesh Manoharan)

9. Ref. NEJM Vol 360, No 3, pp 213-224. Slides courtesy Nico H J Pijls. FAME study Steering Committee: Nico H.J. Pijls, Eindhoven, Netherlands (PI) William F. Fearon, Stanford, CA, USA (PI) Bernard De Bruyne, Aalst, Belgium Pim A.L. Tonino, Eindhoven, Netherlands Data analysis: Uwe Siebert, Boston, MA, USA and Hall, A Rafaele Gothe and Bernard Bornschein, Hall, Austria Clinical Events Committee: Eric Eeckhout, Lausanne, Switzerland Morton Kern, Irvine, CA, USA Mamdouh El Gamal, Eindhoven, NL John Hodgson, Phoenix, AZ, USA Emanuele Barbato, Naples, Italy

10. Ref. NEJM Vol 360, No 3, pp 213-224. Slides courtesy Nico H J Pijls. FAME study: Study Population The FAME study was designed to reflect daily practice in performing PCI in patients with multivessel disease Inclusion criteria: ALL patients with multivessel disease ALL patients with multivessel disease At least 2 stenoses ≥ 50% in 2 or 3 major epicardial At least 2 stenoses ≥ 50% in 2 or 3 major epicardial coronary artery disease, amenable for stenting coronary artery disease, amenable for stenting Exclusion criteria: Left main disease or previous bypass surgery Left main disease or previous bypass surgery ST-elevation MI with CK > 1000 U/l within last 5 days ST-elevation MI with CK > 1000 U/l within last 5 days extremely tortuous or calcified coronary arteries extremely tortuous or calcified coronary arteries Note: patients with previous PCI were not excluded

11. Ref. NEJM Vol 360, No 3, pp 213-224. Slides courtesy Nico H J Pijls. Angiography-guided PCI FFR-guided PCI Measure FFR in all indicated stenoses Stent all indicated stenoses Stent only those stenoses with FFR ≤ 0.80 Randomization Indicate all stenoses ≥ 50% considered for stenting Patient with stenoses ≥ 50% in at least 2 of the 3 major epicardial vessels 1-year follow-up FLOW CHART

12. Ref. NEJM Vol 360, No 3, pp 213-224. Slides courtesy Nico H J Pijls. FAME study: PRIMARY ENDPOINT Composite of death, myocardial infarction, or repeat revascularization (“MACE”) or repeat revascularization (“MACE”) at 1 year at 1 year

13. Ref. NEJM Vol 360, No 3, pp 213-224. Slides courtesy Nico H J Pijls. FAME study: SECONDARY ENDPOINTS individual components of MACE at 1 year individual components of MACE at 1 year functional class functional class use of anti-anginal drugs use of anti-anginal drugs health-related quality of life (EuroQOL-5D) health-related quality of life (EuroQOL-5D) procedure time procedure time amount of contrast agent used during procedure amount of contrast agent used during procedure cost of the procedure cost of the procedure

14. Ref. NEJM Vol 360, No 3, pp 213-224. Slides courtesy Nico H J Pijls. Assessed for eligibility N=1905 Angiography- guided PCI N=496 FFR-guided PCI N=509 Lost to follow-up N=8 Analyzed N=496 Analyzed N=509 Randomized N=1005 Lost to follow-up N=11 Not eligible N= 900 Left main stenosis N= 157 Extreme coronary tortuosity or calcification N= 217 No informed consent N= 105 Contra-indication for DES N= 86 Participation in other study N= 94 Logistic reasons N= 210 Other reasons N= 31 CONSORT-E CHART

15. Ref. NEJM Vol 360, No 3, pp 213-224. Slides courtesy Nico H J Pijls. PCI according to local routine PCI according to local routine Only drug-eluting stents (DES) Only drug-eluting stents (DES) FFR measured by Pressure Wire FFR measured by Pressure Wire ( Certus wire, RADI Medical Systems ) ( Certus wire, RADI Medical Systems ) hyperemia induced by i.v. adenosine 140 µg/kg/min hyperemia induced by i.v. adenosine 140 µg/kg/min in femoral vein in femoral vein EKG, CK, CK-MB, etc during hospital stay EKG, CK, CK-MB, etc during hospital stay Follow-up at 1 month, 6 months, 1 year Follow-up at 1 month, 6 months, 1 year Also in case of repeat-procedure, strictly adherence Also in case of repeat-procedure, strictly adherence to initial randomization to initial randomization FAME study: Treatment

