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Halbach M, Ameskamp C, Mauri V, Ernst A, Lake P, Nienaber S, Baldus S, Adam M, Wienemann H. Prognostic impact of resting full-cycle ratio and diastolic non-hyperemic pressure ratios in patients with deferred revascularization. Clin Res Cardiol 2023; 112:1220-1230. [PMID: 36602599 PMCID: PMC10449998 DOI: 10.1007/s00392-022-02149-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 12/21/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Non-hyperemic pressure ratios (NHPRs) like resting full-cycle ratio (RFR), diastolic pressure ratio during entire diastole (dPR[entire]) and diastolic pressure ratio during wave-free period (dPR[WFP]) are increasingly used to guide revascularization. The effect of NHPRs on mid-term prognosis has not been well established. OBJECTIVE We investigated the prognostic implications of NHRPs in patients whose revascularization was deferred based on fractional flow reserve (FFR) in a single-centre population. METHODS NHPRs and FFR were calculated offline from pressure tracings by an independent core laboratory. Follow-up data were acquired through records of hospital visits or telephone interviews. The primary outcome was a vessel-oriented composite outcome (VOCO) (a composite of cardiac death, vessel-related myocardial infarction, and ischemia-driven revascularization) in deferred vessels at 2 years. RESULTS 316 patients with 377 deferred lesions were analysed. Discordance of NHPRs and FFR was found in 13.0-18.3% of lesions. The correlation coefficient between NHPRs was 0.99 (95% confidence interval 0.99-1.00). At 2 years, VOCO occurred in 19 lesions (5.0%). Estimated glomerular filtration rate < 30 mL/min/1.73 m2 [hazard ratio (HR) 5.7, p = 0.002], previous myocardial infarction (HR 3.3, p = 0.018), diabetes (HR 2.7, p = 0.042), RFR ≤ 0.89 (HR 2.7, p = 0.041) and dPR[WFP] ≤ 0.89 (HR 2.7, p = 0.049) were associated with higher incidence of VOCO at 2 years in the univariable analysis. A non-significant trend was found for dPR[entire] (HR 1.9, p = 0.26). CONCLUSION A positive RFR or dPR[WFP] were associated with a worse prognosis in deferred lesions, suggesting that the use of NHPRs in addition to FFR may improve risk estimation.
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Affiliation(s)
- Marcel Halbach
- Clinic III for Internal Medicine, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Str. 61, 50937, Cologne, Germany.
| | - Christopher Ameskamp
- Clinic III for Internal Medicine, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Str. 61, 50937, Cologne, Germany
| | - Victor Mauri
- Clinic III for Internal Medicine, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Str. 61, 50937, Cologne, Germany
| | - Angela Ernst
- Institute of Medical Statistics and Computational Biology, University of Cologne, Robert-Koch-Str. 10, 50931, Cologne, Germany
| | - Philipp Lake
- Clinic III for Internal Medicine, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Str. 61, 50937, Cologne, Germany
| | - Stephan Nienaber
- Clinic III for Internal Medicine, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Str. 61, 50937, Cologne, Germany
| | - Stephan Baldus
- Clinic III for Internal Medicine, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Str. 61, 50937, Cologne, Germany
| | - Matti Adam
- Clinic III for Internal Medicine, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Str. 61, 50937, Cologne, Germany
| | - Hendrik Wienemann
- Clinic III for Internal Medicine, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Str. 61, 50937, Cologne, Germany
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Yndigegn T, Koul S, Rylance R, Berntorp K, Mohammad MA, Omerovic E, Sarno G, Linder R, Fröbert O, Jensen J, Schiopu A, Erlinge D, Götberg M. Long-term Safety of Revascularization Deferral Based on Instantaneous Wave-Free Ratio or Fractional Flow Reserve. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2023; 2:101046. [PMID: 39132394 PMCID: PMC11307766 DOI: 10.1016/j.jscai.2023.101046] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 05/11/2023] [Accepted: 05/16/2023] [Indexed: 08/13/2024]
Abstract
Background Deferral of coronary revascularization is safe whether guided by instantaneous wave-free ratio (iFR) or by fractional flow reserve (FFR). We aimed to assess long-term outcomes in patients deferred from revascularization based on iFR or FFR in a large real-world population. Methods From 2013 through 2017, 201,933 coronary angiographies were registered in the Swedish Web-System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies (SWEDEHEART). We included all patients (n = 11,324) with at least 1 coronary lesion deferred from PCI during an index procedure using iFR (>0.89; n = 1998) or FFR (>0.80; n = 9326). The primary outcome was major adverse cardiac events (MACE) defined as the composite of all-cause death, nonfatal myocardial infarction, or unplanned revascularization. A multivariable-adjusted Cox proportional hazards model was used, with analysis for interaction of prespecified subgroups. Results Patients presented with stable angina pectoris (iFR 46.9% vs FFR 48.6%), unstable angina or non-ST-elevation myocardial infarction (iFR 37.7% vs FFR 33.1%), ST-elevation myocardial infarction (iFR 1.9% vs FFR 1.6%), and other indications (iFR 12.5% vs FFR 15.7%). The median follow-up was 2 years for both iFR and FFR groups. At the conclusion of the study, the cumulative MACE risks were 26.7 for the iFR group and 25.9% for FFR group. In the adjusted analysis, no difference was found between the 2 groups (adjusted hazard ratio: iFR vs FFR, 0.947; 95% CI, 0.84-1.08; P = 39). Consistent with the overall findings, the prespecified subgroups showed no interaction with the FFR/iFR results. Conclusions Deferral of revascularization showed similar long-term safety whether based on iFR or on FFR.
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Affiliation(s)
- Troels Yndigegn
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
| | - Sasha Koul
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
| | - Rebecca Rylance
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
| | - Karolina Berntorp
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
| | - Moman A. Mohammad
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
| | - Elmir Omerovic
- Department of Cardiology, Sahlgrenska University, Gothenburg, Sweden
| | - Giovanna Sarno
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Rickard Linder
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Ole Fröbert
- Department of Cardiology, Faculty of Health, Örebro University, Örebro, Sweden
| | - Jens Jensen
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
- Department of Cardiology, Capio St Göran Hospital, Stockholm, Sweden
| | - Alexandru Schiopu
- Experimental Cardiovascular Research Unit, Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - David Erlinge
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
| | - Matthias Götberg
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
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Petraco R, Bahl R. Physiology-Guided Deferral of Percutaneous Coronary Intervention in the Real World. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2023; 2:101112. [PMID: 39132406 PMCID: PMC11308855 DOI: 10.1016/j.jscai.2023.101112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 07/14/2023] [Indexed: 08/13/2024]
Affiliation(s)
- Ricardo Petraco
- Department of National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Rahul Bahl
- Department of National Heart and Lung Institute, Imperial College London, London, United Kingdom
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Escaned J, Berry C, De Bruyne B, Shabbir A, Collet C, Lee JM, Appelman Y, Barbato E, Biscaglia S, Buszman PP, Campo G, Chieffo A, Colleran R, Collison D, Davies J, Giacoppo D, Holm NR, Jeremias A, Paradies V, Piróth Z, Raposo L, Roguin A, Rudolph T, Sarno G, Sen S, Toth GG, Van Belle E, Zimmermann FM, Dudek D, Stefanini G, Tarantini G. Applied coronary physiology for planning and guidance of percutaneous coronary interventions. A clinical consensus statement from the European Association of Percutaneous Cardiovascular Interventions (EAPCI) of the European Society of Cardiology. EUROINTERVENTION 2023; 19:464-481. [PMID: 37171503 PMCID: PMC10436072 DOI: 10.4244/eij-d-23-00194] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 04/23/2023] [Indexed: 05/13/2023]
Abstract
The clinical value of fractional flow reserve and non-hyperaemic pressure ratios are well established in determining an indication for percutaneous coronary intervention (PCI) in patients with coronary artery disease (CAD). In addition, over the last 5 years we have witnessed a shift towards the use of physiology to enhance procedural planning, assess post-PCI functional results, and guide PCI optimisation. In this regard, clinical studies have reported compelling data supporting the use of longitudinal vessel analysis, obtained with pressure guidewire pullbacks, to better understand how obstructive CAD contributes to myocardial ischaemia, to establish the likelihood of functionally successful PCI, to identify the presence and location of residual flow-limiting stenoses and to predict long-term outcomes. The introduction of new functional coronary angiography tools, which merge angiographic information with fluid dynamic equations to deliver information equivalent to intracoronary pressure measurements, are now available and potentially also applicable to these endeavours. Furthermore, the ability of longitudinal vessel analysis to predict the functional results of stenting has played an integral role in the evolving field of simulated PCI. Nevertheless, it is important to have an awareness of the value and challenges of physiology-guided PCI in specific clinical and anatomical contexts. The main aim of this European Association of Percutaneous Cardiovascular Interventions clinical consensus statement is to offer up-to-date evidence and expert opinion on the use of applied coronary physiology for procedural PCI planning, disease pattern recognition and post-PCI optimisation.
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Affiliation(s)
- Javier Escaned
- Hospital Clínico San Carlos IdISCC, Complutense University of Madrid, Madrid, Spain
| | - Colin Berry
- Institute of Cardiovascular & Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Bernard De Bruyne
- Cardiovascular Center Aalst, OLV Clinic, Aalst, Belgium
- Department of Cardiology, Lausanne University Center Hospital, Lausanne, Switzerland
| | - Asad Shabbir
- Hospital Clínico San Carlos IdISCC, Complutense University of Madrid, Madrid, Spain
| | - Carlos Collet
- Cardiovascular Center Aalst, OLV Clinic, Aalst, Belgium
| | - Joo Myung Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Yolande Appelman
- Amsterdam UMC, Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Emanuele Barbato
- Cardiovascular Center Aalst, OLV Clinic, Aalst, Belgium
- Division of Cardiology, Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
| | - Simone Biscaglia
- Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Cona, Italy
| | - Piotr P Buszman
- Andrzej Frycz Modrzewski Kraków University, Kraków, Poland
- American Heart of Poland, Ustroń, Poland
| | - Gianluca Campo
- Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Cona, Italy
| | - Alaide Chieffo
- Interventional Cardiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Róisín Colleran
- Cardiovascular Research Institute Dublin and Department of Cardiology, Mater Private Network, Dublin, Ireland
- School of Medicine, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Damien Collison
- West of Scotland Regional Heart & Lung Centre, Golden Jubilee National Hospital, Glasgow, UK
| | - Justin Davies
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | - Daniele Giacoppo
- Cardiovascular Research Institute Dublin and Department of Cardiology, Mater Private Network, Dublin, Ireland
- Department of Cardiology, Alto Vicentino Hospital, Santorso, Italy
- ISAResearch, German Heart Centre Munich, Munich, Germany
| | - Niels R. Holm
- Department of Cardiology, Aarhus University Hospital, Aarhus N, Denmark
| | | | - Valeria Paradies
- Department of Cardiology, Maasstad Hospital, Rotterdam, the Netherlands
| | - Zsolt Piróth
- Gottsegen National Cardiovascular Center, Budapest, Hungary
| | - Luís Raposo
- Unidade de Intervenção Cardiovascular, Serviço de Cardiologia, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Lisboa, Portugal
| | - Ariel Roguin
- Hillel Yaffe Medical Center, Hadera, Israel
- Faculty of Medicine, Technion, Haifa, Israel
| | - Tanja Rudolph
- Heart and Diabetes Center North Rhine-Westphalia, Bad Oeynhausen, Germany
| | - Giovanna Sarno
- Cardiology, Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Sayan Sen
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | - Gabor G Toth
- Department of Cardiology, Medical University of Graz, Graz, Austria
| | - Eric Van Belle
- Department of Interventional Cardiology for Coronary, Valves and Structural Heart Diseases, Institut Coeur Poumon, Lille, France
- Department of Cardiology, Institut Pasteur de Lille, Lille, France
| | | | - Dariusz Dudek
- Interventional Cardiology Unit, Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
- Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Giulio Stefanini
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Humanitas Research Hospital IRCCS, Rozzano, Milan, Italy
| | - Giuseppe Tarantini
- Humanitas Research Hospital IRCCS, Rozzano, Milan, Italy
- University of Padua Medical School, Padua, Italy
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Becker LM, Peper J, Verhappen BJLA, Swart LA, Dedic A, van Dockum WG, van der Ent M, Royaards KJ, Niezen A, Hensen JHJ, van Kuijk JP, Mohamed Hoesein FAA, Leiner T, Bruning TA, Swaans MJ. Real world impact of added FFR-CT to coronary CT angiography on clinical decision-making and patient prognosis - IMPACT FFR study. Eur Radiol 2023; 33:5465-5475. [PMID: 36920521 PMCID: PMC10326083 DOI: 10.1007/s00330-023-09517-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 01/04/2023] [Accepted: 02/06/2023] [Indexed: 03/16/2023]
Abstract
OBJECTIVES The addition of CT-derived fractional flow reserve (FFR-CT) increases the diagnostic accuracy of coronary CT angiography (CCTA). We assessed the impact of FFR-CT in routine clinical practice on clinical decision-making and patient prognosis in patients suspected of stable coronary artery disease (CAD). METHODS This retrospective, single-center study compared a cohort that received CCTA with FFR-CT to a historical cohort that received CCTA before FFR-CT was available. We assessed the clinical management decisions after FFR-CT and CCTA and the rate of major adverse cardiac events (MACEs) during the 1-year follow-up using chi-square tests for independence. Kaplan-Meier curves were used to visualize the occurrence of safety outcomes over time. RESULTS A total of 360 patients at low to intermediate risk of CAD were included, 224 in the CCTA only group, and 136 in the FFR-CT group. During follow-up, 13 MACE occurred in 12 patients, 9 (4.0%) in the CCTA group, and three (2.2%) in the FFR-CT group. Clinical management decisions differed significantly between both groups. After CCTA, 60 patients (26.5%) received optimal medical therapy (OMT) only, 115 (51.3%) invasive coronary angiography (ICA), and 49 (21.9%) single positron emission CT (SPECT). After FFR-CT, 106 patients (77.9%) received OMT only, 27 (19.9%) ICA, and three (2.2%) SPECT (p < 0.001 for all three options). The revascularization rate after ICA was similar between groups (p = 0.15). However, patients in the CCTA group more often underwent revascularization (p = 0.007). CONCLUSION Addition of FFR-CT to CCTA led to a reduction in (invasive) diagnostic testing and less revascularizations without observed difference in outcomes after 1 year. KEY POINTS • Previous studies have shown that computed tomography-derived fractional flow reserve improves the accuracy of coronary computed tomography angiography without changes in acquisition protocols. • This study shows that use of computed tomography-derived fractional flow reserve as gatekeeper to invasive coronary angiography in patients suspected of stable coronary artery disease leads to less invasive testing and revascularization without observed difference in outcomes after 1 year. • This could lead to a significant reduction in costs, complications and (retrospectively unnecessary) usage of diagnostic testing capacity, and a significant increase in patient satisfaction.
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Affiliation(s)
- Leonie M Becker
- Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands.
