151
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Schindler TH. Myocardial blood flow: Putting it into clinical perspective. J Nucl Cardiol 2016; 23:1056-1071. [PMID: 26711100 DOI: 10.1007/s12350-015-0372-4] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 12/01/2015] [Indexed: 01/19/2023]
Abstract
In recent years, positron emission tomography/computed tomography (PET/CT)-determined myocardial perfusion in conjunction with myocardial blood flow (MBF) quantification in mL·g(-1)·min(-1) has emerged from mere research application to initial clinical use in the detection and characterization of the coronary artery disease (CAD) process. The concurrent evaluation of MBF during vasomotor stress and at rest with the resulting myocardial flow reserve (MFR = MBF during stress/MBF at rest) expands the scope of conventional myocardial perfusion imaging not only to the detection of the most advanced and culprit CAD, as evidenced by the stress-related regional myocardial perfusion defect, but also to the less severe or intermediate stenosis in patients with multivessel CAD. Due to the non-specific nature of the hyperemic MBF and MFR, the interpretation of hyperemic flow increases with PET/CT necessitates an appropriate placement in the context with microvascular function, wall motion analysis, and eventually underlying coronary morphology in CAD patients. This review aims to provide a comprehensive overview of various diagnostic scenarios of PET/CT-determined myocardial perfusion and flow quantification in the detection and characterization of clinically manifest CAD.
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Affiliation(s)
- Thomas Hellmut Schindler
- Division of Nuclear Medicine, Cardiovascular Nuclear Medicine, Department of Radiology and Radiological Science SOM, Johns Hopkins University School of Medicine, JHOC 3225, 601 N. Caroline Street, Baltimore, MD, 21287, USA.
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152
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Affiliation(s)
- William Wijns
- From Lambe Institute for Translational Medicine and Curam, National University of Ireland, Galway, and Saolta University Healthcare Group, Galway, Ireland (W.W.); Cardiovascular Research Center Aalst, Belgium (W.W.); and Medizinische Klinik II, Klinikum Coburg, Coburg, Germany (S.A.P.)
| | - Stylianos A. Pyxaras
- From Lambe Institute for Translational Medicine and Curam, National University of Ireland, Galway, and Saolta University Healthcare Group, Galway, Ireland (W.W.); Cardiovascular Research Center Aalst, Belgium (W.W.); and Medizinische Klinik II, Klinikum Coburg, Coburg, Germany (S.A.P.)
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153
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Wolfrum M, Fahrni G, de Maria GL, Knapp G, Curzen N, Kharbanda RK, Fröhlich GM, Banning AP. Impact of impaired fractional flow reserve after coronary interventions on outcomes: a systematic review and meta-analysis. BMC Cardiovasc Disord 2016; 16:177. [PMID: 27608682 PMCID: PMC5017064 DOI: 10.1186/s12872-016-0355-7] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Accepted: 08/26/2016] [Indexed: 12/26/2022] Open
Abstract
Background FFR is routinely used to guide percutaneous coronary interventions (PCI). Visual assessment of the angiographic result after PCI has limited efficacy. Even when the angiographic result seems satisfactory FFR after a PCI might be useful for identifying patients with a suboptimal interventional result and higher risk for poor clinical outcome who might benefit from additional procedures. The aim of this meta-analysis was to investigate available data of studies that examined clinical outcomes of patients with impaired vs. satisfactory fractional flow reserve (FFR) after percutaneous coronary interventions (PCI). Methods This meta-analysis was carried out according to the Cochrane Handbook for Systematic Reviews. The Mantel-Haenszel method using the fixed-effect meta-analysis model was used for combining the results. Studies were identified by searching the literature through mid-January, 2016, using the following search terms: fractional flow reserve, coronary circulation, after, percutaneous coronary intervention, balloon angioplasty, stent implantation, and stenting. Primary endpoint was the rate of major adverse cardiac events (MACE). Secondary endpoints included rates of death, myocardial infarction (MI), repeated revascularisation. Results Eight relevant studies were found including a total of 1337 patients. Of those, 492 (36.8 %) had an impaired FFR after PCI, and 853 (63.2 %) had a satisfactory FFR after PCI. Odds ratios indicated that a low FFR following PCI was associated with an impaired outcome: major adverse cardiac events (MACE, OR: 4.95, 95 % confidence interval [CI]: 3.39–7.22, p <0.001); death (OR: 3.23, 95 % CI: 1.19–8.76, p = 0.022); myocardial infarction (OR: 13.83, 95 % CI: 4.75–40.24, p <0.0001) and repeated revascularisation (OR: 4.42, 95 % CI: 2.73–7.15, p <0.0001). Conclusions Compared to a satisfactory FFR, a persistently low FFR following PCI is associated with a worse clinical outcome. Prospective studies are needed to identify underlying causes, determine an optimal threshold for post-PCI FFR, and clarify whether simple additional procedures can influence the post-PCI FFR and clinical outcome. Electronic supplementary material The online version of this article (doi:10.1186/s12872-016-0355-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Mathias Wolfrum
- Oxford Heart Centre, Oxford University Hospitals, Headley Way, Oxford, OX39DU, UK
| | - Gregor Fahrni
- Oxford Heart Centre, Oxford University Hospitals, Headley Way, Oxford, OX39DU, UK
| | | | - Guido Knapp
- Department of Statistics, TU University Dortmund, Dortmund, Germany
| | - Nick Curzen
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Rajesh K Kharbanda
- Oxford Heart Centre, Oxford University Hospitals, Headley Way, Oxford, OX39DU, UK
| | - Georg M Fröhlich
- Department of Cardiology, Charité Universitätsmedizin Berlin (Campus Benjamin Franklin), Berlin, Germany
| | - Adrian P Banning
- Oxford Heart Centre, Oxford University Hospitals, Headley Way, Oxford, OX39DU, UK.
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154
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Pyxaras SA, Toth GG, Di Gioia G, Ughi GJ, Tu S, Rusinaru D, Adriaenssens T, Reiber JH, Leon MB, Bax JJ, Wijns W. Anatomical and functional assessment of Tryton bifurcation stent before and after final kissing balloon dilatation: Evaluations by three-dimensional coronary angiography, optical coherence tomography imaging and fractional flow reserve. Catheter Cardiovasc Interv 2016; 90:E1-E10. [DOI: 10.1002/ccd.26777] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Revised: 07/28/2016] [Accepted: 08/07/2016] [Indexed: 11/08/2022]
Affiliation(s)
- Stylianos A. Pyxaras
- Cardiovascular Research Center Aalst, OLV Clinic; Aalst Belgium
- II. Medizinische Klinik, Klinikum Coburg; Coburg Germany
| | - Gabor G. Toth
- Cardiovascular Research Center Aalst, OLV Clinic; Aalst Belgium
- Department of Cardiology; University Heart Centre, Graz; Austria
| | | | - Giovanni J. Ughi
- Department of Cardiovascular Medicine; University Hospitals Leuven, KU Leuven; Leuven Belgium
| | - Shengxian Tu
- School of Biomedical Engineering; Shanghai Jiao Tong University; Shanghai China
| | - Dan Rusinaru
- Cardiovascular Research Center Aalst, OLV Clinic; Aalst Belgium
| | - Tom Adriaenssens
- Department of Cardiovascular Medicine; University Hospitals Leuven, KU Leuven; Leuven Belgium
| | - Johan H.C. Reiber
- Division of Image Processing, Department of Radiology; Leiden University Medical Center; Leiden The Netherlands
| | - Martin B. Leon
- Center for Interventional Vascular Therapy, Columbia University Medical Center, New York Presbyterian Hospital; New York New York
| | - Jeroen J. Bax
- Department of Cardiology, Heart & Lung Centrum, Leiden University Medical Center; Leiden The Netherlands
| | - William Wijns
- Cardiovascular Research Center Aalst, OLV Clinic; Aalst Belgium
- The Lambe Institute for Translational Medicine and Curam, National University of Ireland, Galway and Saolta University Healthcare Group; Galway Ireland
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155
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Sarapultsev PA, Sarapultsev AP. Stress cardiomyopathy: Is it limited to Takotsubo syndrome? Problems of definition. Int J Cardiol 2016; 221:698-718. [PMID: 27424315 DOI: 10.1016/j.ijcard.2016.07.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 07/04/2016] [Indexed: 02/09/2023]
Abstract
In 2006, Takotsubo syndrome (TTC) was described as a distinct type of stress-induced cardiomyopathy (stress cardiomyopathy). However, when thinking about Takotsubo cardiomyopathy from the viewpoints of the AHA and ESC classifications, 2 possible problems may arise. The first potential problem is that a forecast of disease outcome is lacking in the ESC classification, whereas the AHA only states that 'outcome is favorable with appropriate medical therapy'. However, based on the literature data, one can make a general conclusion that occurrence of myocardial lesions in TTC (i.e., myocardial fibrosis and contraction-band necrosis) causes the same effects as in other diseases with similar levels of myocardial damage and should not be considered to have a lesser impact on mortality. To summarise, TTC can cause not only severe complications such as pulmonary oedema, cardiogenic shock, and dangerous ventricular arrhythmias, but also damage to the myocardium, which can result in the development of potentially fatal conditions even after the disappearance of LV apical ballooning. The second potential problem arises from the definition of TTC as a stress cardiomyopathy in the AHA classification. In fact, the main factors leading to TTC are stress and microvascular anginas, since, as has been already discussed, coronary spasm can cause myocardium stunning, resulting in persistent apical ballooning. Thus, based on this review, 3 distinct types of stress cardiomyopathies exist (variant angina, microvascular angina, and TTC), with poor prognosis. Adding these diseases to the classification of cardiomyopathies will facilitate diagnosis and preventive prolonged treatment, which should include intensive anti-stress therapy.