16. Ref. NEJM Vol 360, No 3, pp 213-224. Slides courtesy Nico H J Pijls. ANGIO-group N=496 FFR-group N=509 P- value Age, mean±SD 64±1065±100.47 Male, % 73750.30 Diabetes, % 25240.65 Hypertension, % 66610.10 Current smoker, % 32270.12 Hyperlipidemia, % 74720.62 Previous MI, % 36370.84 Unstable angina, % 36290.11 Previous PCI, % 26290.34 LVEF, mean±SD 57±1257±110.92 LVEF < 50%, % 27290.47 FAME study: Baseline Characteristics (1)

17. Ref. NEJM Vol 360, No 3, pp 213-224. Slides courtesy Nico H J Pijls. FAME study: Baseline Characteristics (2) ANGIO-group N=496 FFR-group N=509P-value # indicated lesions per patient 2.7±0.92.8±1.00.34

18. Ref. NEJM Vol 360, No 3, pp 213-224. Slides courtesy Nico H J Pijls. FAME study: Baseline Characteristics (2) ANGIO-group N=496 FFR-group N=509P-value # indicated lesions per patient 2.7±0.92.8±1.00.34 Reference diameter (mm) 2.5±0.62.5±0.70.81 % stenosis severity 61±1760±180.24 MLD (mm) 1.0±0.41.0±0.50.35

19. Ref. NEJM Vol 360, No 3, pp 213-224. Slides courtesy Nico H J Pijls. FAME study: Baseline Characteristics (2) ANGIO-group N=496 FFR-group N=509P-value # indicated lesions per patient 2.7±0.92.8±1.00.34 Reference diameter (mm) 2.5±0.62.5±0.70.81 % stenosis severity 61±1760±180.24 MLD (mm) 1.0±0.41.0±0.50.35 50-70% narrowing, No (%) 550 (41)624 (44)- 70-90% narrowing, No (%) 553 (41)530 (37)- 90-99% narrowing, No (%) 207 (15)202(14)- Total occlusion, No (%) 40 (3)58 (4)- Patients with ≥1 total occlusion (%) 7.510.60.08

20. Ref. NEJM Vol 360, No 3, pp 213-224. Slides courtesy Nico H J Pijls. ANGIO-group N=496 FFR-group N=509P-value # indicated lesions per patient 2.7 ± 0.92.8 ± 1.00.34 FFR results Lesions succesfully measured, No (%) -1329 (98%)- Lesions with FFR ≤ 0.80, No (%) Lesions with FFR ≤ 0.80, No (%) -874 (63%)- Lesions with FFR > 0.80, No (%) Lesions with FFR > 0.80, No (%) -513 (37%)- FFR in ischemic lesions -0.60 ± 0.14- FFR in non-ischemic lesions -0.88 ± 0.05- FAME study: Procedural Results (1)

21. Ref. NEJM Vol 360, No 3, pp 213-224. Slides courtesy Nico H J Pijls. ANGIO-group N=496 FFR-group N=509P-value # indicated lesions per patient 2.7 ± 0.92.8 ± 1.00.34 FFR results Lesions succesfully measured, No (%) -1329 (98%)- Lesions with FFR ≤ 0.80, No (%) Lesions with FFR ≤ 0.80, No (%) -874 (63%)- Lesions with FFR > 0.80, No (%) Lesions with FFR > 0.80, No (%) -513 (37%)- stents per patient 2.7 ± 1.21.9 ± 1.3<0.001 Lesions succesfully stented (%) 92%94%- DES, total, No 1359980- FAME study: Procedural Results (1)

22. Ref. NEJM Vol 360, No 3, pp 213-224. Slides courtesy Nico H J Pijls. FAME study: Procedural Results (2) ANGIO-group N=496 FFR-group N=509P-value Procedure time (min) 70 ± 4471 ± 430.51

23. Ref. NEJM Vol 360, No 3, pp 213-224. Slides courtesy Nico H J Pijls. FAME study: Procedural Results (2) ANGIO-group N=496 FFR-group N=509P-value Procedure time (min) 70 ± 4471 ± 430.51 Contrast agent used (ml) 302 ± 127272 ± 133<0.001