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Joyce Peper
- Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Bram J L A Verhappen
- Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands
| | - Laurens A Swart
- Department of Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Admir Dedic
- Department of Cardiology, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | | | | | - Kees-Jan Royaards
- Department of Cardiology, Maasstad Hospital, Rotterdam, The Netherlands
| | - André Niezen
- Department of Radiology, Maasstad Hospital, Rotterdam, The Netherlands
| | - Jan-Hein J Hensen
- Department of Radiology, Maasstad Hospital, Rotterdam, The Netherlands
| | - Jan-Peter van Kuijk
- Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands
| | | | - Tim Leiner
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Radiology, Mayo Clinic Rochester Minnesota, Rochester, USA
| | - Tobias A Bruning
- Department of Cardiology, Maasstad Hospital, Rotterdam, The Netherlands
| | - Martin J Swaans
- Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands
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Kei CY, Singh K, Dautov RF, Nguyen TH, Chirkov YY, Horowitz JD. Coronary "Microvascular Dysfunction": Evolving Understanding of Pathophysiology, Clinical Implications, and Potential Therapeutics. Int J Mol Sci 2023; 24:11287. [PMID: 37511046 PMCID: PMC10379859 DOI: 10.3390/ijms241411287] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 06/25/2023] [Accepted: 06/28/2023] [Indexed: 07/30/2023] Open
Abstract
Until recently, it has been generally held that stable angina pectoris (SAP) primarily reflects the presence of epicardial coronary artery stenoses due to atheromatous plaque(s), while acute myocardial infarction (AMI) results from thrombus formation on ruptured plaques. This concept is now challenged, especially by results of the ORBITA and ISCHEMIA trials, which showed that angioplasty/stenting does not substantially relieve SAP symptoms or prevent AMI or death in such patients. These disappointing outcomes serve to redirect attention towards anomalies of small coronary physiology. Recent studies suggest that coronary microvasculature is often both structurally and physiologically abnormal irrespective of the presence or absence of large coronary artery stenoses. Structural remodelling of the coronary microvasculature appears to be induced primarily by inflammation initiated by mast cell, platelet, and neutrophil activation, leading to erosion of the endothelial glycocalyx. This leads to the disruption of laminar flow and the facilitation of endothelial platelet interaction. Glycocalyx shedding has been implicated in the pathophysiology of coronary artery spasm, cardiovascular ageing, AMI, and viral vasculitis. Physiological dysfunction is closely linked to structural remodelling and occurs in most patients with myocardial ischemia, irrespective of the presence or absence of large-vessel stenoses. Dysfunction includes the impairment of platelet and vascular responsiveness to autocidal coronary vasodilators, such as nitric oxide, prostacyclin, and hydrogen sulphide, and predisposes both to coronary vasoconstriction and to a propensity for microthrombus formation. These findings emphasise the need for new directions in medical therapeutics for patients with SAP, as well as a wide range of other cardiovascular disorders.
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Affiliation(s)
- Chun Yeung Kei
- Department of Medicine, University of Adelaide, Adelaide 5371, Australia
| | - Kuljit Singh
- Department of Medicine, Griffith University, Southport 4111, Australia
- Gold Coast University Hospital, Gold Coast 4215, Australia
| | - Rustem F Dautov
- Department of Medicine, University of Queensland, Woolloongabba 4102, Australia
- Prince Charles Hospital, Brisbane 4032, Australia
| | - Thanh H Nguyen
- Department of Medicine, University of Adelaide, Adelaide 5371, Australia
- Northern Adelaide Local Health Network, Adelaide 5000, Australia
| | - Yuliy Y Chirkov
- Department of Medicine, University of Adelaide, Adelaide 5371, Australia
- Basil Hetzel Institute for Translational Research, Adelaide 5011, Australia
| | - John D Horowitz
- Department of Medicine, University of Adelaide, Adelaide 5371, Australia
- Basil Hetzel Institute for Translational Research, Adelaide 5011, Australia
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Abe T, Shimazaki K, Moriyama T, Murohashi A, Iwanami Y, Sasaki A, Saito K, Jujo K. Optimal lipid-lowering therapy in patients who were functionally deferred percutaneous coronary intervention. Sci Rep 2023; 13:10880. [PMID: 37407607 DOI: 10.1038/s41598-023-37988-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 06/30/2023] [Indexed: 07/07/2023] Open
Abstract
Deferral of percutaneous coronary intervention (PCI) for functionally insignificant stenosis, defined as fractional flow reserve (FFR) > 0.80, is associated with favorable long-term prognoses. The lower-the-better strategy for low-density lipoprotein cholesterol (LDL-C) management is an established non-angioplasty therapy to improve the clinical outcomes of patients undergoing PCI. We examined the optimal LDL-C management in cases of intermediate coronary stenosis with deferred PCI on the basis of FFR values. This observational study included 273 consecutive patients with a single target vessel and deferred PCI with an FFR > 0.80. Patients with an FFR of 0.81-0.85 (n = 93) and those with FFR > 0.85 (n = 180) were classified into the lower (< 100 mg/dL) and higher (≥ 100 mg/dL) LDL-C groups. The endpoint was major adverse cardiovascular and cerebrovascular events (MACCE), including death, non-fatal myocardial infarction, ischemic stroke, heart failure hospitalization, and unplanned revascularization. Patients with an FFR of 0.81-0.85 had a significantly higher MACCE rate than those with an FFR > 0.85 (log-rank, p = 0.003). In patients with an FFR of 0.81-0.85, the lower LDL-C group showed a significantly lower MACCE rate than the higher LDL-C group (log-rank, p = 0.006). However, the event rate did not differ significantly between the two groups in patients with FFR > 0.85 (log-rank, p = 0.84). Uncontrolled LDL-C levels were associated with higher MACCE rates in cases with deferred PCI due to an FFR of 0.81-0.85. This high-risk population for adverse cardiovascular events should receive strict LDL-C-lowering therapy.
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Affiliation(s)
- Takuro Abe
- Department of Cardiology, Nishiarai Heart Center Hospital, Tokyo, Japan
| | - Kensuke Shimazaki
- Department of Cardiology, Nishiarai Heart Center Hospital, Tokyo, Japan
| | - Tetsu Moriyama
- Department of Cardiology, Nishiarai Heart Center Hospital, Tokyo, Japan
| | - Akira Murohashi
- Department of Cardiology, Nishiarai Heart Center Hospital, Tokyo, Japan
| | - Yuji Iwanami
- Department of Cardiology, Nishiarai Heart Center Hospital, Tokyo, Japan
| | - Akihito Sasaki
- Department of Cardiovascular Surgery, Nishiarai Heart Center Hospital, Tokyo, Japan
| | - Katsumi Saito
- Department of Cardiology, Nishiarai Heart Center Hospital, Tokyo, Japan
| | - Kentaro Jujo
- Department of Cardiology, Nishiarai Heart Center Hospital, Tokyo, Japan.
- Department of Cardiology, Saitama Medical University, Saitama Medical Center, 1981 Kamoda, Kawagoe-shi, Saitama, 350-8550, Japan.
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58
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Ekmejian A, Brieger D, Bhat A, Sritharan H, Nour D, Allahwala U, Ward M, Bhindi R. Vessel-Specific Outcomes of Deferred Revascularization Following Negative Fractional Flow Reserve. Am J Cardiol 2023; 201:320-327. [PMID: 37399598 DOI: 10.1016/j.amjcard.2023.06.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 06/01/2023] [Accepted: 06/05/2023] [Indexed: 07/05/2023]
Abstract
Variations in myocardial supply area and hydrostatic pressure gradients result in greater likelihood of positive fractional flow reserve (FFR) in the left anterior descending (LAD) compared with the circumflex (Cx) and right coronary artery (RCA). However, the same FFR threshold for deferral of revascularization is applied to all arteries, without evidence that this results in equivalent outcomes. We assessed vessel-specific outcomes of deferred revascularization for the 3 major coronary arteries based on FFR > 0.8. In this retrospective study, data were obtained on consecutive patients who underwent indicated FFR assessment across 2 tertiary institutions. Patients with deferred revascularization were followed for 36 months for the primary end point of vessel-specific target lesion failure (TLF). Of 1,916 major coronary arteries (1,579 patients), the odds ratio of positive FFR was highest in the LAD (odds ratio 3.36, p <0.001). In total, 867 vessels (733 patients) with FFR > 0.8 had complete 3-year medical record follow-ups. The TLF rate for deferred vessels was 10.21%, 11.52%, and 10.96% for the LAD, Cx, and RCA respectively. In a multivariate analysis, there was no significant difference in the odds of TLF for the 0.84 (0.53 to 1.33, p = 0.459), 1.17 (0.68 to 2.01, p = 0.582), and 1.11 (0.62 to 2.00, p = 0.715) in the LAD, Cx, and RCA, respectively. In a multivariate analysis, diabetes mellitus was the only baseline characteristic significantly associated at risk of TLF (1.43 [1.01 to 2.02], p = 0.043). In conclusion, despite greater likelihood of positive FFR in the LAD, the FFR threshold for deferred revascularization resulted in equivalent outcomes in all 3 major coronary arteries, and patients with diabetes mellitus may represent a group that requires aggressive surveillance and risk factor modification after deferred revascularization.
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Affiliation(s)
- Avedis Ekmejian
- Department of Cardiology, Royal North Shore Hospital, St Leonards, Australia; Northern Clinical School, Faculty of Medicine, University of Sydney, Camperdown, Australia.
| | - Daniel Brieger
- Department of Cardiology, Royal North Shore Hospital, St Leonards, Australia
| | - Aditya Bhat
- Department of Cardiology, Royal North Shore Hospital, St Leonards, Australia
| | - Hari Sritharan
- Department of Cardiology, Royal North Shore Hospital, St Leonards, Australia; Northern Clinical School, Faculty of Medicine, University of Sydney, Camperdown, Australia
| | - Daniel Nour
- Department of Cardiology, Royal North Shore Hospital, St Leonards, Australia
| | - Usaid Allahwala
- Department of Cardiology, Royal North Shore Hospital, St Leonards, Australia; Northern Clinical School, Faculty of Medicine, University of Sydney, Camperdown, Australia
| | - Michael Ward
- Department of Cardiology, Royal North Shore Hospital, St Leonards, Australia; Northern Clinical School, Faculty of Medicine, University of Sydney, Camperdown, Australia
| | - Ravinay Bhindi
- Department of Cardiology, Royal North Shore Hospital, St Leonards, Australia; Northern Clinical School, Faculty of Medicine, University of Sydney, Camperdown, Australia
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Huang W, Zhang J, Yang L, Hu Y, Leng X, Liu Y, Jin H, Tang Y, Wang J, Liu X, Guo Y, Ye C, Feng Y, Xiang J, Tang L, Du C. Accuracy of intravascular ultrasound-derived virtual fractional flow reserve (FFR) and FFR derived from computed tomography for functional assessment of coronary artery disease. Biomed Eng Online 2023; 22:64. [PMID: 37370077 DOI: 10.1186/s12938-023-01122-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 05/28/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Coronary computed tomography-derived fractional flow reserve (CT-FFR) and intravascular ultrasound-derived fractional flow reserve (IVUS-FFR) are two functional assessment methods for coronary stenoses. However, the calculation algorithms for these methods differ significantly. This study aimed to compare the diagnostic performance of CT-FFR and IVUS-FFR using invasive fractional flow reserve (FFR) as the reference standard. METHODS Six hundred and seventy patients (698 lesions) with known or suspected coronary artery disease were screened for this retrospective analysis between January 2020 and July 2021. A total of 40 patients (41 lesions) underwent intravascular ultrasound (IVUS) and FFR evaluations within six months after completing coronary CT angiography were included. Two novel CFD-based models (AccuFFRct and AccuFFRivus) were used to compute the CT-FFR and IVUS-FFR values, respectively. The invasive FFR ≤ 0.80 was used as the reference standard for evaluating the diagnostic performance of CT-FFR and IVUS-FFR. RESULTS Both AccuFFRivus and AccuFFRct demonstrated a strong correlation with invasive FFR (R = 0.7913, P < 0.0001; and R = 0.6296, P < 0.0001), and both methods showed good agreement with FFR. The area under the receiver operating characteristic curve was 0.960 (P < 0.001) for AccuFFRivus and 0.897 (P < 0.001) for AccuFFRct in predicting FFR ≤ 0.80. FFR ≤ 0.80 were predicted with high sensitivity (96.6%), specificity (85.7%), and the Youden index (0.823) using the same cutoff value of 0.80 for AccuFFRivus. A good diagnostic performance (sensitivity 89.7%, specificity 85.7%, and Youden index 0.754) was also demonstrated by AccuFFRct. CONCLUSIONS AccuFFRivus, computed from IVUS images, exhibited a high diagnostic performance for detecting myocardial ischemia. It demonstrated better diagnostic power than AccuFFRct, and could serve as an accurate computational tool for ischemia diagnosis and assist in clinical decision-making.
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Affiliation(s)
- Wenhao Huang
- Department of Medicine, The Second College of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
| | - Jingyuan Zhang
- Department of Medicine, The Second College of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
| | - Lin Yang
- Department of Geriatrics, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yumeng Hu
- ArteryFlow Technology Co., Ltd., Hangzhou, China
| | | | - Yajun Liu
- Department of Medicine, The Second College of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
| | - Hongfeng Jin
- Department of Cardiology, Zhejiang Hospital, Hangzhou, China
| | - Yiming Tang
- Department of Cardiology, Zhejiang Hospital, Hangzhou, China
| | - Jiangting Wang
- Department of Cardiology, Zhejiang Hospital, Hangzhou, China
| | - Xiaowei Liu
- Department of Cardiology, Zhejiang Hospital, Hangzhou, China
| | - Yitao Guo
- Department of Cardiology, Zhejiang Hospital, Hangzhou, China
| | - Chen Ye
- Department of Cardiology, Zhejiang Hospital, Hangzhou, China
| | - Yue Feng
- Department of Radiology, Zhejiang Hospital, Hangzhou, China
| | | | - Lijiang Tang
- Department of Cardiology, Zhejiang Hospital, Hangzhou, China.
| | - Changqing Du
- Department of Cardiology, Zhejiang Hospital, Hangzhou, China.
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60
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Chester RC, Parikh RV. Go With the Flow: Does Clinical Equipoise Remain for Deferral of Angiographically Intermediate Left Main Coronary Artery Disease With Hemodynamic Significance? Circ Cardiovasc Interv 2023; 16:e013113. [PMID: 37339236 DOI: 10.1161/circinterventions.123.013113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/22/2023]
Affiliation(s)
- Rebecca C Chester
- Department of Cardiology, Honor Health Hospital, Scottsdale, AZ (R.C.C.)
| | - Rushi V Parikh
- Division of Cardiology, University of California Los Angeles (R.V.P)
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61
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Scoccia A, Byrne RA, Banning AP, Landmesser U, Van Belle E, Amat-Santos IJ, Sabaté M, Tijssen JGP, Spitzer E, Daemen J. Fractional flow reserve or 3D-quantitative-coronary-angiography based vessel-FFR guided revascularization. Rationale and study design of the prospective randomized fast III trial. Am Heart J 2023; 260:1-8. [PMID: 36796573 DOI: 10.1016/j.ahj.2023.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 01/29/2023] [Accepted: 02/05/2023] [Indexed: 05/07/2023]
Abstract
BACKGROUND Physiological assessment of intermediate coronary lesions to guide coronary revascularization is currently recommended by international guidelines. Vessel fractional flow reserve (vFFR) has emerged as a new approach to derive fractional flow reserve (FFR) from 3D-quantitative coronary angiography (3D-QCA) without the need for hyperemic agents or pressure wires. STUDY DESIGN AND OBJECTIVES The FAST III is an investigator-initiated, open label, multicenter randomized trial comparing vFFR guided versus FFR guided coronary revascularization in approximately 2228 patients with intermediate coronary lesions (defined as 30%-80% stenosis by visual assessment or QCA). Intermediate lesions are physiologically assessed using on-line vFFR or FFR and treated if vFFR or FFR ≤0.80. The primary end point is a composite of all-cause death, any myocardial infarction, or any revascularization at 1-year post-randomization. Secondary end points include the individual components of the primary end point and cost-effectiveness will be investigated. CONCLUSIONS FAST III is the first randomized trial to explore whether a vFFR guided revascularization strategy is non-inferior to an FFR guided strategy in terms of clinical outcomes at 1-year follow-up in patients with intermediate coronary artery lesions.