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Affiliation(s)
- Petr A Sarapultsev
- Federal State Autonomous Educational Institution of Higher Professional Education, Ural Federal University named after the first President of Russia B. N. Yeltsin, Russia; Institute of Immunology and Physiology of the Ural Branch of the RAS, Russia
| | - Alexey P Sarapultsev
- Federal State Autonomous Educational Institution of Higher Professional Education, Ural Federal University named after the first President of Russia B. N. Yeltsin, Russia; Institute of Immunology and Physiology of the Ural Branch of the RAS, Russia.
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156
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Abu Sharar H, Wohlleben D, Vafaie M, Kristen AV, Volz HC, Bekeredjian R, Katus HA, Giannitsis E. Coronary angiography-related myocardial injury as detected by high-sensitivity cardiac troponin T assay. EUROINTERVENTION 2016; 12:337-44. [PMID: 27320428 DOI: 10.4244/eijv12i3a54] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS We sought to evaluate rates and mechanisms of myocardial injury and type 4a myocardial infarction (MI) after an elective diagnostic coronary angiography (CAG) as detected by high-sensitivity cardiac troponin T (hsTnT) assay. METHODS AND RESULTS Cardiac troponin concentrations were measured in consecutive patients before and after undergoing an elective CAG -with or without coronary intervention (PCI)- using an hsTnT assay. The study population consisted of 545 patients: 320 (58.7%) patients received only an elective CAG and another 225 patients (41.3%) received an additional PCI. Significant hsTnT increases occurred in 97 (30.3%) cases within the CAG group and in 152 (67.6%) cases within the PCI group. Rates of normal baseline hsTnT values (<99th percentile upper reference limit) were 75.9% in the CAG group and 71.6% in the PCI group. In cases with normal baseline hsTnT values, peak levels meeting criteria of MI type 4a according to the second or third version of the universal MI definition were observed in five (1.6%) and one (0.3%) cases within the CAG group, as well as in 32 (14.2%) and 22 (9.8%) cases within the PCI group, respectively. CONCLUSIONS Use of the hsTnT assay may allow identification of myocardial injury during an uneventful diagnostic coronary angiography in the absence of any coronary or non-coronary interventions.
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Affiliation(s)
- Haitham Abu Sharar
- Department of Cardiology, Heidelberg University Hospital, Heidelberg, Germany
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157
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Mynard JP, Smolich JJ. Influence of anatomical dominance and hypertension on coronary conduit arterial and microcirculatory flow patterns: a multiscale modeling study. Am J Physiol Heart Circ Physiol 2016; 311:H11-23. [PMID: 27199135 DOI: 10.1152/ajpheart.00997.2015] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 04/26/2016] [Indexed: 11/22/2022]
Abstract
Coronary hemodynamics are known to be affected by intravascular and extravascular factors that vary regionally and transmurally between the perfusion territories of left and right coronary arteries. However, despite clinical evidence that left coronary arterial dominance portends greater cardiovascular risk, relatively little is known about the effects of left or right dominance on regional conduit arterial and microcirculatory blood flow patterns, particularly in the presence of systemic or pulmonary hypertension. We addressed this issue using a multiscale numerical model of the human coronary circulation situated in a closed-loop cardiovascular model. The coronary model represented left or right dominant anatomies and accounted for transmural and regional differences in vascular properties and extravascular compression. Regional coronary flow dynamics of the two anatomical variants were compared under normotensive conditions, raised systemic or pulmonary pressures with maintained flow demand, and after accounting for adaptations known to occur in acute and chronic hypertensive states. Key findings were that 1) right coronary arterial flow patterns were strongly influenced by dominance and systemic/pulmonary hypertension; 2) dominance had minor effects on left coronary arterial and all microvascular flow patterns (aside from mean circumflex flow); 3) although systemic hypertension favorably increased perfusion pressure, this benefit varied regionally and transmurally and was offset by increased left ventricular and septal flow demands; and 4) pulmonary hypertension had a substantial negative effect on right ventricular and septal flows, which was exacerbated by greater metabolic demands. These findings highlight the importance of interactions between coronary arterial dominance and hypertension in modulating coronary hemodynamics.
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Affiliation(s)
- Jonathan P Mynard
- Heart Research, Clinical Sciences, Murdoch Childrens Research Institute, Parkville, Victoria, Australia; and Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
| | - Joseph J Smolich
- Heart Research, Clinical Sciences, Murdoch Childrens Research Institute, Parkville, Victoria, Australia; and Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
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158
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Adiputra Y, Chen SL. Clinical Relevance of Coronary Fractional Flow Reserve: Art-of-state. Chin Med J (Engl) 2016; 128:1399-406. [PMID: 25963364 PMCID: PMC4830323 DOI: 10.4103/0366-6999.156805] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Objective: The objective was to delineate the current knowledge of fractional flow reserve (FFR) in terms of definition, features, clinical applications, and pitfalls of measurement of FFR. Data Sources: We searched database for primary studies published in English. The database of National Library of Medicine (NLM), MEDLINE, and PubMed up to July 2014 was used to conduct a search using the keyword term “FFR”. Study Selection: The articles about the definition, features, clinical application, and pitfalls of measurement of FFR were identified, retrieved, and reviewed. Results: Coronary pressure-derived FFR rapidly assesses the hemodynamic significance of individual coronary artery lesions and can readily be performed in the catheterization laboratory. The use of FFR has been shown to effectively guide coronary revascularization procedures leading to improved patient outcomes. Conclusions: FFR is a valuable tool to determine the functional significance of coronary stenosis. It combines physiological and anatomical information, and can be followed immediately by percutaneous coronary intervention (PCI) if necessary. The technique of FFR measurement can be performed easily, rapidly, and safely in the catheterization laboratory. By systematic use of FFR in dubious stenosis and multi-vessel disease, PCI can be made an even more effective and better treatment than it is currently. The current clinical evidence for FFR should encourage cardiologists to use this tool in the catheterization laboratory.
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Affiliation(s)
| | - Shao-Liang Chen
- Department of Cardiology, Nanjing First Hospital of Nanjing Medical University, Nanjing, Jiangsu 210006, China
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159
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Parikh V, Agnihotri K, Kadavath S, Patel NJ, Abbott JD. Clinical Application of Fractional Flow Reserve-Guided Percutaneous Coronary Intervention for Stable Coronary Artery Disease. Curr Cardiol Rep 2016; 18:32. [PMID: 26915010 DOI: 10.1007/s11886-016-0711-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Revascularization in stable ischemic heart disease (SIHD) is indicated in patients on optimal medical therapy with angina and/or demonstrable ischemia and a significant stenosis in one or more epicardial coronary arteries. Angiography alone, however, cannot accurately determine the hemodynamic significance of coronary lesions, particularly those of intermediate stenosis severity. A lesion may appear significant on coronary angiogram but may not have functional significance. Percutaneous coronary intervention (PCI) of functionally insignificant coronary artery lesions may have serious consequences; therefore, judicious decision-making in the cardiac catheterization laboratory is indicated. For this reason, it is becoming increasingly important to show that a stenosis is capable to induce myocardial ischemia prior to intervention. Fractional flow reserve (FFR) has emerged as a useful tool for this purpose. In this review, we will briefly discuss the principle of FFR, current evidence and rationale supporting its use, and comparison with other modalities.