24. Ref. NEJM Vol 360, No 3, pp 213-224. Slides courtesy Nico H J Pijls. FAME study: Procedural Results (2) ANGIO-group N=496 FFR-group N=509P-value Procedure time (min) 70 ± 4471 ± 430.51 Contrast agent used (ml) 302 ± 127272 ± 133<0.001 Materials used at procedure (US $) 60075332<0.001

25. Ref. NEJM Vol 360, No 3, pp 213-224. Slides courtesy Nico H J Pijls. FAME study: Procedural Results (2) ANGIO-group N=496 FFR-group N=509P-value Procedure time (min) 70 ± 4471 ± 430.51 Contrast agent used (ml) 302 ± 127272 ± 133<0.001 Materials used at procedure (US $) 60075332<0.001 Length of hospital stay (days) 3.7 ± 3.53.4 ± 3.30.05

26. Ref. NEJM Vol 360, No 3, pp 213-224. Slides courtesy Nico H J Pijls. ANGIO-group N=496 FFR-group N=509P-value Events at 1 year, No (%) Death, MI, CABG, or repeat-PCI 91 (18.4)67 (13.2)0.02 FAME study: Adverse Events at 1 year

27. Ref. NEJM Vol 360, No 3, pp 213-224. Slides courtesy Nico H J Pijls. ANGIO-group N=496 FFR-group N=509P-value Events at 1 year, No (%) Death, MI, CABG, or repeat-PCI 91 (18.4)67 (13.2)0.02 Death15 (3.0)9 (1.8)0.19 Death or myocardial infarction 55 (11.1)37 (7.3)0.04 CABG or repeat PCI 47 (9.5)33 (6.5)0.08 FAME study: Adverse Events at 1 year

28. Ref. NEJM Vol 360, No 3, pp 213-224. Slides courtesy Nico H J Pijls. ANGIO-group N=496 FFR-group N=509P-value Events at 1 year, No (%) Death, MI, CABG, or repeat-PCI 91 (18.4)67 (13.2)0.02 Death15 (3.0)9 (1.8)0.19 Death or myocardial infarction 55 (11.1)37 (7.3)0.04 CABG or repeat PCI 47 (9.5)33 (6.5)0.08 Total no. of MACE 113760.02 FAME study: Adverse Events at 1 year

29. Ref. NEJM Vol 360, No 3, pp 213-224. Slides courtesy Nico H J Pijls. ANGIO-group N=496 FFR-group N=509P-value Events at 1 year, No (%) Death, MI, CABG, or repeat-PCI 91 (18.4)67 (13.2)0.02 Death15 (3.0)9 (1.8)0.19 Death or myocardial infarction 55 (11.1)37 (7.3)0.04 CABG or repeat PCI 47 (9.5)33 (6.5)0.08 Total no. of MACE 113760.02 Myocardial infarction, specified All myocardial infarctions 43 (8.7)29 (5.7)0.07 Small periprocedural CK-MB 3-5 x N 1612 Other infarctions (“late or large”) 2717 FAME study: Adverse Events at 1 year

30. Ref. NEJM Vol 360, No 3, pp 213-224. Slides courtesy Nico H J Pijls. FFR-guided 30 days 2.9% 90 days 3.8% 180 days 4.9% 360 days 5.3% Angio-guided absolute difference in MACE-free survival FAME study: Event-free Survival

31. Ref. NEJM Vol 360, No 3, pp 213-224. Slides courtesy Nico H J Pijls. ANGIO-group N=496 FFR-group N=509P-value Patients without event and free from angina 326 (68)360 (73)0.07 Patients free from angina, No. (%) 374 (78)399 (81)0.20 Number of anti-anginal meds, No. 1.2 ± 0.71.2 ± 0.80.48 EQ-5D visual analogue scale 74 ± 1675 ± 160.65 FAME study: Functional Class at 1 Year

32. Ref. NEJM Vol 360, No 3, pp 213-224. Slides courtesy Nico H J Pijls. FAME study: Consequences In most recently performed studies to PCI in MVD, PCI was performed on an angiography-guided basis (such as in SYNTAX 3-VD) Outcome of PCI in those studies was comparable to outcome in the angiography-guided arm of FAME Outcome in the FFR-guided arm of FAME was comparable to outcome of CABG in SYNTAX and much better than, e.g. outcome of medical treatment in COURAGE