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Affiliation(s)
- Alessandra Scoccia
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Robert A Byrne
- Dept. of Cardiology and Cardiovascular Research Institute (CVRI) Dublin, Mater Private Network, Dublin, Ireland; School of Pharmacy and Biomolecular Sciences, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Adrian P Banning
- Department of Cardiology, John Radcliffe Hospital, Oxford, United Kingdom
| | - Ulf Landmesser
- Department of Cardiology, Charite Universitätsmedizin Berlin, German Center of Cardiovascular Research (DZHK) - Partner Site Berlin; Germany
| | - Eric Van Belle
- Department of Cardiology, Institut Cœur Poumon, CHU Lille, Lille, France; Department of Interventional Cardiology for Coronary Valves and Structural Heart Diseases, Inserm, U1011, Institut Pasteur de Lille, EGID, Université de Lille, Lille, France
| | - Ignacio J Amat-Santos
- Cardiology Department, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Manel Sabaté
- Cardiology Department, Cardiovascular Institute (ICCV), Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, Spain
| | | | - Ernest Spitzer
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, The Netherlands; European Cardiovascular Research Institute, Rotterdam, The Netherlands
| | - Joost Daemen
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, The Netherlands.
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62
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Navarese EP, Lansky AJ, Farkouh ME, Grzelakowska K, Bonaca MP, Gorog DA, Raggi P, Kelm M, Yeo B, Umińska J, Curzen N, Kubica J, Wijns W, Kereiakes DJ. Effects of Elective Coronary Revascularization vs Medical Therapy Alone on Noncardiac Mortality: A Meta-Analysis. JACC Cardiovasc Interv 2023; 16:1144-1156. [PMID: 37225285 DOI: 10.1016/j.jcin.2023.02.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Revised: 02/16/2023] [Accepted: 02/21/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND Uncertainty exists whether coronary revascularization plus medical therapy (MT) is associated with an increase in noncardiac mortality in chronic coronary syndrome (CCS) when compared with MT alone, particularly following recent data from the ISCHEMIA-EXTEND (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trial. OBJECTIVES This study conducted a large-scale meta-analysis of trials comparing elective coronary revascularization plus MT vs MT alone in patients with CCS to determine whether revascularization has a differential impact on noncardiac mortality at the longest follow-up. METHODS We searched for randomized trials comparing revascularization plus MT vs MT alone in patients with CCS. Treatment effects were measured by rate ratios (RRs) with 95% CIs, using random-effects models. Noncardiac mortality was the prespecified endpoint. The study is registered with PROSPERO (CRD42022380664). RESULTS Eighteen trials were included involving 16,908 patients randomized to either revascularization plus MT (n = 8,665) or to MT alone (n = 8,243). No significant differences were detected in noncardiac mortality between the assigned treatment groups (RR: 1.09; 95% CI: 0.94-1.26; P = 0.26), with absent heterogeneity (I2 = 0%). Results were consistent without the ISCHEMIA trial (RR: 1.00; 95% CI: 0.84-1.18; P = 0.97). By meta-regression, follow-up duration did not affect noncardiac death rates with revascularization plus MT vs MT alone (P = 0.52). Trial sequential analysis confirmed the reliability of meta-analysis, with the cumulative Z-curve of trial evidence within the nonsignificance area and reaching futility boundaries. Bayesian meta-analysis findings were consistent with the standard approach (RR: 1.08; 95% credible interval: 0.90-1.31). CONCLUSIONS In patients with CCS, noncardiac mortality in late follow-up was similar for revascularization plus MT compared with MT alone.
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Affiliation(s)
- Eliano P Navarese
- Interventional Cardiology and Cardiovascular Medicine Research, Department of Cardiology and Internal Medicine, Nicolaus Copernicus University, Bydgoszcz, Poland; Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada; SIRIO MEDICINE Research Network, Bydgoszcz, Poland.
| | | | - Michael E Farkouh
- Peter Munk Cardiac Centre, University of Toronto, Toronto, Ontario, Canada; Cedars Sinai Health System, Los Angeles, CA
| | - Klaudyna Grzelakowska
- Interventional Cardiology and Cardiovascular Medicine Research, Department of Cardiology and Internal Medicine, Nicolaus Copernicus University, Bydgoszcz, Poland; SIRIO MEDICINE Research Network, Bydgoszcz, Poland
| | - Marc P Bonaca
- CPC Clinical Research, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Diana A Gorog
- Faculty of Medicine, National Heart and Lung Institute, Imperial College London, London, United Kingdom; Cardiology Department, East and North Hertfordshire NHS Trust, Stevenage, United Kingdom
| | - Paolo Raggi
- Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Malte Kelm
- Heinrich Heine University Medical Center Düsseldorf, Düsseldorf, Germany; Division of Cardiology, Pulmonology, and Vascular Medicine, Cardiovascular Research Institute Düsseldorf, Düsseldorf, Germany
| | - Brandon Yeo
- Interventional Cardiology and Cardiovascular Medicine Research, Department of Cardiology and Internal Medicine, Nicolaus Copernicus University, Bydgoszcz, Poland; SIRIO MEDICINE Research Network, Bydgoszcz, Poland
| | - Julia Umińska
- Interventional Cardiology and Cardiovascular Medicine Research, Department of Cardiology and Internal Medicine, Nicolaus Copernicus University, Bydgoszcz, Poland; SIRIO MEDICINE Research Network, Bydgoszcz, Poland
| | - Nick Curzen
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom; University of Southampton, Southampton, United Kingdom
| | - Jacek Kubica
- Interventional Cardiology and Cardiovascular Medicine Research, Department of Cardiology and Internal Medicine, Nicolaus Copernicus University, Bydgoszcz, Poland; SIRIO MEDICINE Research Network, Bydgoszcz, Poland
| | - William Wijns
- Lambe Institute for Translational Medicine and CÚRAM, National University of Ireland Galway and Saolta University Healthcare Group, Galway, Ireland
| | - Dean J Kereiakes
- Christ Hospital and Lindner Research Center, Cincinnati, Ohio, USA
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Pellegrini D, Caramori PRA, Soccol RC, Lasevitch R, Agostini GL, Dussin A, Ferreira FVC, Wagner MB, Bodanese LC. Prognostic Assessment of Fractional Flow Reserve in Different Strata in Patients with Coronary Artery Disease. Arq Bras Cardiol 2023; 120:e20211051. [PMID: 37341225 PMCID: PMC10263408 DOI: 10.36660/abc.20211051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 01/23/2023] [Accepted: 04/05/2023] [Indexed: 06/22/2023] Open
Abstract
BACKGROUND There are limited real-world data on the clinical course of untreated coronary lesions according to their functional severity. OBJECTIVE To evaluate the 5-year clinical outcomes of patients with revascularized lesions with fractional flow reserve (FFR) ≤ 0.8 and patients with non-revascularized lesions with FFR > 0.8. METHODS The FFR assessment was performed in 218 patients followed for up to 5 years. Participants were classified based on FFR into ischemia group (≤ 0.8, intervention group, n = 55), low-normal FFR group (> 0.8-0.9, n = 91), and high-normal FFR group (> 0.9, n = 72). The primary endpoint was major adverse cardiac events (MACEs), a composite of death, myocardial infarction, and need for repeat revascularization. The significance level was set at 0.05; therefore, results with a p-value < 0.05 were considered statistically significant. RESULTS Most patients were male (62.8%) with a mean age of 64.1 years. Diabetes was present in 27%. On coronary angiography, the severity of stenosis was 62% in the ischemia group, 56.4% in the low-normal FFR group, and 54.3% in the high-normal FFR group (p<0.05). Mean follow-up was 3.5 years. The incidence of MACEs was 25.5%, 13.2%, and 11.1%, respectively (p=0.037). MACE incidence did not differ significantly between the low-normal and high-normal FFR groups. CONCLUSION Patients with FFR indicative of ischemia had poorer outcomes than those in non-ischemia groups. There was no difference in the incidence of events between the low-normal and high-normal FFR groups. Long-term studies with a large sample size are needed to better assess cardiovascular outcomes in patients with moderate coronary stenosis with FFR values between 0.8 and 1.0.
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Affiliation(s)
- Denise Pellegrini
- Pontifícia Universidade Católica do Rio Grande do SulPorto AlegreRSBrasilPontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, RS – Brasil
| | - Paulo R. A. Caramori
- Hospital São LucasPUCRSPorto AlegreRSBrasilHospital São Lucas da PUCRS, Porto Alegre, RS – Brasil
| | - Ricardo Czarnobai Soccol
- Hospital São LucasPUCRSPorto AlegreRSBrasilHospital São Lucas da PUCRS, Porto Alegre, RS – Brasil
| | - Ricardo Lasevitch
- Hospital São LucasPUCRSPorto AlegreRSBrasilHospital São Lucas da PUCRS, Porto Alegre, RS – Brasil
| | - Gustavo Luís Agostini
- Hospital São LucasPUCRSPorto AlegreRSBrasilHospital São Lucas da PUCRS, Porto Alegre, RS – Brasil
| | - Alice Dussin
- Pontifícia Universidade Católica do Rio Grande do SulPorto AlegreRSBrasilPontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, RS – Brasil
| | | | - Mario Bernardes Wagner
- Pontifícia Universidade Católica do Rio Grande do SulPorto AlegreRSBrasilPontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, RS – Brasil
| | - Luiz Carlos Bodanese
- Hospital São LucasPUCRSPorto AlegreRSBrasilHospital São Lucas da PUCRS, Porto Alegre, RS – Brasil
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64
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Boutaleb AM, Ghafari C, Ungureanu C, Carlier S. Fractional flow reserve and non-hyperemic indices: Essential tools for percutaneous coronary interventions. World J Clin Cases 2023; 11:2123-2139. [PMID: 37122527 PMCID: PMC10131021 DOI: 10.12998/wjcc.v11.i10.2123] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 02/22/2023] [Accepted: 03/15/2023] [Indexed: 03/30/2023] Open
Abstract
Hemodynamical evaluation of a coronary artery lesion is an important diagnostic step to assess its functional impact. Fractional flow reserve (FFR) received a class IA recommendation from the European Society of Cardiology for the assessment of angiographically moderate stenosis. FFR evaluation of coronary artery disease offers improvement of the therapeutic strategy, deferring unnecessary procedures for lesions with a FFR > 0.8, improving patients' management and clinical outcome. Post intervention, an optimal FFR > 0.9 post stenting should be reached and > 0.8 post drug eluting balloons. Non-hyperemic pressure ratio measurements have been validated in previous studies with a common threshold of 0.89. They might overestimate the hemodynamic significance of some lesions but remain useful whenever hyperemic agents are contraindicated. FFR remains the gold standard reference for invasive assessment of ischemia. We illustrate this review with two cases introducing the possibility to estimate also non-invasively FFR from reconstructed 3-D angiograms by quantitative flow ratio. We conclude introducing a hybrid approach to intermediate lesions (DFR 0.85-0.95) potentially maximizing clinical decision from all measurements.
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Affiliation(s)
- Amine Mamoun Boutaleb
- Department of Cardiology, Ibn Rochd University Hospital, Casablanca 20230, Casablanca, Morocco
- Department of Cardiology, Centre Hospitalier Universitaire Ambroise Paré, Mons 7000, Belgium
| | - Chadi Ghafari
- Department of Cardiology, University of Mons, Mons 7000, Belgium
| | - Claudiu Ungureanu
- Department of Cardiology, University of Mons, Mons 7000, Belgium
- Catheterization Unit, Jolimont Hospital, La Louvière 7100, Belgium, Belgium
| | - Stéphane Carlier
- Department of Cardiology, Centre Hospitalier Universitaire Ambroise Paré, Mons 7000, Belgium
- Department of Cardiology, University of Mons, Mons 7000, Belgium
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Gaba P, Gersh BJ, Muller J, Narula J, Stone GW. Evolving concepts of the vulnerable atherosclerotic plaque and the vulnerable patient: implications for patient care and future research. Nat Rev Cardiol 2023; 20:181-196. [PMID: 36151312 DOI: 10.1038/s41569-022-00769-8] [Citation(s) in RCA: 40] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/12/2022] [Indexed: 11/08/2022]
Abstract
Understanding the natural history of coronary artery atherosclerosis is necessary to determine prognosis and prescribe effective therapies. Traditional management of coronary artery disease has focused on the treatment of flow-limiting anatomical obstructions that lead to ischaemia. In most scenarios, revascularization of these atherosclerotic plaques has not substantially improved freedom from death or myocardial infarction, questioning the utility of contemporary revascularization strategies to improve prognosis. Advances in non-invasive and invasive imaging techniques have helped to identify the characteristics of obstructive and non-obstructive plaques that are precursors for plaque progression and future acute coronary syndromes as well as cardiac death. These 'vulnerable plaques' develop as a consequence of systemic inflammation and are prone to inducing thrombosis. Vulnerable plaques most commonly have a large plaque burden with a well-formed necrotic core and thin fibrous cap and are metabolically active. Perivascular adipose tissue might, in some patients, be used as a surrogate for coronary inflammation and predict future risk of adverse cardiac events. Vulnerable plaques can be identified in their quiescent state, offering the potential for therapeutic passivation. In this Review, we describe the biological and compositional features of vulnerable plaques, the non-invasive and invasive diagnostic modalities to characterize vulnerable plaques, the prognostic utility of identifying vulnerable plaques, and the future studies needed to explore the value of intensified pharmacological and focal treatments of vulnerable plaques.
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Affiliation(s)
- Prakriti Gaba
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Bernard J Gersh
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - James Muller
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Jagat Narula
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Gregg W Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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66
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Bhagat AA, Fordham MJ, Lohani M, Teressa G. Outcomes of Functional Testing Versus Invasive Cardiac Catheterization for the Evaluation of Intermediate Severity Coronary Stenosis Detected on Cardiac Computed Tomography Angiography. Crit Pathw Cardiol 2023; 22:25-30. [PMID: 36812341 DOI: 10.1097/hpc.0000000000000309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
INTRODUCTION The aim of this study was to evaluate the effectiveness of functional testing in comparison to invasive coronary angiography (ICA) among acute chest pain patients whose first diagnostic modality was a coronary computed tomography angiogram (CCTA) and were found to have intermediate coronary stenosis, defined as 50%-70% luminal stenosis. METHODS We conducted a retrospective review of 4763 acute chest pain patients ≥18 years old who received a CCTA as the initial diagnostic modality. Of these, 118 patients met enrollment criteria and proceeded to either stress test (80/118) or directly to ICA (38/118). The primary outcome was 30-day major adverse cardiac event, consisting of acute myocardial infarction, urgent revascularization, or death. RESULTS There was no difference in 30-day major adverse cardiac event among patients who underwent initial stress testing versus directly referred to ICA (0% vs. 2.6%, P = 0.322) following CCTA. The rate of revascularization without acute myocardial infarction was significantly higher among those who underwent ICA versus stress test [36.8% vs. 3.8%, P < 0.0001; adjusted odds ratio: 9.6, 95% confidence interval, 1.8-49.6]. Patients who underwent ICA had a higher rate of catheterization without revascularization within 30 days of the index admission in comparison to those who underwent initial stress testing (55.3% vs. 12.5%, P < 0.0001; adjusted odds ratio: 26.7, 95% confidence interval, 6.6-109.5). CONCLUSION Among patients with intermediate coronary stenosis on CCTA, a functional stress test compared with ICA may prevent unnecessary revascularization and improve cardiac catheterization yield without negatively affecting the 30-day patient safety profile.