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Affiliation(s)
- Valay Parikh
- Staten Island University Hospital, 475 Seaview Ave, Staten Island, NY, 10305, USA.
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160
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Differences in coronary artery blood velocities in the setting of normal coronary angiography and normal stress echocardiography. Heart Int 2016; 10:e6-e11. [PMID: 27672435 PMCID: PMC4946382 DOI: 10.5301/heartint.5000221] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2015] [Indexed: 12/13/2022] Open
Abstract
Background Normal left anterior descending (LAD) coronary artery as determined by coronary angiography is considered not only to reflect normal angiography but also to correlate with normal anatomy and function. However, subjects who undergo coronary angiography may differ from those who do not need to have invasive evaluation even if their functional noninvasive studies like dobutamine stress echocardiography (DSE) were normal. Aim LAD velocities in subjects with normal angiography and those with normal DSE are equal. Methods A total of 244 subjects were evaluated, 78 had normal LAD by angiography and 166 had normal LAD by DSE. All had Doppler sampling of LAD velocities by transthoracic echocardiography. Results Velocity was higher in the angiographic subgroup in diastole 41 ± 23 vs 33 ± 14 cm/s, p = 0.0078; systole 18 ± 14 vs 13 ± 7 cm/s, p = 0.012; diastolic integral 12.6 ± 5 vs 9.8 ± 3.8 cm, p = 3.15 × 10-5; systolic velocity integral 4 ± 2.9 vs 2.8 ± 1.9, p = 0.0014. While heart rate was similar in both groups, the product of diastolic velocity integral and heart rate of the LAD in the angiographic group was higher: 902 ± 450 vs 656 ± 394, p = 0.00599. Diastolic velocity deceleration time was similar in both groups. Coronary flow reserve defined as diastolic velocity ratio before and immediately after DSE correlated negatively with baseline velocity, r = -0.4. Conclusions Mode of defining normality of coronary artery affects velocity behavior of the vessel, reflecting functional differences possibly related to microvasculature and vasodilatation.
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161
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Adjedj J, De Bruyne B, Floré V, Di Gioia G, Ferrara A, Pellicano M, Toth GG, Bartunek J, Vanderheyden M, Heyndrickx GR, Wijns W, Barbato E. Significance of Intermediate Values of Fractional Flow Reserve in Patients With Coronary Artery Disease. Circulation 2016; 133:502-8. [DOI: 10.1161/circulationaha.115.018747] [Citation(s) in RCA: 92] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Accepted: 12/21/2015] [Indexed: 11/16/2022]
Affiliation(s)
- Julien Adjedj
- From Cardiovascular Research Center Aalst OLV Clinic, Aalst, Belgium (J.A., B.D.B., V.F., G.D.G., A.F., M.P., G.G.T., J.B., M.V., G.R.H., W.W., E.B.); Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II, Italy (G.D.G., M.P., E.B.); and University Heart Centre Graz, Medical University Graz, Austria (G.G.T.)
| | - Bernard De Bruyne
- From Cardiovascular Research Center Aalst OLV Clinic, Aalst, Belgium (J.A., B.D.B., V.F., G.D.G., A.F., M.P., G.G.T., J.B., M.V., G.R.H., W.W., E.B.); Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II, Italy (G.D.G., M.P., E.B.); and University Heart Centre Graz, Medical University Graz, Austria (G.G.T.)
| | - Vincent Floré
- From Cardiovascular Research Center Aalst OLV Clinic, Aalst, Belgium (J.A., B.D.B., V.F., G.D.G., A.F., M.P., G.G.T., J.B., M.V., G.R.H., W.W., E.B.); Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II, Italy (G.D.G., M.P., E.B.); and University Heart Centre Graz, Medical University Graz, Austria (G.G.T.)
| | - Giuseppe Di Gioia
- From Cardiovascular Research Center Aalst OLV Clinic, Aalst, Belgium (J.A., B.D.B., V.F., G.D.G., A.F., M.P., G.G.T., J.B., M.V., G.R.H., W.W., E.B.); Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II, Italy (G.D.G., M.P., E.B.); and University Heart Centre Graz, Medical University Graz, Austria (G.G.T.)
| | - Angela Ferrara
- From Cardiovascular Research Center Aalst OLV Clinic, Aalst, Belgium (J.A., B.D.B., V.F., G.D.G., A.F., M.P., G.G.T., J.B., M.V., G.R.H., W.W., E.B.); Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II, Italy (G.D.G., M.P., E.B.); and University Heart Centre Graz, Medical University Graz, Austria (G.G.T.)
| | - Mariano Pellicano
- From Cardiovascular Research Center Aalst OLV Clinic, Aalst, Belgium (J.A., B.D.B., V.F., G.D.G., A.F., M.P., G.G.T., J.B., M.V., G.R.H., W.W., E.B.); Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II, Italy (G.D.G., M.P., E.B.); and University Heart Centre Graz, Medical University Graz, Austria (G.G.T.)
| | - Gabor G. Toth
- From Cardiovascular Research Center Aalst OLV Clinic, Aalst, Belgium (J.A., B.D.B., V.F., G.D.G., A.F., M.P., G.G.T., J.B., M.V., G.R.H., W.W., E.B.); Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II, Italy (G.D.G., M.P., E.B.); and University Heart Centre Graz, Medical University Graz, Austria (G.G.T.)
| | - Jozef Bartunek
- From Cardiovascular Research Center Aalst OLV Clinic, Aalst, Belgium (J.A., B.D.B., V.F., G.D.G., A.F., M.P., G.G.T., J.B., M.V., G.R.H., W.W., E.B.); Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II, Italy (G.D.G., M.P., E.B.); and University Heart Centre Graz, Medical University Graz, Austria (G.G.T.)
| | - Marc Vanderheyden
- From Cardiovascular Research Center Aalst OLV Clinic, Aalst, Belgium (J.A., B.D.B., V.F., G.D.G., A.F., M.P., G.G.T., J.B., M.V., G.R.H., W.W., E.B.); Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II, Italy (G.D.G., M.P., E.B.); and University Heart Centre Graz, Medical University Graz, Austria (G.G.T.)
| | - Guy R. Heyndrickx
- From Cardiovascular Research Center Aalst OLV Clinic, Aalst, Belgium (J.A., B.D.B., V.F., G.D.G., A.F., M.P., G.G.T., J.B., M.V., G.R.H., W.W., E.B.); Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II, Italy (G.D.G., M.P., E.B.); and University Heart Centre Graz, Medical University Graz, Austria (G.G.T.)
| | - William Wijns
- From Cardiovascular Research Center Aalst OLV Clinic, Aalst, Belgium (J.A., B.D.B., V.F., G.D.G., A.F., M.P., G.G.T., J.B., M.V., G.R.H., W.W., E.B.); Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II, Italy (G.D.G., M.P., E.B.); and University Heart Centre Graz, Medical University Graz, Austria (G.G.T.)
| | - Emanuele Barbato
- From Cardiovascular Research Center Aalst OLV Clinic, Aalst, Belgium (J.A., B.D.B., V.F., G.D.G., A.F., M.P., G.G.T., J.B., M.V., G.R.H., W.W., E.B.); Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II, Italy (G.D.G., M.P., E.B.); and University Heart Centre Graz, Medical University Graz, Austria (G.G.T.)
