Physiological Patterns of Coronary Artery Disease and Drug-Coated Balloon Performance

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BACKGROUND: Diffuse coronary artery disease (CAD) challenges stent-based percutaneous coronary intervention (PCI). Drug-coated balloons (DCBs) offer a stentless strategy, but the physiological response in focal compared with diffuse disease remains unclear. OBJECTIVES: The authors aimed to investigate the impact of physiological patterns on angiographic and physiological outcomes after DCB-PCI. METHODS: In this international cohort, patients underwent DCB-PCI for de novo lesions with angiographic follow-up at 5 months (IQR: 3-7). Quantitative coronary angiography and Murray's law-based quantitative flow ratio (μFR) were analyzed by a core laboratory. Virtual μFR pull backs generated the pull back pressure gradient index (PPGi), classifying disease as focal (PPGi ≥0.78) or diffuse (PPGi <0.78). RESULTS: Among 230 patients/lesions, 139 of 230 (60.4%) were focal and 91 of 230 (39.6%) diffuse. Baseline μFR was comparable between diffuse and focal disease (0.64 [0.45-0.80] vs 0.61 [0.32-0.79]; P = 0.21). After PCI, diffuse disease showed lower acute functional gain (ΔμFR 0.23 [0.09-0.36] vs 0.29 [0.12-0.51]; P = 0.03), lower post-PCI μFR (0.89 [0.82-0.93] vs 0.91 [0.86-0.94]; P = 0.03), and more suboptimal physiology (19 of 91, 20.9% vs 12 of 139, 8.6%; P = 0.01). At follow-up, late functional loss was minimal and similar (+0.01 [-0.04 to 0.06] vs -0.01 [-0.04 to 0.04]; P = 0.53), yet diffuse CAD maintained lower μFR (0.88 [0.78-0.93] vs 0.91 [0.85-0.95]; P = 0.03) and more ischemic physiology (27 of 91, 29.7% vs 16 of 139, 11.5%; P = 0.01). CONCLUSIONS: PPGi stratifies outcomes after DCB-PCI: diffuse CAD shows smaller acute μFR gain and more suboptimal post-PCI physiology, despite minimal late angiographic and functional loss, highlighting the importance of optimal acute physiological results, particularly in diffuse disease.