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Affiliation(s)
- Aditi A Bhagat
- From the Division of Cardiology, Stony Brook University, Stony Brook, NY
| | | | - Minisha Lohani
- Department of Medicine, Stony Brook University, Stony Brook, NY
| | - Getu Teressa
- Department of Medicine, Stony Brook University, Stony Brook, NY
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67
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Ekmejian A, Allahwala U, Ward M, Bhindi R. Impact of coronary disease patterns, anatomical factors, micro-vascular disease and non-coronary cardiac factors on invasive coronary physiology. Am Heart J 2023; 257:51-61. [PMID: 36509137 DOI: 10.1016/j.ahj.2022.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 11/22/2022] [Accepted: 12/07/2022] [Indexed: 05/11/2023]
Abstract
Invasive coronary physiology has been applied by interventional cardiologists to guide the management of coronary artery disease (CAD), with well-defined thresholds applied to determine whether CAD should be managed with optimal medical therapy (OMT) alone or OMT and percutaneous coronary intervention (PCI). There are multiple modalities in clinical use, including hyperaemic and non-hyperaemic indices. Despite endorsement in the major guidelines, there are various factors which impact and confound the readings of invasive coronary physiology, both within the coronary tree and beyond. This review article aims to summarise the mechanisms by which these factors impact invasive coronary physiology, and distinguish factors that contribute to ischaemia from confounding factors. The potential for mis-classification of ischaemic status is highlighted. Lastly, the authors identify targets for future research to improve the precision of physiology-guided management of CAD.
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Affiliation(s)
- Avedis Ekmejian
- Royal North Shore Hospital, Department of Cardiology, Sydney, NSW, Australia; University of Sydney Northern Clinical School, Sydney, NSW, Australia; Kolling Institute of Medical Research, Sydney, NSW, Australia.
| | - Usaid Allahwala
- Royal North Shore Hospital, Department of Cardiology, Sydney, NSW, Australia; University of Sydney Northern Clinical School, Sydney, NSW, Australia; Kolling Institute of Medical Research, Sydney, NSW, Australia
| | - Michael Ward
- Royal North Shore Hospital, Department of Cardiology, Sydney, NSW, Australia; University of Sydney Northern Clinical School, Sydney, NSW, Australia; Kolling Institute of Medical Research, Sydney, NSW, Australia
| | - Ravinay Bhindi
- Royal North Shore Hospital, Department of Cardiology, Sydney, NSW, Australia; University of Sydney Northern Clinical School, Sydney, NSW, Australia; Kolling Institute of Medical Research, Sydney, NSW, Australia
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68
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de Vos A, Jansen TPJ, van 't Veer M, Dimitriu-Leen A, Konst RE, Elias-Smale S, Paradies V, Rodwell L, van den Oord S, Smits P, van Royen N, Pijls N, Damman P. Microvascular Resistance Reserve to Assess Microvascular Dysfunction in ANOCA Patients. JACC Cardiovasc Interv 2023; 16:470-481. [PMID: 36858668 DOI: 10.1016/j.jcin.2022.12.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 12/09/2022] [Accepted: 12/13/2022] [Indexed: 03/02/2023]
Abstract
BACKGROUND Microvascular resistance reserve (MRR) is a new index to assess coronary microvascular (dys)function, which can be easily measured invasively using continuous thermodilution. In contrast to coronary flow reserve (CFR), MRR is independent of epicardial coronary disease and hemodynamic variations. Its measurement is accurate, reproducible, and operator independent. OBJECTIVES The aim of this study was to establish the range of normal values for MRR and to determine an optimal cutoff point. METHODS In this exploratory study in 214 patients with angina and no obstructive coronary artery disease, after excluding significant epicardial disease, all physiological parameters, such as fractional flow reserve, index of microvascular resistance, CFR, absolute blood flow, absolute microvascular resistance, and MRR, were measured. On the basis of concordant positive or concordant negative results of index of microvascular resistance and CFR, subgroups of patients were defined with high probability of either normal (n = 122) or abnormal (n = 24) microcirculatory function, and MRR was studied in these groups. RESULTS Mean MRR in the "normal" group was 3.4 compared with a mean MRR of 1.9 in the "abnormal" group; these values were significantly different between the groups. MRR >2.7 ruled out coronary microvascular dysfunction (CMD) with a certainty of 96%, whereas MRR <2.1 indicated the presence of CMD with a similar high certainty of 96%. CONCLUSIONS MRR is a suitable index to distinguish the presence or absence of CMD in patients with angina and no obstructive coronary artery disease. The present data indicate that an MRR of 2.7 virtually excludes the presence of CMD, while an MRR value <2.1 confirms its presence.
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Affiliation(s)
- Annemiek de Vos
- Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands.
| | - Tijn P J Jansen
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Marcel van 't Veer
- Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands
| | | | - Regina E Konst
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Suzette Elias-Smale
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Valeria Paradies
- Department of Cardiology, Maasstad Hospital, Rotterdam, the Netherlands
| | - Laura Rodwell
- Department of Health Evidence, Section Biostatistics, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Stijn van den Oord
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Pieter Smits
- Department of Cardiology, Maasstad Hospital, Rotterdam, the Netherlands
| | - Niels van Royen
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Nico Pijls
- Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands
| | - Peter Damman
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, the Netherlands
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Long-term prognostic implications of hemodynamic and plaque assessment using coronary CT angiography. Atherosclerosis 2023; 373:58-65. [PMID: 36872186 DOI: 10.1016/j.atherosclerosis.2023.02.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 01/09/2023] [Accepted: 02/21/2023] [Indexed: 03/02/2023]
Abstract
BACKGROUND AND AIMS Hemodynamic and plaque characteristics can be analyzed using coronary CT angiography (CTA). We aimed to explore long-term prognostic implications of hemodynamic and plaque characteristics using coronary CT angiography (CTA). METHODS Invasive fractional flow reserve (FFR) and CTA-derived FFR (FFRCT) were undertaken for 136 lesions in 78 vessels and followed-up to 10 years until December 2020. FFRCT, wall shear stress (WSS), change in FFRCT across the lesion (ΔFFRCT), total plaque volume (TPV), percent atheroma volume (PAV), and low-attenuation plaque volume (LAPV) for target lesions [L] and vessels [V] were obtained by independent core laboratories. Their collective influence was evaluated for the clinical endpoints of target vessel failure (TVF) and target lesion failure (TLF). RESULTS During a median follow-up of 10.1 years, PAV[V] (per 10% increase, HR 2.32 [95% CI 1.11-4.86], p = 0.025), and FFRCT[V] (per 0.1 increase, HR 0.56 [95% CI 0.37-0.84], p = 0.006) were independent predictors of TVF for the per-vessel analysis, and WSS[L] (per 100 dyne/cm2 increase, HR 1.43 [1.09-1.88], p = 0.010), LAPV[L] (per 10 mm3 increase, HR 3.81 [1.16-12.5], p = 0.028), and ΔFFRCT[L] (per 0.1 increase, HR 1.39 [1.02-1.90], p = 0.040) were independent predictors of TLF for the per-lesion analysis after adjustment for clinical and lesion characteristics. The addition of both plaque and hemodynamic predictors improved the predictability for 10-year TVF and TLF of clinical and lesion characteristics (all p < 0.05). CONCLUSIONS Vessel- and lesion-level hemodynamic characteristics, and vessel-level plaque quantity, and lesion-level plaque compositional characteristics assessed by CTA offer independent and additive long-term prognostic value.
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Groenland FTW, Huang J, Scoccia A, Neleman T, Ziedses Des Plantes AC, Nuis RJ, den Dekker WK, Wilschut JM, Diletti R, Kardys I, Van Mieghem NM, Daemen J. Vessel fractional flow reserve-based non-culprit lesion reclassification in patients with ST-segment elevation myocardial infarction: Impact on treatment strategy and clinical outcome (FAST STEMI I study). Int J Cardiol 2023; 373:33-38. [PMID: 36436683 DOI: 10.1016/j.ijcard.2022.11.043] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 11/16/2022] [Accepted: 11/22/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Complete revascularization in patients with ST-segment elevation myocardial (STEMI) improves clinical outcome. Vessel fractional flow reserve (vFFR) has been validated as a non-invasive physiological technology to evaluate hemodynamic lesion significance without need for a dedicated pressure wire or hyperemic agent. This study aimed to assess discordance between vFFR reclassification and treatment strategy in intermediate non-culprit lesions of STEMI patients and to assess the clinical impact of this discordance. METHODS This was a single-center, retrospective cohort study. From January 2018 to December 2019, consecutive eligible STEMI patients were screened based on the presence of a non-culprit vessel with an intermediate lesion (30-80% angiographic stenosis) feasible for offline vFFR analysis. The primary outcome was the percentage of non-culprit vessels with discordance between vFFR and actual treatment strategy. The secondary outcome was two-year vessel-oriented composite endpoint (VOCE), a composite of vessel-related cardiovascular death, vessel-related myocardial infarction, and target vessel revascularization. RESULTS A total of 441 patients (598 non-culprit vessels) met the inclusion criteria. Median vFFR was 0.85 (0.73-0.91). Revascularization was performed in 34.4% of vessels. Discordance between vFFR and actual treatment strategy occurred in 126 (21.1%) vessels. Freedom from VOCE was higher for concordant vessels (97.5%) as compared to discordant vessels (90.6%)(p = 0.003), particularly due to higher adverse event rates in discordant vessels with a vFFR ≤0.80 but deferred revascularization. CONCLUSIONS In STEMI patients with multivessel disease, discordance between vFFR reclassification and treatment strategy was observed in 21.1% of non-culprit vessels with an intermediate lesion and was associated with increased vessel-related adverse events.
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Affiliation(s)
- Frederik T W Groenland
- Department of (Interventional) Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Jager Huang
- Department of (Interventional) Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Alessandra Scoccia
- Department of (Interventional) Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Tara Neleman
- Department of (Interventional) Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | - Rutger-Jan Nuis
- Department of (Interventional) Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Wijnand K den Dekker
- Department of (Interventional) Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Jeroen M Wilschut
- Department of (Interventional) Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Roberto Diletti
- Department of (Interventional) Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Isabella Kardys
- Department of (Interventional) Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Nicolas M Van Mieghem
- Department of (Interventional) Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Joost Daemen
- Department of (Interventional) Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands.
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Rodriguez-Leor O, Toledano B, López-Palop R, Rivero F, Brugaletta S, Linares JA, Benito T, Carrillo P, Puigfel M, Cediel G, Sadaba M, Vaquerizo B, Rondán J, Gómez I, Alfonso F, Sáez R, Planas A, Lozano F, Hernández F, Sabaté M, Ruíz-Arroyo JR, Torres F, de la Torre Hernández JM, Gutiérrez E, Cid-Álvarez AB, Díez JL, Fernández L, Moreu J, Ojeda S, Cerrato P, Ruiz-Quevedo V, Sanchis J, Gómez-Menchero A, Ocaranza R, Mohandes M, Hernández JM, Alfageme MM, Aguiar P, López Mínguez JR, Pérez de Prado A. Changes in the treatment strategy following intracoronary pressure wire in a contemporaneous real-life cohort of patients with intermediate coronary stenosis. Results from a nationwide registry. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2023; 51:55-64. [PMID: 36822975 DOI: 10.1016/j.carrev.2023.01.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 12/27/2022] [Accepted: 01/30/2023] [Indexed: 02/05/2023]
Abstract
BACKGROUND Intracoronary pressure wire is useful to guide revascularization in patients with coronary artery disease. AIMS To evaluate changes in diagnosis (coronary artery disease extent), treatment strategy and clinical results after intracoronary pressure wire study in real-life patients with intermediate coronary artery stenosis. METHODS Observational, prospective and multicenter registry of patients in whom pressure wire was performed. The extent of coronary artery disease and the treatment strategy based on clinical and angiographic criteria were recorded before and after intracoronary pressure wire guidance. 12-month incidence of MACE (cardiovascular death, non-fatal myocardial infarction or new revascularization of the target lesion) was assessed. RESULTS 1414 patients with 1781 lesions were included. Complications related to the procedure were reported in 42 patients (3.0 %). The extent of coronary artery disease changed in 771 patients (54.5 %). There was a change in treatment strategy in 779 patients (55.1 %) (18.0 % if medical treatment; 68.8 % if PCI; 58.9 % if surgery (p < 0.001 for PCI vs medical treatment; p = 0.041 for PCI vs CABG; p < 0.001 for medical treatment vs CABG)). In patients with PCI as the initial strategy, the change in strategy was associated with a lower rate of MACE (4.6 % vs 8.2 %, p = 0.034). CONCLUSIONS The use of intracoronary pressure wire was safe and led to the reclassification of the extent of coronary disease and change in the treatment strategy in more than half of the cases, especially in patients with PCI as initial treatment.
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Affiliation(s)
- Oriol Rodriguez-Leor
- Institut del Cor, Hospital Universitari Germans Trias i Pujol, Badalona, Spain; CIBER de Enfermedades CardioVasculares (CIBERCV) Instituto de Salud Carlos III, Madrid, Spain; Institut de Recerca en Ciències de la Salut Germans Trias i Pujol, Badalona, Spain.
| | - Beatriz Toledano
- Institut del Cor, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | | | - Fernando Rivero
- Servicio de Cardiología, Hospital de la Princesa, Madrid, Spain
| | - Salvatore Brugaletta
- Servicio de Cardiología, Hospital Clínic i Provincial de Barcelona, Barcelona, Spain
| | | | - Tomás Benito
- Servicio de Cardiología, Hospital de León, León, Spain
| | - Pilar Carrillo
- Servicio de Cardiología, Hospital de Sant Joan, Alacant, Spain
| | - Martí Puigfel
- Servicio de Cardiología, Hospital Josep Trueta de Girona, Girona, Spain
| | - German Cediel
- Institut del Cor, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Mario Sadaba
- Servicio de Cardiología, Hospital de Galdakao, Galdakao, Spain
| | | | - Juan Rondán
- Servicio de Cardiología, Hospital de Cabueñes, Gijón, Spain
| | - Iván Gómez
- Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain
| | | | - Roberto Sáez
- Servicio de Cardiología, Hospital de Basurto, Basurto, Spain
| | - Ana Planas
- Servicio de Cardiología, Hospital de Castellón, Castellón de la Plana, Spain
| | - Fernando Lozano
- Servicio de Cardiología, Hospital de Ciudad Real, Ciudad Real, Spain
| | - Felipe Hernández
- Servicio de Cardiología, Clínica Universitaria de Navarra, Madrid, Spain
| | - Manel Sabaté
- Servicio de Cardiología, Hospital Clínic i Provincial de Barcelona, Barcelona, Spain
| | | | | | | | - Enrique Gutiérrez
- Servicio de Cardiología, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Ana Belén Cid-Álvarez
- Servicio de Cardiología, Hospital Clínico de Santiago, Santiago de Compostela, Spain
| | - José Luís Díez
- Servicio de Cardiología, Hospital Universitari de la Fe, Valencia, Spain
| | - Luis Fernández
- Servicio de Cardiología, Hospital de Cruces, Barakaldo, Spain
| | - José Moreu
- Servicio de Cardiología, Hospital de Toledo, Toledo, Spain
| | - Soledad Ojeda
- Servicio de Cardiología, Hospital Universitario Reina Sofía, Córdoba, Spain
| | - Pablo Cerrato
- Servicio de Cardiología, Hospital de Mérida, Mérida, Spain
| | | | - Juan Sanchis
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | | | | | - Mohsen Mohandes
- Servicio de Cardiología, Hospital Universitari Joan XXIII, Tarragona, Spain
| | | | | | - Pablo Aguiar
- Servicio de Cardiología, Hospital San Pedro de Logroño, Logroño, Spain
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Berntorp K, Rylance R, Yndigegn T, Koul S, Fröbert O, Christiansen EH, Erlinge D, Götberg M. Clinical Outcome of Revascularization Deferral With Instantaneous Wave-Free Ratio and Fractional Flow Reserve: A 5-Year Follow-Up Substudy From the iFR-SWEDEHEART Trial. J Am Heart Assoc 2023; 12:e028423. [PMID: 36734349 PMCID: PMC9973641 DOI: 10.1161/jaha.122.028423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Background Although physiology-based assessment of coronary artery stenosis using instantaneous wave-free ratio (iFR) and fractional flow reserve (FFR) are established methods of guiding coronary revascularization, its clinical outcome in long-term deferral needs further evaluation, especially with acute coronary syndrome as a clinical presentation. The aim was to evaluate the long-term clinical outcome of deferral of revascularization based on iFR or FFR. Methods and Results This is a substudy of the iFR-SWEDEHEART (Instantaneous Wave-Free Ratio Versus Fractional Flow Reserve in Patients With Stable Angina Pectoris or Acute Coronary Syndrome) randomized clinical trial, where patients deferred from revascularization from each study arm were selected. Nine hundred eight patients deferred from coronary revascularization with iFR (n=473) and FFR (n=435) were followed for 5 years. The national quality registry, SWEDEHEART (Swedish Web-System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies), was used for patient data collection and clinical follow-up. The end point was major adverse cardiac events and their individual components all-cause death, cardiovascular death, noncardiovascular death, nonfatal myocardial infarction, and unplanned revascularization. No significant difference was found in major adverse cardiac events (iFR 18.6% versus FFR 16.8%; adjusted hazard ratio, 1.08 [95% CI, 0.79-1.48]; P=0.63) or their individual components. Conclusions No differences in clinical outcomes after 5-year follow-up were noted when comparing iFR versus FFR as methods for deferral of coronary revascularization in patients presenting with stable angina pectoris and acute coronary syndrome. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02166736.