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Cheruvu C, Naoum C, Blanke P, Norgaard B, Leipsic J. Beyond Stenosis With Fractional Flow Reserve Via Computed Tomography and Advanced Plaque Analyses for the Diagnosis of Lesion-Specific Ischemia. Can J Cardiol 2016; 32:1315.e1-1315.e9. [PMID: 27032888 DOI: 10.1016/j.cjca.2016.01.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2015] [Revised: 12/14/2015] [Accepted: 01/04/2016] [Indexed: 12/24/2022] Open
Abstract
In the treatment of stable coronary artery disease (CAD), the determination of stenosis severity by invasive coronary angiography (ICA) is a critical procedure, and for borderline lesions, the detection of ischemia through invasive fractional flow reserve (FFR) is the gold standard. With advances in computational fluid dynamics, FFR can now be calculated noninvasively using anatomic data from coronary computed tomographic angiography (CCTA). This technique is known as FFRCT. The purpose of this review is to summarize the science of FFRCT, describe its diagnostic accuracy, discuss its clinical and economic impact, and elucidate factors beyond stenosis severity that may mechanistically relate to lesion-specific ischemia. These factors include adverse atherosclerotic plaque characteristics such as positive remodelling, low-attenuation plaque, and spotty calcification, as well as aggregate plaque volume. These factors can be appreciated noninvasively by CCTA but not by ICA. The diagnostic accuracy of FFRCT, compared with the gold standard of FFR, has been validated in 3 prospective multicentre blinded core laboratory-controlled trials, and as a result FFRCT has been approved by the US Food and Drug Administration for clinical use. FFRCT has also been shown in a clinical utility trial to better identify patients without obstructive CAD when compared with standard noninvasive assessment of stable CAD, thereby avoiding unnecessary angiograms. In addition, the use of FFRCT has been shown to allow for a significant cost savings compared with traditional care. It is therefore important for cardiologists to appreciate the value of this important new methodology.
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Affiliation(s)
- Chaitu Cheruvu
- Department of Radiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Christopher Naoum
- Department of Radiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Philipp Blanke
- Department of Radiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Bjarne Norgaard
- Department of Cardiology, Aarhus University Hospital, Aarhus Skejby, Denmark
| | - Jonathon Leipsic
- Department of Medicine and Radiology, University of British Columbia, Vancouver, British Columbia, Canada.
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Smolich JJ, Mynard JP. A step toward clinically applicable noninvasive coronary wave intensity analysis. Am J Physiol Heart Circ Physiol 2016; 310:H525-7. [PMID: 26825516 DOI: 10.1152/ajpheart.00014.2016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Joseph J Smolich
- Heart Research, Clinical Sciences, Murdoch Childrens Research Institute and Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Jonathan P Mynard
- Heart Research, Clinical Sciences, Murdoch Childrens Research Institute and Department of Paediatrics, University of Melbourne, Melbourne, Australia
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164
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Iliescu CA, Grines CL, Herrmann J, Yang EH, Cilingiroglu M, Charitakis K, Hakeem A, Toutouzas KP, Leesar MA, Marmagkiolis K. SCAI Expert consensus statement: Evaluation, management, and special considerations of cardio-oncology patients in the cardiac catheterization laboratory (endorsed by the cardiological society of india, and sociedad Latino Americana de Cardiologıa intervencionista). Catheter Cardiovasc Interv 2016; 87:E202-23. [PMID: 26756277 DOI: 10.1002/ccd.26379] [Citation(s) in RCA: 127] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Accepted: 11/28/2015] [Indexed: 12/24/2022]
Abstract
In the United States alone, there are currently approximately 14.5 million cancer survivors, and this number is expected to increase to 20 million by 2020. Cancer therapies can cause significant injury to the vasculature, resulting in angina, acute coronary syndromes (ACS), stroke, critical limb ischemia, arrhythmias, and heart failure, independently from the direct myocardial or pericardial damage from the malignancy itself. Consequently, the need for invasive evaluation and management in the cardiac catheterization laboratory (CCL) for such patients has been increasing. In recognition of the need for a document on special considerations for cancer patients in the CCL, the Society for Cardiovascular Angiography and Interventions (SCAI) commissioned a consensus group to provide recommendations based on the published medical literature and on the expertise of operators with accumulated experience in the cardiac catheterization of cancer patients.
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Affiliation(s)
- Cezar A Iliescu
- MD Anderson Cancer Center, University of Texas, Houston, Texas
| | - Cindy L Grines
- Detroit Medical Center, Cardiovascular Institute, Detroit, Michigan
| | - Joerg Herrmann
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Eric H Yang
- Division of Cardiology, University of California at Los Angeles, Los Angeles, California
| | - Mehmet Cilingiroglu
- School of Medicine, Arkansas Heart Hospital, Little Rock, Arkansas.,Department of Cardiology, Koc University, Istanbul, Turkey
| | | | - Abdul Hakeem
- Department of Cardiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | | | - Massoud A Leesar
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Alabama
| | - Konstantinos Marmagkiolis
- Department of Cardiology, Citizens Memorial Hospital, Bolivar, Missouri.,Department of Medicine, University of Missouri, Columbia, Missouri
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165
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Jin H, Yun H, Ma J, Chen Z, Chang S, Zeng M. Coronary Microembolization with Normal Epicardial Coronary Arteries and No Visible Infarcts on Nitrobluetetrazolium Chloride-Stained Specimens: Evaluation with Cardiac Magnetic Resonance Imaging in a Swine Model. Korean J Radiol 2016; 17:83-92. [PMID: 26798220 PMCID: PMC4720817 DOI: 10.3348/kjr.2016.17.1.83] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 10/15/2015] [Indexed: 01/16/2023] Open
Abstract
Objective To assess magnetic resonance imaging (MRI) features of coronary microembolization in a swine model induced by small-sized microemboli, which may cause microinfarcts invisible to the naked eye. Materials and Methods Eleven pigs underwent intracoronary injection of small-sized microspheres (42 µm) and catheter coronary angiography was obtained before and after microembolization. Cardiac MRI and measurement of cardiac troponin T (cTnT) were performed at baseline, 6 hours, and 1 week after microembolization. Postmortem evaluation was performed after completion of the imaging studies. Results Coronary angiography pre- and post-microembolization revealed normal epicardial coronary arteries. Systolic wall thickening of the microembolized regions decreased significantly from 42.6 ± 2.0% at baseline to 20.3 ± 2.3% at 6 hours and 31.5 ± 2.1% at 1 week after coronary microembolization (p < 0.001 for both). First-pass perfusion defect was visualized at 6 hours but the extent was largely decreased at 1 week. Delayed contrast enhancement MRI (DE-MRI) demonstrated hyperenhancement within the target area at 6 hours but not at 1 week. The microinfarcts on gross specimen stained with nitrobluetetrazolium chloride were invisible to the naked eye and only detectable microscopically. Increased cTnT was observed at 6 hours and 1 week after microembolization. Conclusion Coronary microembolization induced by a certain load of small-sized microemboli may result in microinfarcts invisible to the naked eye with normal epicardial coronary arteries. MRI features of myocardial impairment secondary to such microembolization include the decline in left ventricular function and myocardial perfusion at cine and first-pass perfusion imaging, and transient hyperenhancement at DE-MRI.
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Affiliation(s)
- Hang Jin
- Department of Radiology, Zhongshan Hospital, Fudan University and Shanghai Institute of Medical Imaging, Shanghai 200032, China.; Department of Medical Imaging, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Hong Yun
- Department of Radiology, Zhongshan Hospital, Fudan University and Shanghai Institute of Medical Imaging, Shanghai 200032, China.; Department of Medical Imaging, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Jianying Ma
- Department of Cardiology, Zhongshan Hospital, Fudan University and Shanghai Institute of Cardiovascular Diseases, Shanghai 200032, China
| | - Zhangwei Chen
- Department of Cardiology, Zhongshan Hospital, Fudan University and Shanghai Institute of Cardiovascular Diseases, Shanghai 200032, China
| | - Shufu Chang
- Department of Cardiology, Zhongshan Hospital, Fudan University and Shanghai Institute of Cardiovascular Diseases, Shanghai 200032, China
| | - Mengsu Zeng
- Department of Radiology, Zhongshan Hospital, Fudan University and Shanghai Institute of Medical Imaging, Shanghai 200032, China.; Department of Medical Imaging, Shanghai Medical College, Fudan University, Shanghai 200032, China
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166
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Nørgaard BL, Leipsic J, Koo BK, Zarins CK, Jensen JM, Sand NP, Taylor CA. Coronary Computed Tomography Angiography Derived Fractional Flow Reserve and Plaque Stress. CURRENT CARDIOVASCULAR IMAGING REPORTS 2016; 9:2. [PMID: 26941886 PMCID: PMC4751165 DOI: 10.1007/s12410-015-9366-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Fractional flow reserve (FFR) measured during invasive coronary angiography is an independent prognosticator in patients with coronary artery disease and the gold standard for decision making in coronary revascularization. The integration of computational fluid dynamics and quantitative anatomic and physiologic modeling now enables simulation of patient-specific hemodynamic parameters including blood velocity, pressure, pressure gradients, and FFR from standard acquired coronary computed tomography (CT) datasets. In this review article, we describe the potential impact on clinical practice and the science behind noninvasive coronary computed tomography (CT) angiography derived fractional flow reserve (FFRCT) as well as future applications of this technology in treatment planning and quantifying forces on atherosclerotic plaques.
