American College of Cardiology

American College of Cardiology

Perspective from Morton J. Kern, MD
March 10, 2018
3 min read

DEFINE-FLAIR: iFR confers cost savings vs. FFR

Perspective from Morton J. Kern, MD
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Manesh R. Patel

ORLANDO, Fla. — When instantaneous wave-free ratio was used to guide revascularization, a savings of almost $900 per patient occurred compared with fractional flow reserve-guided procedures, according to new data from DEFINE-FLAIR presented at the American College of Cardiology Scientific Session.

Manesh R. Patel, MD, professor of medicine and chief of the divisions of cardiology and clinical pharmacology at Duke University Medical Center and member of the Duke Clinical Research Institute, and colleagues assessed whether iFR was cost-effective compared with FFR in the DEFINE-FLAIR cohort. Unlike FFR, iFR does not use adenosine.

As Cardiology Today’s Intervention previously reported, in the DEFINE-FLAIR study of 2,492 patients (mean age, 65 years; 76% men) assigned to iFR- or FFR-guided revascularization, iFR was noninferior to FFR for the primary endpoint of MACE and the individual components of all-cause death, nonfatal MI or unplanned revascularization, and saved 4.5 minutes per procedure over FFR. There were no differences in outcomes between patients deferred for revascularization vs. those revascularized right away.

For the present analysis, Patel and colleagues calculated estimated health care use and health outcomes based on 1 year of patient data. Cost estimates included the index catheterization and Medicare costs for subsequent revascularizations, ambulatory care and adverse events.

“One of the major things around the world now is showing that any major technology has health economic value,” Justin Davies, MBBS, PhD, consultant cardiologist at Imperial College London and principal investigator of DEFINE-FLAIR, told Cardiology Today’s Intervention. “It was going to be important if we could see any differences, and if there were, to be able to quantify them in the most accurate way.”

Justin Davies
Justin Davies

At 1 year, total costs for the assessment procedure were $2,489.24 (95% CI, 2469.05-2509.42) for iFR and $2,564.39 (95% CI, 2544.46-2584.32) for FFR, while total costs for PCI were $1,726.25 (95% CI, 1595.71-1856.79) for iFR and $1,865.09 (95% CI, 1733.99-1996.19) for FFR, Patel said.

Total costs for ambulatory care were more than $50 lower per patient in iFR vs. FFR, and total admissions costs were more than $240 lower per patient for iFR, he said.

“As we go down all of the possible things that can happen to patients after the procedure, there was numerically less cost in the iFR group,” Patel said during a presentation.

Notably, Davies said, “all of the estimates in the model were very, very conservative. The savings may be significantly more.”

Rates of unplanned PCI and unplanned CABG were numerically lower in the iFR group, but other serious outcomes were similar, he said.

“In the iFR group, we may be selecting people more accurately,” Davies said. “We’re going to know more about this over the next 5 years.”

Quality of life data were not different between the groups.

After adjustments, the mean cost difference between iFR and FFR at 1 year was $896 in favor of iFR (95% CI, 1,537 to –255), with no differences in health outcomes, according to the researchers.

“We saw previously that the coronary physiology strategies of iFR and FFR led to similar clinical outcomes, and when you preferentially opt for iFR guidance, this cost analysis suggests a savings in U.S. dollars of around $896 per patient,” Patel said. – by Erik Swain


Patel M, et al. Featured Clinical Research I. Presented at: American College of Cardiology Scientific Session; March 10-12, 2018; Orlando, Fla.

Disclosure: Davies reports financial ties with Medtronic and Philips/Volcano and being an inventor of the iFR technique. Patel reports he consults for or receives honoraria from Bayer, Genzyme, Janssen and Medscape and receives research grants from AstraZeneca, Bayer, Janssen, Procryon and Philips/Volcano.