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Affiliation(s)
- Karolina Berntorp
- Department of CardiologySkåne University Hospital, Clinical Sciences, Lund UniversityLundSweden
| | - Rebecca Rylance
- Department of CardiologySkåne University Hospital, Clinical Sciences, Lund UniversityLundSweden
| | - Troels Yndigegn
- Department of CardiologySkåne University Hospital, Clinical Sciences, Lund UniversityLundSweden
| | - Sasha Koul
- Department of CardiologySkåne University Hospital, Clinical Sciences, Lund UniversityLundSweden
| | - Ole Fröbert
- Faculty of Health, Department of CardiologyÖrebro University HospitalÖrebroSweden
| | | | - David Erlinge
- Department of CardiologySkåne University Hospital, Clinical Sciences, Lund UniversityLundSweden
| | - Matthias Götberg
- Department of CardiologySkåne University Hospital, Clinical Sciences, Lund UniversityLundSweden
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Tsaban G, Zahger D, Abramowitz Y. Editorial Commentary: The COURAGE to face ISCHEMIA: Applying data from randomized studies to real-life. Trends Cardiovasc Med 2023; 33:131-132. [PMID: 34801663 DOI: 10.1016/j.tcm.2021.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 11/13/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Gal Tsaban
- Department of Cardiology, Soroka University Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva, Israel
| | - Doron Zahger
- Department of Cardiology, Soroka University Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva, Israel
| | - Yigal Abramowitz
- Department of Cardiology, Soroka University Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva, Israel.
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Yamanaka F, Shishido K, Yokota S, Moriyama N, Ochiai T, Yamada T, Hayashi T, Miyashita H, Yokoyama H, Yamanaga K, Tabata N, Yamaguchi M, Yamagishi T, Matsumoto T, Tobita K, Mizuno S, Tanaka Y, Murakami M, Takahashi S, Saito S, Tsujita K. Discordance between fractional flow reserve and instantaneous wave-free ratio in patients with severe aortic stenosis: A retrospective cohort study. J Cardiol 2023; 81:138-143. [PMID: 36057484 DOI: 10.1016/j.jjcc.2022.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 07/31/2022] [Accepted: 08/03/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND Discordance between fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) occurs in approximately 20 % of cases. However, no studies have reported the discordance in patients with severe aortic stenosis (AS). We aimed to evaluate the diagnostic discordance between FFR and iFR in patients with severe AS. METHODS We examined 140 consecutive patients with severe AS (164 intermediate coronary artery stenosis vessels). FFR and iFR were calculated in four quadrants based on threshold FFR and iFR values of ≤0.8 and ≤0.89, respectively (Group 1: iFR >0.89, FFR >0.80; Group 2: iFR ≤0.89, FFR >0.80; Group 3: iFR >0.89, FFR ≤0.80; and Group 4: iFR ≤0.89, FFR ≤0.80). Concordant groups were Groups 1 and 4, and discordant groups were Groups 2 and 3. Positive and negative discordant groups were Groups 3 and 2, respectively. RESULTS The median (Q1, Q3) FFR and iFR were 0.84 (0.76, 0.88) and 0.85 (0.76, 0.91), respectively. Discordance was observed in 48 vessels (29.3 %). In the discordant group, negative discordance (Group 2: iFR ≤0.89 and FFR >0.80) was predominant (45 cases, 93.6 %). Multivariate analysis showed that the left anterior descending artery [odds ratio (OR), 3.88; 95 % confidence interval (CI): 1.54-9.79, p = 0.004] and peak velocity ≥5.0 m/s (OR, 3.21; 95%CI: 1.36-7.57, p = 0.008) were independently associated with negative discordance (FFR >0.8 and iFR ≤0.89). CONCLUSIONS In patients with severe AS, discordance between FFR and iFR was predominantly negative and observed in 29.3 % of vessels. The left anterior descending artery and peak velocity ≥5.0 m/s were independently associated with negative discordance.
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Affiliation(s)
- Futoshi Yamanaka
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan; Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan.
| | - Koki Shishido
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Shohei Yokota
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Noriaki Moriyama
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Tomoki Ochiai
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Takashi Yamada
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Takahiro Hayashi
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Hirokazu Miyashita
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Hiroaki Yokoyama
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Kenshi Yamanaga
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Noriaki Tabata
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Masashi Yamaguchi
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Tamiharu Yamagishi
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Takashi Matsumoto
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Kazuki Tobita
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Shingo Mizuno
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Yutaka Tanaka
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Masato Murakami
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Saeko Takahashi
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Shigeru Saito
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
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Kanoun Schnur SS, Achim A, Toth GG. Clinical application of results of the ISCHEMIA trial. Trends Cardiovasc Med 2023; 33:125-130. [PMID: 34737088 DOI: 10.1016/j.tcm.2021.10.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 10/20/2021] [Accepted: 10/28/2021] [Indexed: 02/07/2023]
Abstract
More than a decade after the Clinical Outcomes Utilising Revascularization and Aggressive Drug Evaluation (COURAGE) trial, International Study of Comparative Health Effectiveness With Medical And Invasive Approaches (ISCHEMIA) is the second large clinical trial to challenge the concept of revascularization in chronic coronary syndromes whilst addressing some of the shortfalls of its predecessor.
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Affiliation(s)
- Sadeek S Kanoun Schnur
- Graz University Heart Center Graz, Medical University Graz, Graz Austria; South West Peninsula Deanery, University Plymouth Hospitals NHS Trust, Plymouth, UK.
| | - Alexandru Achim
- Graz University Heart Center Graz, Medical University Graz, Graz Austria; Medicala 1 Invasive Cardiology Department, University of Medicine and Pharmacy "Iuliu Hatieganu", Cluj-Napoca, Romania; Doctoral School of Clinical Medicine, Faculty of Medicine, University of Szeged, Szeged, Hungary"
| | - Gabor G Toth
- Graz University Heart Center Graz, Medical University Graz, Graz Austria
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76
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Ekmejian A, Sritharan H, Selvakumar D, Venkateshka V, Allahwala U, Ward M, Bhindi R. Outcomes of deferred revascularisation following negative fractional flow reserve in diabetic and non-diabetic patients: a meta-analysis. Cardiovasc Diabetol 2023; 22:22. [PMID: 36717847 PMCID: PMC9887893 DOI: 10.1186/s12933-023-01751-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 01/23/2023] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Fractional Flow Reserve (FFR) is a widely applied invasive physiological assessment, endorsed by major guidelines to aid in the decision to perform or defer revascularisation. While a threshold of > 0.8 has been applied universally, clinical outcomes may be affected by numerous factors, including the presence of diabetes. This meta-analysis aims to investigate the outcomes of diabetic versus non-diabetic patients in whom revascularisation was deferred based on negative FFR. METHODS We performed a meta-analysis investigating the outcomes of diabetic and non-diabetic patients in whom revascularisation was deferred based on negative FFR. A search was performed on MEDLINE, PubMed and EMBASE, and peer-reviewed studies that reported MACE for diabetic and non-diabetic patients with deferred revascularisation based on FFR > 0.8 were included. The primary end point was MACE. RESULTS The meta-analysis included 7 studies in which 4275 patients had revascularisation deferred based on FFR > 0.8 (1250 diabetic). Follow up occurred over a mean of 3.2 years. Diabetes was associated with a higher odds of MACE (OR = 1.66, 95% CI 1.35-2.04, p = < 0.001), unplanned revascularisation (OR = 1.48, 95% CI 1.06-2.06, p = 0.02), all-cause mortality (OR = 1.74, 95% CI 1.20-2.52, p = 0.004) and cardiovascular mortality (OR = 2.08, 95% CI 1.07-4.05, p = 0.03). CONCLUSIONS For patients with stable coronary syndromes and deferred revascularisation based on FFR > 0.8, the presence of diabetes portends an increased long-term risk of MACE compared to non-diabetic patients. Trail registration URL: https://www.crd.york.ac.uk/PROSPERO/ ; Unique identifier: CRD42022367312.
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Affiliation(s)
- Avedis Ekmejian
- Department of Cardiology, Interventional Cardiologist, Royal North Shore Hospital, Reserve Rd, St Leonards, Sydney, 2065, Australia. .,University of Sydney, Camperdown, Australia.
| | - Hari Sritharan
- grid.412703.30000 0004 0587 9093Department of Cardiology, Interventional Cardiologist, Royal North Shore Hospital, Reserve Rd, St Leonards, Sydney, 2065 Australia ,grid.1013.30000 0004 1936 834XUniversity of Sydney, Camperdown, Australia
| | - Dinesh Selvakumar
- grid.412703.30000 0004 0587 9093Department of Cardiology, Interventional Cardiologist, Royal North Shore Hospital, Reserve Rd, St Leonards, Sydney, 2065 Australia
| | - Venkateshka Venkateshka
- grid.482157.d0000 0004 0466 4031Northern Sydney Local Health District Executive, Hornsby, Australia
| | - Usaid Allahwala
- grid.412703.30000 0004 0587 9093Department of Cardiology, Interventional Cardiologist, Royal North Shore Hospital, Reserve Rd, St Leonards, Sydney, 2065 Australia ,grid.1013.30000 0004 1936 834XUniversity of Sydney, Camperdown, Australia
| | - Michael Ward
- grid.412703.30000 0004 0587 9093Department of Cardiology, Interventional Cardiologist, Royal North Shore Hospital, Reserve Rd, St Leonards, Sydney, 2065 Australia ,grid.1013.30000 0004 1936 834XUniversity of Sydney, Camperdown, Australia
| | - Ravinay Bhindi
- grid.412703.30000 0004 0587 9093Department of Cardiology, Interventional Cardiologist, Royal North Shore Hospital, Reserve Rd, St Leonards, Sydney, 2065 Australia ,grid.1013.30000 0004 1936 834XUniversity of Sydney, Camperdown, Australia
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Nijjer SS. Using Physiology Pullback for Percutaneous Coronary Intervention Guidance: Is this the Future? Interv Cardiol Clin 2023; 12:41-53. [PMID: 36372461 DOI: 10.1016/j.iccl.2022.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
Modern coronary intervention requires integration of angiographic, physiologic, and intravascular imaging. This article describes the use and techniques needed to understand coronary physiology pullback data and how use it to make revascularization decisions. The article describes instantaneous wave-free ratio, fractional flow reserve, and the data that support their use and how they differ when used in tandem disease. Common practical mistakes and errors are discussed together with a brief review of the limited published research data.
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Affiliation(s)
- Sukhjinder Singh Nijjer
- Department of Cardiology, Imperial College London, Hammersmith Hospital, Du Cane Road, London, W12 0HS, United Kingdom. https://twitter.com/SukhNijjer
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Ziedses des Plantes AC, Scoccia A, Gijsen F, van Soest G, Daemen J. Intravascular Imaging-Derived Physiology-Basic Principles and Clinical Application. Interv Cardiol Clin 2023; 12:83-94. [PMID: 36372464 DOI: 10.1016/j.iccl.2022.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
Intravascular imaging-derived physiology is emerging as a promising tool allowing simultaneous anatomic and functional lesion assessment. Recently, several optical coherence tomography-based and intravascular ultrasound-based fractional flow reserve (FFR) indices have been developed that compute FFR through computational fluid dynamics, fluid dynamics equations, or machine-learning methods. This review aims to provide an overview of the currently available intravascular imaging-based physiologic indices, their diagnostic performance, and clinical application.
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Affiliation(s)
- Annemieke C Ziedses des Plantes
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, P.O. Box 2040, 3000 CA, Rotterdam, the Netherlands
| | - Alessandra Scoccia
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, P.O. Box 2040, 3000 CA, Rotterdam, the Netherlands
| | - Frank Gijsen
- Department of Biomedical Engineering, Erasmus University Medical Center, P.O. Box 2040, 3000 CA, Rotterdam, the Netherlands
| | - Gijs van Soest
- Department of Biomedical Engineering, Erasmus University Medical Center, P.O. Box 2040, 3000 CA, Rotterdam, the Netherlands
| | - Joost Daemen
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, P.O. Box 2040, 3000 CA, Rotterdam, the Netherlands.
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Fawaz S, Cook CM. Understanding the Basis for Hyperemic and Nonhyperemic Coronary Pressure Assessment. Interv Cardiol Clin 2023; 12:1-12. [PMID: 36372454 DOI: 10.1016/j.iccl.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
Despite the now routine integration of invasive physiologic systems into coronary catheter laboratories worldwide, it remains critical that all operators maintain a sound understanding of the fundamental physiologic basis for coronary pressure assessment. More specifically, performing operators should be well informed regarding the basis for hyperemic (ie, fractional flow reserve) and nonhyperemic (ie, instantaneous wave-free ratio and other nonhyperemic pressure ratio) coronary pressure assessment. In this article, we provide readers a comprehensive history charting the inception, development, and validation of hyperemic and nonhyperemic coronary pressure assessment.
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Affiliation(s)
- Samer Fawaz
- Essex Cardiothoracic Centre, Mid and South Essex NHS Hospitals Trust, Basildon SS16 5NL, United Kingdom; Anglia Ruskin University, Chelmsford, Essex CM1 1SQ, United Kingdom
| | - Christopher M Cook
- Essex Cardiothoracic Centre, Mid and South Essex NHS Hospitals Trust, Basildon SS16 5NL, United Kingdom; Anglia Ruskin University, Chelmsford, Essex CM1 1SQ, United Kingdom.