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Affiliation(s)
| | - Jonathon Leipsic
- Department of Radiology and Medicine, St. Paul's Hospital, University of British Columbia, Vancouver, Canada
| | - Bon-Kwon Koo
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Christopher K Zarins
- Heart Flow, Inc., Redwood City, CA USA ; Department of Surgery, Stanford University, Stanford, CA USA
| | | | - Niels Peter Sand
- Department of Cardiology, Hospital of South West Denmark, Esbjerg, Denmark ; Institute of Regional Health Services Research, University of Southern Denmark, Odense M, Denmark
| | - Charles A Taylor
- Heart Flow, Inc., Redwood City, CA USA ; Department of Bioengineering, Stanford University, Stanford, CA USA
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167
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168
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Horie K, Kikuchi Y, Takizawa K, Inoue N. Role of Coronary Calcium Scoring in the Assessment of Physiological Ischemia in Patients with Intermediate Stenosis. Int J Angiol 2015; 24:283-91. [PMID: 26648671 DOI: 10.1055/s-0035-1554943] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Although coronary artery calcium (CAC) is an established marker of coronary atherosclerosis, whether it also reflects the physiological significance is unknown. This study aims to evaluate if CAC could indicate physiological ischemia in intermediate stenosis defined by an invasive fractional flow reserve (FFR). CAC score (CACS) derived from either whole coronary arteries or individual arteries was measured by computed tomography among patients with intermediate de novo lesions (percent diameter stenosis from 30% to less than 70%). All stenoses were evaluated by invasive FFR; lesions with an FFR ≤ 0.80 were considered significant. We enrolled 119 patients with 143 lesions. Of these, 42 lesions (29.4%) demonstrated significant ischemia by FFR measurement. FFR values had modest but significant correlations with CACS in individual arteries with intermediate stenosis (r = - 0.290; p < 0.001). A receiver operating characteristic curve analysis showed that CACS of individual arteries with intermediate stenosis had 71.4% sensitivity and 67.3% specificity as a predictor of significant ischemia at a cut off value of 145.9. Multivariable analysis showed that percent diameter stenosis and CACS in individual arteries with intermediate stenosis were independent predictors for significant ischemia. By net reclassification improvement analysis, CACS in individual arteries with intermediate stenosis provided incremental prediction for significant ischemia over minimum lumen diameter, percent diameter stenosis, and lesion length. CACS measured in each artery, but not the total CACS, provides additional information as to whether an angiographically intermediate stenosis within the artery is significant enough to cause myocardial ischemia.
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Affiliation(s)
- Kazunori Horie
- Division of Cardiovascular Medicine, Sendai Kousei Hospital, Sendai, Miyagi, Japan
| | - Yuichi Kikuchi
- Miyagi East Department of Interventional Cardiology, Higashi-Matsushima, Miyagi, Japan
| | - Kaname Takizawa
- Division of Cardiovascular Medicine, Sendai Kousei Hospital, Sendai, Miyagi, Japan
| | - Naoto Inoue
- Division of Cardiovascular Medicine, Sendai Kousei Hospital, Sendai, Miyagi, Japan
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169
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Kundi H, Gok M, Kiziltunc E, Topcuoglu C, Cetin M, Cicekcioglu H, Ugurlu B, Ulusoy FV. The Relationship Between Serum Endocan Levels With the Presence of Slow Coronary Flow: A Cross-Sectional Study. Clin Appl Thromb Hemost 2015; 23:472-477. [PMID: 26607436 DOI: 10.1177/1076029615618024] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND The aim of this study was to investigate the relationship between endocan levels with the presence of slow coronary flow (SCF). METHODS In this cross-sectional study, a total of 88 patients, who admitted to our hospital, were included in this study. Of these, 53 patients with SCF and 35 patients with normal coronary flow were included in the final analysis. Coronary flow rates of all patients were determined by the Timi Frame Count (TFC) method. RESULTS In correlation analysis, endocan levels revealed a significantly positive correlation with high sensitive C-reactive protein and corrected TFC. In multivariate logistic regression analysis, the endocan levels were found as independently associated with the presence of SCF. Finally, using a cutoff level of 2.3, endocan level predicted the presence of SCF with a sensitivity of 77.2% and specificity of 75.2%. CONCLUSION In conclusion, our study showed that higher endocan levels were significantly and independently related to the presence of SCF.
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Affiliation(s)
- Harun Kundi
- 1 Cardiology Department, Ankara Numune Education and Research Hospital, Ankara, Turkey
| | - Murat Gok
- 1 Cardiology Department, Ankara Numune Education and Research Hospital, Ankara, Turkey
| | - Emrullah Kiziltunc
- 1 Cardiology Department, Ankara Numune Education and Research Hospital, Ankara, Turkey
| | - Canan Topcuoglu
- 2 Biochemistry Department, Ankara Numune Education and Research Hospital, Ankara, Turkey
| | - Mustafa Cetin
- 1 Cardiology Department, Ankara Numune Education and Research Hospital, Ankara, Turkey
| | - Hulya Cicekcioglu
- 1 Cardiology Department, Ankara Numune Education and Research Hospital, Ankara, Turkey
| | - Burcu Ugurlu
- 1 Cardiology Department, Ankara Numune Education and Research Hospital, Ankara, Turkey
| | - Feridun Vasfi Ulusoy
- 1 Cardiology Department, Ankara Numune Education and Research Hospital, Ankara, Turkey
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170
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Mittal SR. Diagnosis of coronary microvascular dysfunction - Present status. Indian Heart J 2015; 67:552-60. [PMID: 26702685 PMCID: PMC4699946 DOI: 10.1016/j.ihj.2015.08.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Revised: 07/28/2015] [Accepted: 08/10/2015] [Indexed: 12/14/2022] Open
Abstract
Definite clinical diagnosis of microvascular angina is not possible with the existing knowledge. Resting electrocardiogram may be normal, and exercise electrocardiogram may be unremarkable. Echocardiography usually does not show regional wall motion abnormalities. Transthoracic Doppler echocardiography can satisfactorily evaluate only left anterior descending coronary artery and that too in some patients. Radio-isotope imaging can detect only severe localized disease. Noninvasive diagnosis needs high index of suspicion. At present, definite diagnosis is based on documentation of normal epicardial coronaries, coronary flow reserve less than 2.5 on adenosine induced hyperemia, and absence of spasm of epicardial coronaries on acetylcholine provocation. Invasive evaluation is costly, needs sophisticated equipments and expertise. Therapeutic and prognostic implications of various parameters remains to be evaluated. At present invasive evaluation is recommended only for patients with intractable symptoms with unconfirmed diagnosis, requiring repeated hospitalization and evaluation with failure of empirical therapy.
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Affiliation(s)
- S R Mittal
- Department of Cardiology, Mittal Hospital & Research Centre, Pushkar Road, Ajmer 305001, Rajasthan, India.
