Long‐Term Outcomes of Patients With Suspected Angina Pectoris Following Clinical Decision‐Making Guided by ATP‐FFR Versus Nicorandil‐FFR

BACKGROUND: Fractional flow reserve (FFR)-guided revascularization improves long-term outcomes in patients with coronary artery disease. Although adenosine triphosphate (ATP) is the standard hyperemic agent, nicorandil (NIC) has emerged as a practical alternative due to its combined nitrate-like and ATP-sensitive potassium channel-activating properties. However, data on long-term vessel-related outcomes guided by NIC-induced FFR are limited. AIMS: To compare long-term clinical and vessel-based outcomes in patients with suspected angina pectoris whose treatment strategies were guided by ATP-induced FFR (ATP-FFR) versus intracoronary nicorandil-induced FFR (NIC-FFR). METHODS: This single-center, prospective registry enrolled 363 consecutive patients (543 vessels) who underwent FFR measurement between April 2012 and December 2017. FFR was assessed using intravenous ATP infusion (150 µg/kg/min) and/or intracoronary NIC (2 mg bolus). Ischemic and non-ischemic groups were defined as FFR ≤ 0.80 and > 0.80, respectively. Long-term clinical events were evaluated over a mean follow-up of 6.4 ± 3.1 years. RESULTS: Percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) were performed in 123 (33.9%) and 5 (1.4%) patients, respectively. Overall, target vessel revascularization occurred in 3.0% of vessels. In the ischemic groups (FFR ≤ 0.80), the incidence of acute coronary syndrome (ACS) was 0.0% for ATP-FFR and 0.4% for NIC-FFR (log-rank p = 0.328), and chronic coronary syndrome (CCS) occurred in 15.9% and 16.4%, respectively (p = 0.059). Among non-ischemic vessels (FFR > 0.80), ACS occurred in 0.7% versus 0.3% (p = 0.521) and CCS in 7.6% versus 5.8% (p = 0.374). Kaplan-Meier analyses showed no significant differences between the two hyperemic agents across all subgroups. CONCLUSIONS: Intracoronary NIC can be safely and effectively used as an alternative hyperemic agent for FFR measurement. Long-term vessel-related outcomes guided by NIC-FFR showed no statistically significant differences compared with those guided by ATP-FFR, supporting its applicability in real-world practice.