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Galli M, Benenati S, Zito A, Capodanno D, Zoccai GB, Ortega-Paz L, Iaconelli A, D'Amario D, Porto I, Burzotta F, Trani C, De Caterina R, Gaudino M, Escaned J, Angiolillo DJ, Crea F. Revascularization strategies versus optimal medical therapy in chronic coronary syndrome: A network meta-analysis. Int J Cardiol 2023; 370:58-64. [PMID: 36265647 DOI: 10.1016/j.ijcard.2022.10.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Revised: 10/11/2022] [Accepted: 10/12/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND The impact of myocardial revascularization on outcomes and prognosis in patients with chronic coronary syndrome (CCS) without left main (LM) disease or reduced left ventricle ejection fraction (LVEF) may be influenced by the revascularization strategy adopted. METHODS We performed a network meta-analysis including 18 randomized controlled trials comparing different revascularization strategies, including angiography-guided percutaneous coronary intervention (PCI), physiology-guided PCI and coronary artery bypass graft (CABG), in patients with CCS without LM disease or reduced LVEF. RESULTS Compared with medical therapy, all revascularization strategies were associated with a reduction of the primary endpoint, as defined in each trial, the extent of which was modest with angiography-guided PCI (IRR 0.86, 95% CI 0.75-0.99) and greater with physiology-guided PCI (IRR 0.60, 95% CI 0.47-0.77) and CABG (IRR 0.58, 95% CI 0.48-0.70). Moreover, angiography-guided PCI was associated with an increase of the primary endpoint compared to physiology-guided PCI (IRR 1.43, 95% CI 1.14-1.79) and CABG (IRR 1.49, 95% CI 1.27-1.74). CABG was the only strategy associated with reduced myocardial infarction (IRR 0.68, 95% CI 0.52-0.90), cardiovascular death (IRR 0.76, 95% CI 0.64-0.89), and all-cause death (IRR 0.87, 95% CI 0.77-0.99), but increased stroke (IRR 1.69, 95% CI 1.04-2.76). CONCLUSIONS In CCS patients without LM disease or reduced LVEF, physiology-guided PCI and CABG are associated with better outcomes than angiography-guided PCI. Compared with medical therapy, CABG is the only revascularization strategy associated with a reduction of myocardial infarction and death rates, at the cost of higher risk of stroke. STUDY REGISTRATION This study is registered in PROSPERO (CRD42022313612).
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Affiliation(s)
- Mattia Galli
- Catholic University of the Sacred Heart, Rome, Italy; Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy.
| | - Stefano Benenati
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, IRCCS Italian Cardiology Network, Genova, Italy
| | - Andrea Zito
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania, Italy
| | - Giuseppe Biondi Zoccai
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University, Latina, Rome, Italy; Mediterranea Cardiocentro, Napoli, Italy
| | - Luis Ortega-Paz
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, United States
| | - Antonio Iaconelli
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Domenico D'Amario
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Italo Porto
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, IRCCS Italian Cardiology Network, Genova, Italy; Cardiovascular Disease Chair, Department of Internal Medicine (Di.M.I.), University of Genoa, Genoa, Italy
| | - Francesco Burzotta
- Catholic University of the Sacred Heart, Rome, Italy; Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Carlo Trani
- Catholic University of the Sacred Heart, Rome, Italy; Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Raffaele De Caterina
- University of Pisa and University Cardiology Division, Pisa University Hospital, Pisa, Italy; Fondazione VillaSerena per la Ricerca, Città Sant'Angelo, Pescara, Italy
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York City, NY, United States
| | - Javier Escaned
- Hospital Clinico San Carlos IDISSC, Complutense University, Madrid, Spain
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, United States
| | - Filippo Crea
- Catholic University of the Sacred Heart, Rome, Italy; Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
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Shabbir A, Travieso A, Mejía-Rentería H, Espejo-Paeres C, Gonzalo N, Banning AP, Serruys PW, Escaned J. Coronary Physiology as Part of a State-of-the-Art Percutaneous Coronary Intervention Strategy: Lessons from SYNTAX II and Beyond. Interv Cardiol Clin 2023; 12:141-153. [PMID: 36372458 DOI: 10.1016/j.iccl.2022.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
The use of coronary physiology allows for rational decision making at the time of PCI, contributing to better patient outcomes. Yet, coronary physiology is only one aspect of optimal revascularization. State-of-the-art PCI must also consider other important aspects such as intracoronary imaging guidance and specific procedural expertise, as tested in the SYNTAX II study. In this review, we highlight the technical aspects pertaining to the use of physiology as used in that trial and offer a glimpse into the future with emerging physiologic metrics, including functional coronary angiography, which have already established themselves as useful indices to guide decision making.
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Affiliation(s)
- Asad Shabbir
- Interventional Cardiology Unit, Hospital Clínico San Carlos IDISCC, Complutense University of Madrid, Calle del Prof Martín Lagos, Madrid 28040, Spain
| | - Alejandro Travieso
- Interventional Cardiology Unit, Hospital Clínico San Carlos IDISCC, Complutense University of Madrid, Calle del Prof Martín Lagos, Madrid 28040, Spain
| | - Hernán Mejía-Rentería
- Interventional Cardiology Unit, Hospital Clínico San Carlos IDISCC, Complutense University of Madrid, Calle del Prof Martín Lagos, Madrid 28040, Spain
| | - Carolina Espejo-Paeres
- Interventional Cardiology Unit, Hospital Clínico San Carlos IDISCC, Complutense University of Madrid, Calle del Prof Martín Lagos, Madrid 28040, Spain
| | - Nieves Gonzalo
- Interventional Cardiology Unit, Hospital Clínico San Carlos IDISCC, Complutense University of Madrid, Calle del Prof Martín Lagos, Madrid 28040, Spain
| | - Adrian P Banning
- Heart Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Patrick W Serruys
- Department of Cardiology, National University of Ireland, Galway, Ireland; National Heart and Lung Institute, Imperial College London, London, UK
| | - Javier Escaned
- Interventional Cardiology Unit, Hospital Clínico San Carlos IDISCC, Complutense University of Madrid, Calle del Prof Martín Lagos, Madrid 28040, Spain.
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Kovach CP, Hebbe A, Glorioso TJ, Barrett C, Barón AE, Mavromatis K, Valle JA, Waldo SW. Association of Residual Ischemic Disease With Clinical Outcomes After Percutaneous Coronary Intervention. JACC Cardiovasc Interv 2022; 15:2475-2486. [PMID: 36543441 DOI: 10.1016/j.jcin.2022.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 11/01/2022] [Accepted: 11/03/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Anatomical scoring systems have been used to assess completeness of revascularization but are challenging to apply to large real-world datasets. OBJECTIVES The aim of this study was to assess the prevalence of complete revascularization and its association with longitudinal clinical outcomes in the U.S. Department of Veterans Affairs (VA) health care system using an automatically computed anatomic complexity score. METHODS Patients undergoing percutaneous coronary intervention (PCI) between October 1, 2007, and September 30, 2020, were identified, and the burden of prerevascularization and postrevascularization ischemic disease was quantified using the VA SYNTAX (Synergy Between PCI With Taxus and Cardiac Surgery) score. The association between residual VA SYNTAX score and long-term major adverse cardiovascular events (MACE; death, myocardial infarction, repeat revascularization, and stroke) was assessed. RESULTS A total of 57,476 veterans underwent PCI during the study period. After adjustment, the highest tertile of residual VA SYNTAX score was associated with increased hazard of MACE (HR: 2.06; 95% CI: 1.98-2.15) and death (HR: 1.50; 95% CI: 1.41-1.59) at 3 years compared to complete revascularization (residual VA SYNTAX score = 0). Hazard of 1- and 3-year MACE increased as a function of residual disease, regardless of baseline disease severity or initial presentation with acute or chronic coronary syndrome. CONCLUSIONS Residual ischemic disease was strongly associated with long-term clinical outcomes in a contemporary national cohort of PCI patients. Automatically computed anatomic complexity scores can be used to assess the longitudinal risk for residual ischemic disease after PCI and may be implemented to improve interventional quality.
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Affiliation(s)
- Christopher P Kovach
- Division of Cardiology, Department of Medicine, University of Colorado, Aurora, Colorado, USA; Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado, USA
| | - Annika Hebbe
- Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado, USA; CART Program, Office of Quality and Patient Safety, Veterans Health Administration, Washington, District of Columbia, USA
| | - Thomas J Glorioso
- Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado, USA; CART Program, Office of Quality and Patient Safety, Veterans Health Administration, Washington, District of Columbia, USA
| | - Christopher Barrett
- Division of Cardiology, Department of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Anna E Barón
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, Aurora, Colorado, USA
| | | | - Javier A Valle
- Division of Cardiology, Department of Medicine, University of Colorado, Aurora, Colorado, USA; Michigan Heart and Vascular Institute, Ann Arbor, Michigan, USA
| | - Stephen W Waldo
- Division of Cardiology, Department of Medicine, University of Colorado, Aurora, Colorado, USA; Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado, USA; CART Program, Office of Quality and Patient Safety, Veterans Health Administration, Washington, District of Columbia, USA.
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Dobrolinska MM, Gąsior P, Błach A, Gocoł R, Hudziak D, Wojakowski W. Myocardial Perfusion and Coronary Physiology Assessment of Microvascular Dysfunction in Patients Undergoing Transcatheter Aortic Valve Implantation-Rationale and Design. Biomimetics (Basel) 2022; 7:230. [PMID: 36546930 PMCID: PMC9775333 DOI: 10.3390/biomimetics7040230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 12/01/2022] [Accepted: 12/06/2022] [Indexed: 12/14/2022] Open
Abstract
The prevalence of coronary artery disease (CAD) in patients with severe aortic stenosis (AS) is 30-68%. Nevertheless, there is still not enough evidence to use invasive assessment of lesion severity, because the hemodynamic milieu of AS may impact the fractional flow reserve (FFR) and non-hyperemic indices. Therefore, the aim of the study is two-fold. First, to measure acute and long-term changes of FFR, index of microvascular resistance (IMR), and coronary flow reserve (CFR) in patients undergoing TAVI procedure. Second, to compare the diagnostic accuracy of intracoronary indices with myocardial perfusion measured by cadmium-zinc-telluride single-photon emission tomography (CZT-SPECT) and find cut-off values defining significant stenosis. We plan to enroll 40 patients eligible for TAVI with intermediate stenosis (30-70%) in the left anterior descending (LAD) coronary artery. In each patient FFR, CFR, and IMR will be measured in addition to myocardial blood flow calculated by CZT-SPECT before and either immediately after TAVI (acute cohort) or in 6 months (late cohort) after the procedure. FFR, CFR, and IMR will be matched with the results of myocardial perfusion measured by CZT-SPECT in the area of LAD. As a result, cut-off values of FFR, CFR, and IMR defining the decreased blood flow will be found.
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Affiliation(s)
- M. M. Dobrolinska
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia in Katowice, 40-635 Katowice, Poland
| | - P. Gąsior
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia in Katowice, 40-635 Katowice, Poland
| | - A. Błach
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia in Katowice, 40-635 Katowice, Poland
- Nuclear Medicine Department, Voxel Medical Diagnostic Centre, 40-635 Katowice, Poland
| | - R. Gocoł
- Department of Cardiac Surgery, Medical University of Silesia, 40-635 Katowice, Poland
| | - D. Hudziak
- Department of Cardiac Surgery, Medical University of Silesia, 40-635 Katowice, Poland
| | - W. Wojakowski
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia in Katowice, 40-635 Katowice, Poland
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Massalha S, Keidar Z. Image fusion: the beauty of the truth from the inside and out. J Nucl Cardiol 2022; 29:3278-3280. [PMID: 35381963 DOI: 10.1007/s12350-022-02955-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 03/06/2022] [Indexed: 01/14/2023]
Affiliation(s)
- Samia Massalha
- Department of Cardiology, Rambam Health Care Campus, Haifa, Israel
| | - Zohar Keidar
- Department of Nuclear Medicine, Rambam Health Care Campus, Haifa, Israel.
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Current Concepts and Future Applications of Non-Invasive Functional and Anatomical Evaluation of Coronary Artery Disease. Life (Basel) 2022; 12:life12111803. [PMID: 36362957 PMCID: PMC9696378 DOI: 10.3390/life12111803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 10/31/2022] [Accepted: 11/04/2022] [Indexed: 11/09/2022] Open
Abstract
Over the last decades, significant advances have been achieved in the treatment of coronary artery disease (CAD). Proper non-invasive diagnosis and appropriate management based on functional information and the extension of ischemia or viability remain the cornerstone in the fight against adverse CAD events. Stress echocardiography and single photon emission computed tomography are often used for the evaluation of ischemia. Advancements in non-invasive imaging modalities such as computed tomography (CT) coronary angiography and cardiac magnetic resonance imaging (MRI) have not only allowed non-invasive imaging of coronary artery lumen but also provide additional functional information. Other characteristics regarding the plaque morphology can be further evaluated with the latest modalities achieving a morpho-functional evaluation of CAD. Advances in the utilization of positron emission tomography (PET), as well as software advancements especially regarding cardiac CT, may provide additional prognostic information to a more evidence-based treatment decision. Since the armamentarium on non-invasive imaging modalities has evolved, the knowledge of the capabilities and limitations of each imaging modality should be evaluated in a case-by-case basis to achieve the best diagnosis and treatment decision. In this review article, we present the most recent advances in the noninvasive anatomical and functional evaluation of CAD.
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Abstract
PURPOSE OF REVIEW Coronary artery disease (CAD) is responsible for >50% of heart failures cases. Patients with ischemic left ventricular systolic dysfunction (iLVSD) are known to have poorer outcomes after percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) compared to patients with a normal ejection fraction. Nevertheless, <1% of patients in coronary revascularization trials to date had iLVSD. The purpose of this review is to describe coronary revascularization modalities in patients with iLVSD and highlight the need for randomized controlled trial evidence comparing these treatments in this patient population. RECENT FINDINGS Network meta-analytic findings of observational studies suggest that PCI is associated with higher rates of mortality, cardiac death, myocardial infarction, and repeat revascularization but not stroke compared to CABG in iLVSD. In recent years, outcomes for patients undergoing PCI have improved as a result of advances in technologies and techniques. SUMMARY The optimal coronary revascularization modality in patients with iLVSD remains unknown. In observational studies, CABG appears superior to PCI; however, direct randomized evidence is absent and developments in PCI techniques have improved post-PCI outcomes in recent years. The Surgical Treatment for Ischemic Heart Failure 3.0 consortium of trials will seek to address the clinical equipoise in coronary revascularization in patients with iLVSD.