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171
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Xu R, Li C, Qian J, Ge J. Computed Tomography-Derived Fractional Flow Reserve in the Detection of Lesion-Specific Ischemia: An Integrated Analysis of 3 Pivotal Trials. Medicine (Baltimore) 2015; 94:e1963. [PMID: 26579804 PMCID: PMC4652813 DOI: 10.1097/md.0000000000001963] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Invasive fractional flow reserve (FFR) is the gold standard for the determination of physiologic stenosis severity and the need for revascularization. FFR computed from standard acquired coronary computed tomographic angiography datasets (FFRCT) is an emerging technology which allows calculation of FFR using resting image data from coronary computed tomographic angiography (CCTA). However, the diagnostic accuracy of FFRCT in the evaluation of lesion-specific myocardial ischemia remains to be confirmed, especially in patients with intermediate coronary stenosis. We performed an integrated analysis of data from 3 prospective, international, and multicenter trials, which assessed the diagnostic performance of FFRCT using invasive FFR as a reference standard. Three studies evaluating 609 patients and 1050 vessels were included. The total calculated sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of FFRCT were 82.8%, 77.7%, 60.8%, 91.6%, and 79.2%, respectively, for the per-vessel analysis, and 89.4%, 70.5%, 69.7%, 89.7%, and 78.7%, respectively, for the per-patient analysis. Compared with CCTA alone, FFRCT demonstrated significantly improved accuracy (P < 0.001) in detecting lesion-specific ischemia. In patients with intermediate coronary stenosis, FFRCT remained both highly sensitive and specific with respect to the diagnosis of ischemia. In conclusion, FFRCT appears to be a reliable noninvasive alternative to invasive FFR, as it demonstrates high accuracy in the determination of anatomy and lesion-specific ischemia, which justifies the performance of additional randomized controlled trials to evaluate both the clinical benefits and the cost-effectiveness of FFRCT-guided coronary revascularization.
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Affiliation(s)
- Rende Xu
- From the Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China
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172
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Sakoda K, Tanaka N, Hokama Y, Hoshino K, Murata N, Yamashita J, Yamashina A. Association of moderate chronic kidney disease with insufficient improvement of fractional flow reserve after stent implantation. Catheter Cardiovasc Interv 2015; 88:E38-44. [DOI: 10.1002/ccd.26258] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2015] [Revised: 08/20/2015] [Accepted: 09/16/2015] [Indexed: 11/11/2022]
Affiliation(s)
- Kunihiro Sakoda
- Division of Cardiology, Department of Internal Medicine; Tokyo Medical University; Tokyo Japan
| | - Nobuhiro Tanaka
- Division of Cardiology, Department of Internal Medicine; Tokyo Medical University; Tokyo Japan
| | - Yohei Hokama
- Division of Cardiology, Department of Internal Medicine; Tokyo Medical University; Tokyo Japan
| | - Kou Hoshino
- Division of Cardiology, Department of Internal Medicine; Tokyo Medical University; Tokyo Japan
| | - Naotaka Murata
- Division of Cardiology, Department of Internal Medicine; Tokyo Medical University; Tokyo Japan
| | - Jun Yamashita
- Division of Cardiology, Department of Internal Medicine; Tokyo Medical University; Tokyo Japan
| | - Akira Yamashina
- Division of Cardiology, Department of Internal Medicine; Tokyo Medical University; Tokyo Japan
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173
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Min JK, Taylor CA, Achenbach S, Koo BK, Leipsic J, Nørgaard BL, Pijls NJ, De Bruyne B. Noninvasive Fractional Flow Reserve Derived From Coronary CT Angiography. JACC Cardiovasc Imaging 2015; 8:1209-1222. [DOI: 10.1016/j.jcmg.2015.08.006] [Citation(s) in RCA: 160] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Revised: 08/24/2015] [Accepted: 08/27/2015] [Indexed: 11/25/2022]
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174
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Johnson NP, Kirkeeide RL, Gould KL. History and Development of Coronary Flow Reserve and Fractional Flow Reserve for Clinical Applications. Interv Cardiol Clin 2015; 4:397-410. [PMID: 28581927 DOI: 10.1016/j.iccl.2015.06.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
We discuss the historical development of clinical coronary physiology, emphasizing coronary flow reserve (CFR) and fractional flow reserve (FFR). Our analysis focuses on the clinical motivations and technologic advances that prompted and enabled the application of physiology for patient diagnosis. CFR grew from the general concepts of physiologic and coronary reserve, linking the anatomic severity of a lesion to its impact on hyperemic flow. FFR developed from existing models relating pressure measurements to the potential for flow to increase after removing a stenosis. Because pressure measurements have proved easier and more robust than flow measurements, FFR has become the dominant metric.
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Affiliation(s)
- Nils P Johnson
- Division of Cardiology, Department of Medicine, Weatherhead PET Center for Preventing and Reversing Atherosclerosis, Memorial Hermann Hospital, University of Texas Medical School at Houston, 6431 Fannin Street, Room MSB 4.256, Houston, TX 77030, USA.
| | - Richard L Kirkeeide
- Division of Cardiology, Department of Medicine, Weatherhead PET Center for Preventing and Reversing Atherosclerosis, Memorial Hermann Hospital, University of Texas Medical School at Houston, 6431 Fannin Street, Room MSB 4.256, Houston, TX 77030, USA
| | - K Lance Gould
- Division of Cardiology, Department of Medicine, Weatherhead PET Center for Preventing and Reversing Atherosclerosis, Memorial Hermann Hospital, University of Texas Medical School at Houston, 6431 Fannin Street, Room MSB 4.256, Houston, TX 77030, USA
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175
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Park HB, Heo R, Ó Hartaigh B, Cho I, Gransar H, Nakazato R, Leipsic J, Mancini GBJ, Koo BK, Otake H, Budoff MJ, Berman DS, Erglis A, Chang HJ, Min JK. Atherosclerotic plaque characteristics by CT angiography identify coronary lesions that cause ischemia: a direct comparison to fractional flow reserve. JACC Cardiovasc Imaging 2015; 8:1-10. [PMID: 25592691 DOI: 10.1016/j.jcmg.2014.11.002] [Citation(s) in RCA: 221] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Revised: 11/05/2014] [Accepted: 11/06/2014] [Indexed: 12/24/2022]
Abstract
OBJECTIVES This study evaluated the association between atherosclerotic plaque characteristics (APCs) by coronary computed tomographic angiography (CTA), and lesion ischemia by fractional flow reserve (FFR). BACKGROUND FFR is the gold standard for determining lesion ischemia. Although APCs by CTA-including aggregate plaque volume % (%APV), positive remodeling (PR), low attenuation plaque (LAP), and spotty calcification (SC)-are associated with future coronary syndromes, their relationship to lesion ischemia is unclear. METHODS 252 patients (17 centers, 5 countries; mean age 63 years; 71% males) underwent coronary CTA, with FFR performed for 407 coronary lesions. Coronary CTA was interpreted for <50% and ≥50% stenosis, with the latter considered obstructive. APCs by coronary CTA were defined as: 1) PR, lesion diameter/reference diameter >1.10; 2) LAP, any voxel <30 Hounsfield units; and 3) SC, nodular calcified plaque <3 mm. Odds ratios (OR) and net reclassification improvement of APCs for lesion ischemia, defined by FFR ≤0.8, were analyzed. RESULTS By FFR, ischemia was present in 151 lesions (37%). %APV was associated with a 50% increased risk of ischemia per 5% additional APV. PR, LAP, and SC were associated with ischemia, with a 3 to 5 times higher prevalence than in nonischemic lesions. In multivariable analyses, a stepwise increased risk of ischemia was observed for 1 (OR: 4.0, p < 0.001) and ≥2 (OR: 12.1, p < 0.001) APCs. These findings were APC dependent, with PR (OR: 5.3, p < 0.001) and LAP (OR: 2.1, p = 0.038) associated with ischemia, but not SC. When examined by stenosis severity, PR remained a predictor of ischemia for all lesions, whereas %APV and LAP were associated with ischemia for only ≥50%, but not for <50%, stenosis. CONCLUSIONS %APV and APCs by coronary CTA improve identification of coronary lesions that cause ischemia. PR is associated with all ischemia-causing lesions, whereas %APV and LAP are only associated with ischemia-causing lesions ≥50%. (Determination of Fractional Flow Reserve by Anatomic Computed Tomographic Angiography; NCT01233518).