33. Ref. NEJM Vol 360, No 3, pp 213-224. Slides courtesy Nico H J Pijls. TREATMENT OPTIONS FOR MVD Therefore, it might be expected that indications for PCI as treatment of MVD, will expand in 2 directions R/x PCI CABG

34. Ref. NEJM Vol 360, No 3, pp 213-224. Slides courtesy Nico H J Pijls. TREATMENT OPTIONS FOR MVD Therefore, it might be expected that indications for PCI as treatment of MVD, will expand in 2 directions R/x PCI CABG

35. Ref. NEJM Vol 360, No 3, pp 213-224. Slides courtesy Nico H J Pijls. 20 0 10 % MACE in SYNTAX – 3VD and FAME SYNTAX FAME PCI CABG PCI - angio PCI - FFR 19.1 18.4 11.2 13.2

36. Ref. NEJM Vol 360, No 3, pp 213-224. Slides courtesy Nico H J Pijls. 20 0 10 % MACCE in SYNTAX – 3VD and FAME SYNTAX FAME PCI CABG 19.1 15.8 11.2 11.0 similar definition of MACCE, including CVA and excluding CKMB 3-5 x N PCI - angio PCI - FFR

37. Ref. NEJM Vol 360, No 3, pp 213-224. Slides courtesy Nico H J Pijls. 20 0 10 % MACE in SYNTAX – 3VD and FAME SYNTAX UPPER MIDDLE LOWER FAME ALL TERTILE TERTILE TERTILE PCI CABG PCI CABG PCI CABG PCI - angio PCI - FFR PCI CABG 19.1 21.5 18.6 17.2 18.4 11.2 8.810.1 14.7 13.2

38. Ref. NEJM Vol 360, No 3, pp 213-224. Slides courtesy Nico H J Pijls. 20 0 10 % MACCE in SYNTAX – 3VD and FAME SYNTAX UPPER MIDDLE LOWER FAME ALL TERTILE TERTILE TERTILE PCI CABG PCI CABG PCI CABG PCI - angio PCI - FFR PCI CABG 19.1 21.5 18.6 17.2 15.8 11.2 8.810.1 14.7 11.0 similar definition of MACCE, including CVA and excluding CKMB 3-5 x N

39. Ref. NEJM Vol 360, No 3, pp 213-224. Slides courtesy Nico H J Pijls. FAME study: CONCLUSIONS (1) Routine measurement of FFR during PCI with DES in patients with multivessel disease, when compared to current angiography guided strategy reduces the rate of the composite endpoint of reduces the rate of the composite endpoint of death, myocardial infarction, re-PCI and CABG death, myocardial infarction, re-PCI and CABG at 1 year by ~ 30% at 1 year by ~ 30% reduces mortality and myocardial infarction at reduces mortality and myocardial infarction at 1 year by ~ 35 % 1 year by ~ 35 %

40. Ref. NEJM Vol 360, No 3, pp 213-224. Slides courtesy Nico H J Pijls. FAME study: CONCLUSIONS (2) Routine measurement of FFR during PCI with DES in patients with multivessel disease, when compared to current angiography guided strategy, furthermore: is cost-saving and does not prolong the procedure is cost-saving and does not prolong the procedure reduces the number of stents used reduces the number of stents used decreases the amount of contrast agent used decreases the amount of contrast agent used results in a similar, if not better, functional status results in a similar, if not better, functional status

41. Ref. NEJM Vol 360, No 3, pp 213-224. Slides courtesy Nico H J Pijls. Routine measurement of FFR during DES-stenting in patients with multivessel disease is superior in patients with multivessel disease is superior to current angiography guided treatment. to current angiography guided treatment. It improves outcome of PCI significantly It improves outcome of PCI significantly It supports the evolving paradigm of It supports the evolving paradigm of “Functionally Complete Revascularization”, “Functionally Complete Revascularization”, i.e. stenting of ischemic lesions and i.e. stenting of ischemic lesions and medical treatment of non-ischemic ones. medical treatment of non-ischemic ones. FAME study: CONCLUSIONS (3)