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Lee CH, Hwang J, Kim IC, Cho YK, Park HS, Yoon HJ, Kim H, Han S, Hur SH, Kim KB, Kim JY, Chung JW, Lee JM, Doh JH, Shin ES, Koo BK, Nam CW. Effect of Atorvastatin on Serial Changes in Coronary Physiology and Plaque Parameters. JACC. ASIA 2022; 2:691-703. [PMID: 36444331 PMCID: PMC9700034 DOI: 10.1016/j.jacasi.2022.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 07/13/2022] [Accepted: 07/16/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND The effects of statin on coronary physiology have not been well evaluated. OBJECTIVES The authors performed this prospective study to investigate changes in coronary flow indexes and plaque parameters, and their associations with atorvastatin therapy in patients with coronary artery disease (CAD). METHODS Ninety-five patients with intermediate CAD who received atorvastatin therapy underwent comprehensive physiological assessments with fractional flow reserve (FFR), coronary flow reserve, index of microcirculatory resistance, and intravascular ultrasound at the index procedure, and underwent the same evaluations at 12-month follow-up. Optimal low-density lipoprotein cholesterol (LDL-C) was defined as LDL-C <70 mg/dL or ≥50% reduction from the baseline. The primary endpoint was a change in the FFR. RESULTS Baseline FFR, minimal lumen area, and percent atheroma volume (PAV) were 0.88 ± 0.05, 3.87 ± 1.28, 55.92 ± 7.30, respectively. During 12 months, the percent change in LDL-C was -33.2%, whereas FFR was unchanged (0.87 ± 0.06 at 12 months; P = 0.694). Vessel area, lumen area, and PAV were significantly decreased (all P values <0.05). The achieved LDL-C level and the change of PAV showed significant inverse correlations with the change in FFR. In patients with optimally modified LDL-C, the FFR had increased (0.87 ± 0.06 vs 0.89 ± 0.07; P = 0.014) and the PAV decreased (56.81 ± 6.44% vs 55.18 ± 8.19%; P = 0.031), whereas in all other patients, the FFR had decreased (0.88 ± 0.05 vs 0.86 ± 0.06; P = 0.025) and the PAV remained unchanged. CONCLUSIONS In patients with CAD, atorvastatin did not change FFR despite a decrease in the PAV. However, in patients who achieved the optimal LDL-C target level with atorvastatin, the FFR had significantly increased with decrease of the PAV. (Effect of Atorvastatin on Fractional Flow Reserve in Coronary Artery Disease [FORTE]; NCT01946815).
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Key Words
- CAD, coronary artery disease
- CFR, coronary flow reserve
- FFR, fractional flow reserve
- IMR, index of microcirculatory resistance
- IVUS, intravascular ultrasound
- LDL-C, low-density lipoprotein cholesterol
- LLT, lipid-lowering therapy
- MLA, minimal lumen area
- OR, odds ratio
- PAV, percent atheroma volume
- Pa, proximal aortic pressure
- Pd, distal coronary pressure
- TAV, total atheroma volume
- Tmn, mean transit time
- VH, virtual histology
- fractional flow reserve
- intermediate coronary artery disease
- statin therapy
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Affiliation(s)
- Cheol Hyun Lee
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Daegu, Republic of Korea
| | - Jongmin Hwang
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Daegu, Republic of Korea
| | - In-Cheol Kim
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Daegu, Republic of Korea
| | - Yun-Kyeong Cho
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Daegu, Republic of Korea
| | - Hyoung-Seob Park
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Daegu, Republic of Korea
| | - Hyuck-Jun Yoon
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Daegu, Republic of Korea
| | - Hyungseop Kim
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Daegu, Republic of Korea
| | - Seongwook Han
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Daegu, Republic of Korea
| | - Seung-Ho Hur
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Daegu, Republic of Korea
| | - Kwon-Bae Kim
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Daegu, Republic of Korea
| | - Jin Young Kim
- Department of Radiology, Keimyung University Dongsan Hospital, Daegu, Republic of Korea
| | - Jin-Wook Chung
- Division of Cardiology, Department of Internal Medicine, Keimyung University Daegu Dongsan Hospital, Daegu, Republic of Korea
| | - Joo Myung Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Joon-Hyung Doh
- Department of Medicine, Inje University Ilsan Paik Hospital, Goyang, Republic of Korea
| | - Eun-Seok Shin
- Department of Internal Medicine, Ulsan University Hospital, Ulsan, Republic of Korea
| | - Bon-Kwon Koo
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Chang-Wook Nam
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Daegu, Republic of Korea
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Liang L, Zhu Y, Li F, Guo K, Chang S, Li Q, Zhang Y, Li D. Comparative analysis of instantaneous wave-free ratio and quantitative real-time myocardial contrast echocardiography for the assessment of myocardial perfusion. Front Cardiovasc Med 2022; 9:893647. [DOI: 10.3389/fcvm.2022.893647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 10/06/2022] [Indexed: 01/10/2023] Open
Abstract
Background and hypothesisThe field of coronary artery physiology is developing rapidly and changing the practice of interventional cardiology. A new functional evaluation technique using the instantaneous wave-free ratio (iFR) has become an alternative to fractional flow reserve. Future research studies need to determine whether physiological indicators play a role in evaluating myocardial perfusion in the catheter room.Materials and methodsThirty-eight patients scheduled for coronary angiography and iFR evaluation underwent a real-time myocardial contrast echocardiography (RT-MCE) examination at rest. The myocardial perfusion parameters (A, β, and A × β) on the myocardial perfusion curve were quantitatively analyzed using Q-Lab software. Coronary angiography and iFR assessment were completed within 1 week after the RT-MCE examination in all patients. Correlation analysis was used to identify iFR- and MCE-related indicators. The sensitivity and specificity of iFR in the quantitative detection of coronary microcirculation were obtained.ResultsThe correlation coefficients between iFR and A, β, and A × β were 0.81, 0.66, and 0.82, respectively. The cut-off value for iFR was 0.85 for microvascular ischemia detection, while the sensitivity and specificity for the diagnosis of myocardial perfusion were 90.7 and 89.9%, respectively. The receiver operating characteristic (ROC) curve area for iFR was 0.946 in the segments related to myocardial blood flow.ConclusionThe iFR is an effective tool for detecting myocardial microcirculation perfusion, with satisfactory diagnostic performance and a demonstrated role in physiological indices used for the perfusion assessment.
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Nagasaka T, Amanai S, Ishibashi Y, Aihara K, Ohyama Y, Takama N, Koitabashi N, Ishii H. Long-term outcomes of intermediate coronary stenosis in patients undergoing hemodialysis after deferred revascularization based on fractional flow reserve. Catheter Cardiovasc Interv 2022; 100:971-978. [PMID: 36262079 DOI: 10.1002/ccd.30421] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 08/29/2022] [Accepted: 10/02/2022] [Indexed: 11/10/2022]
Abstract
OBJECTIVES This study aimed to assess the long-term outcomes of patients undergoing hemodialysis (HD) after deferred revascularization based on fractional flow reserve (FFR). BACKGROUND FFR is a practical technique for assessing the functional severity of intermediate coronary stenosis. Prior research has revealed a satisfactory outcome in patients after the deferral of percutaneous coronary intervention for coronary lesions based on FFR measurement. However, little research has been conducted focusing on patients undergoing HD. METHODS The retrospective study comprised 225 consecutive patients with FFR assessment and deferred revascularization between January 2016 and December 2019. Based on a deferral cutoff FFR value of >0.80, we assessed the differences in all-cause death, major adverse cardiac events (MACEs), and target vessel failure (TVF) between the HD (n = 69) and non-HD groups (n = 156) during a mean ± standard deviation routine follow-up of 32.2 ± 13.4 months. RESULTS Although the HD group had significantly higher rates of diabetes mellitus than the non-HD group (53.6% vs. 37.2%, p = 0.021), there were no significant differences in sex, left ventricular ejection fraction, or other risk factors between the groups, nor with respect to stenosis diameter or mean FFR. The HD group had a significantly higher incidence of TVF than the non-HD group (34.8% vs. 14.1%, p < 0.001), as well as a significantly higher risk of all-cause death and MACEs. CONCLUSIONS The study revealed that deferred revascularization in coronary lesions with an FFR value of >0.80 in patients undergoing HD was associated with poor outcomes. Therefore, it is important to carefully monitor patients with intermediate coronary stenosis undergoing HD.
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Affiliation(s)
- Takashi Nagasaka
- Department of Cardiovascular Medicine, Gunma University School of Medicine, Maebashi, Japan
| | - Shiro Amanai
- Department of Cardiovascular Medicine, Gunma University School of Medicine, Maebashi, Japan
| | - Yohei Ishibashi
- Department of Cardiovascular Medicine, Gunma University School of Medicine, Maebashi, Japan
| | - Kazufumi Aihara
- Department of Cardiovascular Medicine, Gunma University School of Medicine, Maebashi, Japan
| | - Yoshiaki Ohyama
- Department of Cardiovascular Medicine, Gunma University School of Medicine, Maebashi, Japan
| | - Noriaki Takama
- Department of Cardiovascular Medicine, Gunma University School of Medicine, Maebashi, Japan
| | - Norimichi Koitabashi
- Department of Cardiovascular Medicine, Gunma University School of Medicine, Maebashi, Japan
| | - Hideki Ishii
- Department of Cardiovascular Medicine, Gunma University School of Medicine, Maebashi, Japan
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90
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Shiono Y. Benefits of Fractional Flow Reserve-Guided Percutaneous Coronary Intervention. JACC. ASIA 2022; 2:604-606. [PMID: 36624787 PMCID: PMC9823274 DOI: 10.1016/j.jacasi.2022.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Yasutsugu Shiono
- Address for correspondence: Dr Yasutsugu Shiono, Department of Cardiovascular Medicine, Wakayama Medical University, 811-1, Kimiidera, Wakayama 641-8509, Japan.
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91
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Morris PD, Al-Lamee RK, Berry C. Coronary physiological assessment in the catheter laboratory: haemodynamics, clinical assessment and future perspectives. Heart 2022; 108:1737-1746. [PMID: 35768192 PMCID: PMC9606498 DOI: 10.1136/heartjnl-2020-318743] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Paul D Morris
- Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, UK
| | | | - Colin Berry
- BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
- Department of Cardiology, Golden Jubilee National Hospital, Clydebank, UK
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92
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Fezzi S, Huang J, Lunardi M, Ding D, Ribichini FL, Tu S, Wijns W. Coronary physiology in the catheterisation laboratory: an A to Z practical guide. ASIAINTERVENTION 2022; 8:86-109. [PMID: 36798834 PMCID: PMC9890586 DOI: 10.4244/aij-d-22-00022] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 04/21/2022] [Indexed: 11/16/2022]
Abstract
Coronary revascularisation, either percutaneous or surgical, aims to improve coronary flow and relieve myocardial ischaemia. The decision-making process in patients with coronary artery disease (CAD) remains largely based on invasive coronary angiography (ICA), even though until recently ICA could not assess the functional significance of coronary artery stenoses. Invasive wire-based approaches for physiological evaluations were developed to properly assess the ischaemic relevance of epicardial CAD. Fractional flow reserve (FFR) and later, instantaneous wave-free ratio (iFR), were shown to improve clinical outcomes in several patient subsets when used for coronary revascularisation guidance or deferral and for procedural optimisation of percutaneous coronary intervention (PCI) results. Despite accumulating evidence and positive guideline recommendations, the adoption of invasive physiology has remained quite low, mainly due to technical and economic issues as well as to operator-resistance to change. Coronary image-based computational physiology has been recently developed, with promising results in terms of accuracy and a reduction in computational time, costs, radiation exposure and risks for the patient. Lastly, the integration of intracoronary imaging and physiology allows for individualised PCI treatment, aiming at complete relief of ischaemia through optimised morpho-functional immediate procedural results. Instead of a conventional state-of-the-art review, this A to Z dictionary attempts to provide a practical guide for the application of coronary physiology in the catheterisation laboratory, exploring several methods, their pitfalls, and useful tips and tricks.
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Affiliation(s)
- Simone Fezzi
- The Lambe Institute for Translational Medicine, The Smart Sensors Lab and Curam, National University of Ireland, University Road, Galway, Ireland,Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Jiayue Huang
- The Lambe Institute for Translational Medicine, The Smart Sensors Lab and Curam, National University of Ireland, University Road, Galway, Ireland,Biomedical Instrument Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Mattia Lunardi
- The Lambe Institute for Translational Medicine, The Smart Sensors Lab and Curam, National University of Ireland, University Road, Galway, Ireland,Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Daixin Ding
- The Lambe Institute for Translational Medicine, The Smart Sensors Lab and Curam, National University of Ireland, University Road, Galway, Ireland,Biomedical Instrument Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Flavio L. Ribichini
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Shengxian Tu
- Biomedical Instrument Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China,Department of Cardiology, Fujian Medical University Union Hospital, Fujian, China
| | - William Wijns
- The Lambe Institute for Translational Research, Galway National University of Ireland Galway (NUIG), Costello Road, Shantalla, Galway, H91 V4AY, Ireland
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93
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Hong D, Lee SH, Shin D, Choi KH, Kim HK, Park TK, Yang JH, Song YB, Hahn JY, Choi SH, Gwon HC, Lee JM. Prognosis and Medical Cost of Measuring Fractional Flow Reserve in Percutaneous Coronary Intervention. JACC. ASIA 2022; 2:590-603. [PMID: 36518721 PMCID: PMC9743455 DOI: 10.1016/j.jacasi.2022.04.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 03/17/2022] [Accepted: 04/13/2022] [Indexed: 02/07/2023]
Abstract
Background There are limited data regarding comparative prognosis and medical cost between fractional flow reserve (FFR)-based and angiography-based percutaneous coronary intervention (PCI) among revascularized patients. Objectives This study evaluates prognosis and medical cost of FFR use in revascularized patients by PCI. Methods Using the National Health Insurance Service database, stable or unstable angina patients who underwent PCI from 2011 to 2017 were evaluated. Eligible patients were divided into 2 groups according to use of FFR in PCI. Primary outcome was a composite of all-cause death or spontaneous myocardial infarction (MI). Secondary outcomes included individual components of the primary outcome, unplanned revascularization, and medical costs. Results Among 134,613 eligible patients, PCI was performed based on angiography (n = 129,497) and FFR (n = 5,116). During the study period, both the annual number and proportion of use of FFR in PCI increased (all P for trend <0.001). The FFR group showed significantly lower risk of the primary outcome (7.0% vs 9.5%; P < 0.001), all-cause death (5.8% vs 7.7%; P = 0.001), and spontaneous MI (1.6% vs 2.2%; P = 0.022) than the angiography group. Although the FFR group showed higher medical cost during index admission than angiography group (median: $6,265.10 vs $5,385.60; P < 0.001), cumulative medical cost after index admission was significantly lower ($2,696.50 vs. $3,142.10; P < 0.001). Conclusions Use of FFR in PCI in stable or unstable angina patients showed significantly lower risk of all-cause death and spontaneous MI compared to angiography-based PCI. Although the FFR group had higher initial medical cost than the angiography group, cumulative medical cost after index admission was significantly lower.
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Affiliation(s)
- David Hong
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Seung Hun Lee
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Doosup Shin
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Ki Hong Choi
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hyun Kuk Kim
- Department of Internal Medicine and Cardiovascular Center, Chosun University Hospital, University of Chosun College of Medicine, Gwangju, Republic of Korea
| | - Taek Kyu Park
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jeong Hoon Yang
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Young Bin Song
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Joo-Yong Hahn
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Seung-Hyuk Choi
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hyeon-Cheol Gwon
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Joo Myung Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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94
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Dąbrowski EJ, Kożuch M, Dobrzycki S. Left Main Coronary Artery Disease-Current Management and Future Perspectives. J Clin Med 2022; 11:jcm11195745. [PMID: 36233613 PMCID: PMC9573137 DOI: 10.3390/jcm11195745] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 09/22/2022] [Accepted: 09/26/2022] [Indexed: 02/05/2023] Open
Abstract
Due to its anatomical features, patients with an obstruction of the left main coronary artery (LMCA) have an increased risk of death. For years, coronary artery bypass grafting (CABG) has been considered as a gold standard for revascularization. However, notable advancements in the field of percutaneous coronary intervention (PCI) led to its acknowledgement as an important treatment alternative, especially in patients with low and intermediate anatomical complexity. Although recent years brought several random clinical trials that investigated the safety and efficacy of the percutaneous approach in LMCA, there are still uncertainties regarding optimal revascularization strategies. In this paper, we provide a comprehensive review of state-of-the-art diagnostic and treatment methods of LMCA disease, focusing on percutaneous methods.