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Affiliation(s)
- Hyung-Bok Park
- Department of Radiology, New York-Presbyterian Hospital and the Weill Cornell Medical College, New York, New York; Division of Cardiology, Severance Cardiovascular Hospital and Severance Biomedical Science Institute, Yonsei University College of Medicine, Seoul, South Korea; Cardiovascular Center, Myongji Hospital, Goyang, Korea
| | - Ran Heo
- Department of Radiology, New York-Presbyterian Hospital and the Weill Cornell Medical College, New York, New York; Division of Cardiology, Severance Cardiovascular Hospital and Severance Biomedical Science Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Bríain Ó Hartaigh
- Department of Radiology, New York-Presbyterian Hospital and the Weill Cornell Medical College, New York, New York
| | - Iksung Cho
- Department of Radiology, New York-Presbyterian Hospital and the Weill Cornell Medical College, New York, New York; Division of Cardiology, Severance Cardiovascular Hospital and Severance Biomedical Science Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Heidi Gransar
- Departments of Imaging and Medicine, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Ryo Nakazato
- Cardiovascular Center, St. Luke's International Hospital, Tokyo, Japan
| | - Jonathon Leipsic
- Department of Radiology, St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - G B John Mancini
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Bon-Kwon Koo
- Department of Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Hiromasa Otake
- Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Matthew J Budoff
- Department of Medicine, Harbor UCLA Medical Center, Los Angeles, California
| | - Daniel S Berman
- Departments of Imaging and Medicine, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Andrejs Erglis
- Department of Medicine, Pauls Stradins Clinical University Hospital, Riga, Latvia
| | - Hyuk-Jae Chang
- Division of Cardiology, Severance Cardiovascular Hospital and Severance Biomedical Science Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - James K Min
- Department of Radiology, New York-Presbyterian Hospital and the Weill Cornell Medical College, New York, New York.
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176
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Affiliation(s)
- William F Fearon
- From the Division of Cardiovascular Medicine, Stanford University Medical Center, CA.
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177
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Mousa TM, Akinseye OA, Kerwin TC. Inadequate Blood Pressure Control in Hypertensive Patients Referred for Cardiac Stress Test. J Clin Hypertens (Greenwich) 2015; 17:709-12. [PMID: 26011137 PMCID: PMC8032160 DOI: 10.1111/jch.12586] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2015] [Revised: 03/02/2015] [Accepted: 03/08/2015] [Indexed: 11/27/2022]
Abstract
The current study examined the degree of blood pressure (BP) control and incidence of myocardial ischemia in hypertensive patients (n=2039) referred for cardiac stress test. Patients were categorized into well-controlled (<140/90 mm Hg), poorly controlled (140-160/90-100 mm Hg), and very poorly controlled (>160/100 mm Hg) groups according to their resting BP. The mean age[±standard error of the mean] of the patients was 68±13 years, and 885 (43.4%) were men. The prevalence of well-controlled hypertension (HTN) was 47.2%, poorly controlled HTN was 29.5%, and very poorly controlled HTN was 23.3%. Evidence of ischemia was seen in 19.8% and 19.3% of the well-controlled and poorly controlled groups, respectively. The very poorly controlled group had the lowest incidence of ischemia (14.3%) (P<.05) compared with the other two groups. Symptoms that mimic ischemic heart disease in hypertensive patients may be partly explained by poorly controlled BP. Quality of care might be improved by optimally controlling BP in patients with angina symptoms prior to ordering diagnostic testing associated with radiation exposure and cost.
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Affiliation(s)
| | | | - Todd C. Kerwin
- The New York Hospital Medical Center of QueensCornell University Medical CollegeFlushing
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178
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Wijns W, Shite J, Jones MR, Lee SWL, Price MJ, Fabbiocchi F, Barbato E, Akasaka T, Bezerra H, Holmes D. Optical coherence tomography imaging during percutaneous coronary intervention impacts physician decision-making: ILUMIEN I study. Eur Heart J 2015; 36:3346-55. [PMID: 26242713 PMCID: PMC4677272 DOI: 10.1093/eurheartj/ehv367] [Citation(s) in RCA: 180] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Accepted: 07/15/2015] [Indexed: 01/19/2023] Open
Abstract
AIMS ILUMIEN I is the largest prospective, non-randomized, observational study of percutaneous coronary intervention (PCI) procedural practice in patients undergoing intra-procedural pre- and post-PCI fractional flow reserve (FFR) and optical coherence tomography (OCT). We report on the impact of OCT on physician decision-making and the association with post-PCI FFR values and early clinical events. METHODS AND RESULTS Optical coherence tomography and documentary FFR were performed pre- and post-PCI in 418 patients (with 467 stenoses) with stable or unstable angina or NSTEMI. Based on pre-PCI OCT, the procedure was altered in 55% of patients (57% of all stenoses) by selecting different stent lengths (shorter in 25%, longer in 43%). After clinically satisfactory stent implantation using angiographic guidance, post-PCI FFR and OCT were repeated. Optical coherence tomography abnormalities deemed unsatisfactory by the implanting physician were identified: 14.5% malapposition, 7.6% under-expansion, 2.7% edge dissection and prompted further stent optimization based on OCT in 25% of patients (27% of all stenoses) using additional in-stent post-dilatation (81%, 101/124) or placement of 20 new stents (12%). Optimization subgroups were identified post hoc: stent placement without reaction to OCT findings (n = 137), change in PCI planning by pre-PCI OCT (n = 165), post-PCI optimization based on post-PCI OCT (n = 41), change in PCI planning, and post-PCI optimization based on OCT (n = 65). Post-PCI FFR values were significantly different (P = 0.003) between optimization groups (lower in cases with pre- and post-PCI reaction to OCT) but no longer different after post-PCI stent optimization. MACE events at 30 days were low: death 0.25%, MI 7.7%, repeat PCI 1.7%, and stent thrombosis 0.25%. CONCLUSION Physician decision-making was affected by OCT imaging prior to PCI in 57% and post-PCI in 27% of all cases. CLINICALTRIALS. GOV IDENTIFIER NCT01663896, Observational Study of Optical Coherence Tomography (OCT) in Patients Undergoing Fractional Flow Reserve (FFR) and Percutaneous Coronary Intervention (ILUMIEN I).
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Affiliation(s)
- William Wijns
- Cardiovascular Research Center, OLV Hospital, Moorselbaan 164, Aalst B 9300, Belgium
| | - Junya Shite
- Osaka Saiseikai Nakatsu Hospital, Osaka, Japan
| | | | - Stephen W L Lee
- University of Hong Kong, Queen Mary Hospital, Hospital Authority, Pok Fu Lam, Hong Kong
| | | | | | - Emanuele Barbato
- Cardiovascular Research Center, OLV Hospital, Moorselbaan 164, Aalst B 9300, Belgium
| | | | - Hiram Bezerra
- University Hospitals Case Medical Center, Harrington Heart and Vascular Institute, Cleveland, OH, USA
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Kakouros N, Rade JJ. Role of Fractional-Flow Reserve in Guiding Percutaneous Revascularization in Stable Coronary Artery Disease. Curr Atheroscler Rep 2015. [DOI: 10.1007/s11883-015-0530-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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180
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Mirelis JG, García-Pavía P, Cavero MA, González-López E, Echavarria-Pinto M, Pastrana M, Segovia J, Oteo JF, Alonso-Pulpón L, Escaned J. Resonancia magnética para la detección no invasiva de la enfermedad microcirculatoria asociada a la vasculopatía de alotrasplante: validación de la determinación intracoronaria. Rev Esp Cardiol 2015. [DOI: 10.1016/j.recesp.2014.07.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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181
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Mirelis JG, García-Pavía P, Cavero MA, González-López E, Echavarria-Pinto M, Pastrana M, Segovia J, Oteo JF, Alonso-Pulpón L, Escaned J. Magnetic Resonance for Noninvasive Detection of Microcirculatory Disease Associated With Allograft Vasculopathy: Intracoronary Measurement Validation. ACTA ACUST UNITED AC 2015; 68:571-8. [DOI: 10.1016/j.rec.2014.07.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Accepted: 07/18/2014] [Indexed: 01/13/2023]
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182
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Nørgaard BL, Hansson NC, Christiansen EH, Kaltoft A, Bøtker HE, Lassen JF, Mæng M, Jensen JM. A “normal” invasive coronary angiogram may not be normal. J Cardiovasc Comput Tomogr 2015; 9:264-6. [DOI: 10.1016/j.jcct.2015.05.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Revised: 03/27/2015] [Accepted: 05/10/2015] [Indexed: 12/17/2022]
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183
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Sinclair MD, Lee J, Cookson AN, Rivolo S, Hyde ER, Smith NP. Measurement and modeling of coronary blood flow. WILEY INTERDISCIPLINARY REVIEWS-SYSTEMS BIOLOGY AND MEDICINE 2015; 7:335-56. [PMID: 26123867 DOI: 10.1002/wsbm.1309] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Revised: 05/19/2015] [Accepted: 05/21/2015] [Indexed: 01/10/2023]
Abstract
Ischemic heart disease that comprises both coronary artery disease and microvascular disease is the single greatest cause of death globally. In this context, enhancing our understanding of the interaction of coronary structure and function is not only fundamental for advancing basic physiology but also crucial for identifying new targets for treating these diseases. A central challenge for understanding coronary blood flow is that coronary structure and function exhibit different behaviors across a range of spatial and temporal scales. While experimental studies have sought to understand this feature by isolating specific mechanisms, in tandem, computational modeling is increasingly also providing a unique framework to integrate mechanistic behaviors across different scales. In addition, clinical methods for assessing coronary disease severity are continuously being informed and updated by findings in basic physiology. Coupling these technologies, computational modeling of the coronary circulation is emerging as a bridge between the experimental and clinical domains, providing a framework to integrate imaging and measurements from multiple sources with mathematical descriptions of governing physical laws. State-of-the-art computational modeling is being used to combine mechanistic models with data to provide new insight into coronary physiology, optimization of medical technologies, and new applications to guide clinical practice.