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95
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Gallinoro E, Paolisso P, Di Gioia G, Bermpeis K, Fernandez-Peregrina E, Candreva A, Esposito G, Fabbricatore D, Bertolone DT, Bartunek J, Vanderheyden M, Wyffels E, Sonck J, Collet C, De Bruyne B, Barbato E. Deferral of Coronary Revascularization in Patients With Reduced Ejection Fraction Based on Physiological Assessment: Impact on Long-Term Survival. J Am Heart Assoc 2022; 11:e026656. [PMID: 36129045 DOI: 10.1161/jaha.122.026656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Deferring revascularization in patients with nonsignificant stenoses based on fractional flow reserve (FFR) is associated with favorable clinical outcomes up to 15 years. Whether this holds true in patients with reduced left ventricular ejection fraction is unclear. We aimed to investigate whether FFR provides adjunctive clinical benefit compared with coronary angiography in deferring revascularization of patients with intermediate coronary stenoses and reduced left ventricular ejection fraction. Methods and Results Consecutive patients with reduced left ventricular ejection fraction (≤50%) undergoing coronary angiography between 2002 and 2010 were screened. We included patients with at least 1 intermediate coronary stenosis (diameter stenosis ≥40%) in whom revascularization was deferred based either on angiography plus FFR (FFR guided) or angiography alone (angiography guided). The primary end point was the cumulative incidence of all-cause death at 10 years. The secondary end point (incidence of major adverse cardiovascular and cerebrovascular events) was a composite of all-cause death, myocardial infarction, any revascularization, and stroke. A total of 840 patients were included (206 in the FFR-guided group and 634 in the angiography-guided group). Median follow-up was 7 years (interquartile range, 3.22-11.08 years). After 1:1 propensity-score matching, baseline characteristics between the 2 groups were similar. All-cause death was significantly lower in the FFR-guided group compared with the angiography-guided group (94 [45.6%] versus 119 [57.8%]; hazard ratio [HR], 0.65 [95% CI, 0.49-0.85]; P<0.01). The rate of major adverse cardiovascular and cerebrovascular events was lower in the FFR-guided group (123 [59.7%] versus 139 [67.5%]; HR, 0.75 [95% CI, 0.59-0.95]; P=0.02). Conclusions In patients with reduced left ventricular ejection fraction, deferring revascularization of intermediate coronary stenoses based on FFR is associated with a lower incidence of death and major adverse cardiovascular and cerebrovascular events at 10 years.
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Affiliation(s)
- Emanuele Gallinoro
- Cardiovascular Center Aalst Onze Lieve Vrouwziekenhuis Hospital Aalst Belgium.,Department of Translational Medical Sciences University of Campania "Luigi Vanvitelli" Naples Italy
| | - Pasquale Paolisso
- Cardiovascular Center Aalst Onze Lieve Vrouwziekenhuis Hospital Aalst Belgium.,Department of Advanced Biomedical Sciences University of Naples Federico II Naples Italy
| | - Giuseppe Di Gioia
- Cardiovascular Center Aalst Onze Lieve Vrouwziekenhuis Hospital Aalst Belgium
| | | | | | - Alessandro Candreva
- Cardiovascular Center Aalst Onze Lieve Vrouwziekenhuis Hospital Aalst Belgium.,Department of Cardiology Zurich University Hospital Zurich Switzerland.,PoliToBIO Med Lab Department of Mechanical and Aerospace Engineering Politecnico di Torino Italy
| | - Giuseppe Esposito
- Cardiovascular Center Aalst Onze Lieve Vrouwziekenhuis Hospital Aalst Belgium.,Department of Advanced Biomedical Sciences University of Naples Federico II Naples Italy
| | - Davide Fabbricatore
- Cardiovascular Center Aalst Onze Lieve Vrouwziekenhuis Hospital Aalst Belgium.,Department of Advanced Biomedical Sciences University of Naples Federico II Naples Italy
| | - Dario Tino Bertolone
- Cardiovascular Center Aalst Onze Lieve Vrouwziekenhuis Hospital Aalst Belgium.,Department of Advanced Biomedical Sciences University of Naples Federico II Naples Italy
| | - Jozef Bartunek
- Cardiovascular Center Aalst Onze Lieve Vrouwziekenhuis Hospital Aalst Belgium
| | - Marc Vanderheyden
- Cardiovascular Center Aalst Onze Lieve Vrouwziekenhuis Hospital Aalst Belgium
| | - Eric Wyffels
- Cardiovascular Center Aalst Onze Lieve Vrouwziekenhuis Hospital Aalst Belgium
| | - Jeroen Sonck
- Cardiovascular Center Aalst Onze Lieve Vrouwziekenhuis Hospital Aalst Belgium
| | - Carlos Collet
- Cardiovascular Center Aalst Onze Lieve Vrouwziekenhuis Hospital Aalst Belgium
| | - Bernard De Bruyne
- Cardiovascular Center Aalst Onze Lieve Vrouwziekenhuis Hospital Aalst Belgium.,Department of Cardiology Lausanne University Hospital Lausanne Switzerland
| | - Emanuele Barbato
- Cardiovascular Center Aalst Onze Lieve Vrouwziekenhuis Hospital Aalst Belgium.,Department of Advanced Biomedical Sciences University of Naples Federico II Naples Italy
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96
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Lei Y, Zhang S, Li M, Wang J, Wang Y, Zhao L, Yan W, Chen M, Su Y, Yu J, Yu N, Dong T, Cao X, Yan L. The guiding value of hybrid resting full-cycle ratio and fractional flow reserve strategy for percutaneous coronary intervention in a Chinese real-world cohort with non-ST elevation acute coronary syndrome. Front Cardiovasc Med 2022; 9:991161. [PMID: 36158818 PMCID: PMC9505915 DOI: 10.3389/fcvm.2022.991161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 08/23/2022] [Indexed: 01/10/2023] Open
Abstract
Objective The study aimed to assess the correlation and agreement between resting full-cycle ratio (RFR) and fractional flow reserve (FFR), and evaluate the guiding value of a hybrid RFR-FFR strategy for percutaneous coronary intervention (PCI) in a Chinese real-world cohort with non-ST elevation acute coronary syndrome (NSTE-ACS). Materials and methods A total of 109 patients with NSTE-ACS (149 diseased vessels), who underwent an invasive physiological assessment in Cangzhou Central Hospital, Hebei Medical University, were prospectively enrolled from September 2021 to May 2022. FFR ≤ 0.80 was used as the gold standard for coronary artery functional ischemia. We utilized the Pearson correlation and Bland-Altman analysis to assess the correlation and agreement between RFR and FFR. The diagnostic value of RFR predicting FFR ≤ 0.80 was evaluated in accordance with the receiver operating characteristic (ROC) curve. The hybrid RFR-FFR strategy, which was established according to determining the “gray zone” of RFR (FFR was further assessed using vasodilators only for diseased vessels in the “gray zone”), needed to afford over 95% global agreement with the FFR-only strategy. Results Resting full-cycle ratio was significantly linearly linked with FFR (R2 = 0.636, P < 0.001). The accuracy, specificity, and sensitivity for RFR ≤ 0.89 predicting FFR ≤ 0.80 were 81.2, 70.8, and 86.1%, respectively. The area under the ROC curve for RFR predicting FFR ≤ 0.80 was 0.881 (P < 0.001), and the cutoff value was 0.90. The “gray zone” of RFR was 0.85–0.93. The positive and negative predictive values of the hybrid RFR-FFR strategy were 0.95 and 0.93, respectively. The hybrid RFR-FFR strategy exhibited an agreement of 96.0% with FFR and obviated the need for a vasodilator by 60.4%. Conclusion Resting full-cycle ratio and FFR have high correlation and consistency. The hybrid RFR-FFR strategy highlights considerably enhanced agreement with the FFR-only strategy, whilst making the requirement of vasodilator administration less than a half.
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97
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Wienemann H, Ameskamp C, Mejía-Rentería H, Mauri V, Hohmann C, Baldus S, Adam M, Escaned J, Halbach M. Diagnostic performance of quantitative flow ratio versus fractional flow reserve and resting full-cycle ratio in intermediate coronary lesions. Int J Cardiol 2022; 362:59-67. [PMID: 35662563 DOI: 10.1016/j.ijcard.2022.05.066] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 05/23/2022] [Accepted: 05/29/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Quantitative flow ratio (QFR) is a novel angiography-derived index aimed to assess the functional relevance of coronary stenoses without pressure wires and adenosine. Good diagnostic yield with the hyperemic fractional flow reserve (FFR) have been reported, while data on the comparison of QFR to non-hyperemic pressure ratios (NHPR) are scarce. METHODS In this retrospective, observational and single-center study with a large population representative of the real practice, we assessed and compared the diagnostic performance of contrast flow (cQFR) and fixed flow (fQFR) QFR against the NHPR resting full-cyle ratio (RFR) using FFR as reference standard. RESULTS A total of 626 lesions from 544 patients were investigated. Mean diameter stenosis, FFR, cQFR, fQFR and RFR were 44.8%, 0.842, 0.847, 0.857 and 0.912, respectively. The correlation between cQFR and FFR was stronger (r = 0.830, P < 0.001) compared to that between FFR and RFR (r = 0.777, P < 0.001) and between cQFR and RFR (r = 0.687, P < 0.001). Using FFR ≤0.80 as reference, the sensitivity, specificity, positive predictive value, negative predictive value, and overall diagnostic accuracy for cQFR were 82%, 95%, 87%, 92%, and 91%, respectively. cQFR displayed a higher area under the curve (AUC) than fQFR and RFR (0.938 vs. 0.891 vs. 0.869, P < 0.01). The good diagnostic yield of cQFR appeared to be maintained in different clinical subsets including female gender, aortic valve stenosis and atrial fibrillation, and in different anatomical subsets including focal and non-focal lesions. CONCLUSION cQFR has a high and better diagnostic performance than the NHPR RFR in predicting FFR-based functional significance of coronary stenoses.
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Affiliation(s)
- Hendrik Wienemann
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, Kerpener Str. 61, 50937 Cologne, Germany
| | - Christopher Ameskamp
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, Kerpener Str. 61, 50937 Cologne, Germany
| | - Hernán Mejía-Rentería
- Department of Cardiology, Hospital Clínico San Carlos IDISSC and Universidad Complutense de Madrid, Madrid, Spain
| | - Victor Mauri
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, Kerpener Str. 61, 50937 Cologne, Germany
| | - Christopher Hohmann
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, Kerpener Str. 61, 50937 Cologne, Germany
| | - Stephan Baldus
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, Kerpener Str. 61, 50937 Cologne, Germany
| | - Matti Adam
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, Kerpener Str. 61, 50937 Cologne, Germany
| | - Javier Escaned
- Department of Cardiology, Hospital Clínico San Carlos IDISSC and Universidad Complutense de Madrid, Madrid, Spain
| | - Marcel Halbach
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, Kerpener Str. 61, 50937 Cologne, Germany.
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98
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Alalawi LH, Dookhan CM, Verghese D, Manubolu VS, Aldana-Bitar J, Lakshmanan S, Ahmad K, Shafter A, Alchokhachi Z, Ghanem A, Golub IS, Budoff M, Roy S. Assessment of left main coronary artery disease: a comparison between invasive and noninvasive. Coron Artery Dis 2022; 33:490-498. [PMID: 35757932 DOI: 10.1097/mca.0000000000001154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Left main coronary artery disease has significant therapeutic as well as prognostic implications. The presence of left main coronary artery stenosis is strongly associated with poor short- and long-term prognoses. Accurate identification of left main stenosis is extremely important since it would be the main factor to guide management. There are several modalities used to determine the presence of atherosclerosis and the degree of stenosis in a left main coronary artery. Newer modalities allow for an accurate evaluation of left main stenosis and atherosclerosis. In this review, we go through different invasive and noninvasive modalities to diagnose left main stenosis, shedding more light into coronary computed tomography angiography, and its accuracy in this specific diagnosis.
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Affiliation(s)
- Luay H Alalawi
- The Lundquist Institute, Harbor-UCLA Medical Center, Torrance, California
| | - Christina M Dookhan
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Dhiran Verghese
- The Lundquist Institute, Harbor-UCLA Medical Center, Torrance, California
| | - Venkat S Manubolu
- The Lundquist Institute, Harbor-UCLA Medical Center, Torrance, California
| | - Jairo Aldana-Bitar
- The Lundquist Institute, Harbor-UCLA Medical Center, Torrance, California
| | | | - Khadije Ahmad
- The Lundquist Institute, Harbor-UCLA Medical Center, Torrance, California
| | - Ahmad Shafter
- The Lundquist Institute, Harbor-UCLA Medical Center, Torrance, California
| | - Zahra Alchokhachi
- The Lundquist Institute, Harbor-UCLA Medical Center, Torrance, California
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ahmed Ghanem
- The Lundquist Institute, Harbor-UCLA Medical Center, Torrance, California
| | - Ilana S Golub
- The Lundquist Institute, Harbor-UCLA Medical Center, Torrance, California
| | - Matthew Budoff
- The Lundquist Institute, Harbor-UCLA Medical Center, Torrance, California
| | - Sion Roy
- The Lundquist Institute, Harbor-UCLA Medical Center, Torrance, California
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99
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Impact of Coronary Artery Disease on the Myocardium: Importance of Ischemia, Infarction, and Contractility. JACC Cardiovasc Imaging 2022; 15:1423-1426. [PMID: 35926900 DOI: 10.1016/j.jcmg.2022.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 05/23/2022] [Indexed: 11/20/2022]
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100
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Coerkamp CF, Hoogewerf M, van Putte BP, Appelman Y, Doevendans PA. Revascularization strategies for patients with established chronic coronary syndrome. Eur J Clin Invest 2022; 52:e13787. [PMID: 35403216 PMCID: PMC9539712 DOI: 10.1111/eci.13787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 04/03/2022] [Accepted: 04/04/2022] [Indexed: 11/28/2022]
Abstract
Coronary artery disease is the most common type of cardiovascular disease, leading to high mortality rates worldwide. Although the vast majority can be treated effectively and safely by medical therapy, revascularization strategies remain essential for numerous patients. Outcomes of both percutaneous coronary intervention and coronary artery bypass grafting improve in a rapid pace, resulting from technical innovation and ongoing research. Progress has been achieved by technical improvements in coronary stents, optimal coronary target and graft selection, and the availability of minimally invasive surgical strategies. Besides technical progress, evidence-based patient-tailored decision-making by the Heart Team is the basic precondition for optimal outcome. The combination of fast innovation and long-term clinical evaluations creates a dynamic field. Research outcomes should be carefully interpreted according to the techniques used and the trial's design. Therefore, more and more trial outcomes suggest that revascularization strategies should be tailored towards the specific patient. Although the European Society of Cardiology/European Association for Cardio-Thoracic Surgery guidelines on myocardial revascularization date from 2018 and a large variety of trial outcomes on revascularization strategies in chronic coronary syndrome have been published since, we aim to provide an updated overview within this review.
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Affiliation(s)
- Casper F. Coerkamp
- Department of Cardiology, Amsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Marieke Hoogewerf
- Department of Cardiothoracic SurgerySt. Antonius HospitalNieuwegeinThe Netherlands
- Department of CardiologyUniversity Medical Centre UtrechtUtrechtThe Netherlands
| | - Bart P. van Putte
- Department of Cardiothoracic SurgerySt. Antonius HospitalNieuwegeinThe Netherlands
| | - Yolande Appelman
- Department of CardiologyAmsterdam UMCAmsterdam Cardiovascular SciencesUniversity of AmsterdamAmsterdamThe Netherlands
| | - Pieter A. Doevendans
- Department of CardiologyUniversity Medical Centre UtrechtUtrechtThe Netherlands
- Netherlands Heart InstituteUtrechtThe Netherlands
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