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Affiliation(s)
- Matthew D Sinclair
- Division of Imaging Sciences and Biomedical Engineering, British Heart Foundation (BHF) Centre of Excellence, King's College London, London, UK
| | - Jack Lee
- Division of Imaging Sciences and Biomedical Engineering, British Heart Foundation (BHF) Centre of Excellence, King's College London, London, UK
| | - Andrew N Cookson
- Division of Imaging Sciences and Biomedical Engineering, British Heart Foundation (BHF) Centre of Excellence, King's College London, London, UK
| | - Simone Rivolo
- Division of Imaging Sciences and Biomedical Engineering, British Heart Foundation (BHF) Centre of Excellence, King's College London, London, UK
| | - Eoin R Hyde
- Division of Imaging Sciences and Biomedical Engineering, British Heart Foundation (BHF) Centre of Excellence, King's College London, London, UK
| | - Nicolas P Smith
- Division of Imaging Sciences and Biomedical Engineering, British Heart Foundation (BHF) Centre of Excellence, King's College London, London, UK.,Department of Engineering, University of Auckland, Auckland, New Zealand
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Abstract
Coronary angiography is the gold standard for the diagnosis of coronary artery disease and guides revascularization strategies. The emergence of new diagnostic modalities has provided clinicians with adjunctive physiologic and image-based data to help formulate treatment strategies. Fractional flow reserve can predict whether percutaneous intervention will benefit a patient. Intravascular ultrasonography and optical coherence tomography are intracoronary imaging modalities that facilitate the anatomic visualization of the vessel lumen and characterize plaques. Near-infrared spectroscopy can characterize plaque composition and potentially provide valuable prognostic information. This article reviews the indications, basic technology, and supporting clinical studies for these modalities.
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Affiliation(s)
- Elliott M Groves
- Division of Cardiology, Department of Internal Medicine, University of California, 333 City Blvd West, Suite 400, Orange, CA 92868-3298, USA; Department of Biomedical Engineering, University of California, 3120 Natural Sciences II, Irvine, CA 92697-2715, USA
| | - Arnold H Seto
- Division of Cardiology, Department of Internal Medicine, University of California, 333 City Blvd West, Suite 400, Orange, CA 92868-3298, USA; Division of Cardiology, Department of Internal Medicine, Long Beach Veterans Administration Hospital, 5901 East Seventh Street, Long Beach, CA 90822, USA.
| | - Morton J Kern
- Division of Cardiology, Department of Internal Medicine, University of California, 333 City Blvd West, Suite 400, Orange, CA 92868-3298, USA; Division of Cardiology, Department of Internal Medicine, Long Beach Veterans Administration Hospital, 5901 East Seventh Street, Long Beach, CA 90822, USA
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185
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Gould KL, Johnson NP, Kaul S, Kirkeeide RL, Mintz GS, Rentrop KP, Sdringola S, Virmani R, Narula J. Patient Selection for Elective Revascularization to Reduce Myocardial Infarction and Mortality. Circ Cardiovasc Imaging 2015; 8:CIRCIMAGING.114.003099. [DOI: 10.1161/circimaging.114.003099] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- K. Lance Gould
- From the Division of Cardiology, Department of Medicine, Weatherhead PET Center for Preventing and Reversing Atherosclerosis, University of Texas Medical School at Houston and Memorial Hermann Hospital (K.L.G., N.P.J., R.L.K., S.S.); Division of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA (S.K.); Cardiovascular Research Foundation, New York, NY (G.S.M.); Department of Medicine, Cardiovascular Disease, New York Presbyterian Hospital, The University Hospital of Columbia and Cornell, New
| | - Nils P. Johnson
- From the Division of Cardiology, Department of Medicine, Weatherhead PET Center for Preventing and Reversing Atherosclerosis, University of Texas Medical School at Houston and Memorial Hermann Hospital (K.L.G., N.P.J., R.L.K., S.S.); Division of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA (S.K.); Cardiovascular Research Foundation, New York, NY (G.S.M.); Department of Medicine, Cardiovascular Disease, New York Presbyterian Hospital, The University Hospital of Columbia and Cornell, New
| | - Sanjay Kaul
- From the Division of Cardiology, Department of Medicine, Weatherhead PET Center for Preventing and Reversing Atherosclerosis, University of Texas Medical School at Houston and Memorial Hermann Hospital (K.L.G., N.P.J., R.L.K., S.S.); Division of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA (S.K.); Cardiovascular Research Foundation, New York, NY (G.S.M.); Department of Medicine, Cardiovascular Disease, New York Presbyterian Hospital, The University Hospital of Columbia and Cornell, New
| | - Richard L. Kirkeeide
- From the Division of Cardiology, Department of Medicine, Weatherhead PET Center for Preventing and Reversing Atherosclerosis, University of Texas Medical School at Houston and Memorial Hermann Hospital (K.L.G., N.P.J., R.L.K., S.S.); Division of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA (S.K.); Cardiovascular Research Foundation, New York, NY (G.S.M.); Department of Medicine, Cardiovascular Disease, New York Presbyterian Hospital, The University Hospital of Columbia and Cornell, New
| | - Gary S. Mintz
- From the Division of Cardiology, Department of Medicine, Weatherhead PET Center for Preventing and Reversing Atherosclerosis, University of Texas Medical School at Houston and Memorial Hermann Hospital (K.L.G., N.P.J., R.L.K., S.S.); Division of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA (S.K.); Cardiovascular Research Foundation, New York, NY (G.S.M.); Department of Medicine, Cardiovascular Disease, New York Presbyterian Hospital, The University Hospital of Columbia and Cornell, New
| | - K. Peter Rentrop
- From the Division of Cardiology, Department of Medicine, Weatherhead PET Center for Preventing and Reversing Atherosclerosis, University of Texas Medical School at Houston and Memorial Hermann Hospital (K.L.G., N.P.J., R.L.K., S.S.); Division of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA (S.K.); Cardiovascular Research Foundation, New York, NY (G.S.M.); Department of Medicine, Cardiovascular Disease, New York Presbyterian Hospital, The University Hospital of Columbia and Cornell, New
| | - Stefano Sdringola
- From the Division of Cardiology, Department of Medicine, Weatherhead PET Center for Preventing and Reversing Atherosclerosis, University of Texas Medical School at Houston and Memorial Hermann Hospital (K.L.G., N.P.J., R.L.K., S.S.); Division of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA (S.K.); Cardiovascular Research Foundation, New York, NY (G.S.M.); Department of Medicine, Cardiovascular Disease, New York Presbyterian Hospital, The University Hospital of Columbia and Cornell, New
| | - Renu Virmani
- From the Division of Cardiology, Department of Medicine, Weatherhead PET Center for Preventing and Reversing Atherosclerosis, University of Texas Medical School at Houston and Memorial Hermann Hospital (K.L.G., N.P.J., R.L.K., S.S.); Division of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA (S.K.); Cardiovascular Research Foundation, New York, NY (G.S.M.); Department of Medicine, Cardiovascular Disease, New York Presbyterian Hospital, The University Hospital of Columbia and Cornell, New
| | - Jagat Narula
- From the Division of Cardiology, Department of Medicine, Weatherhead PET Center for Preventing and Reversing Atherosclerosis, University of Texas Medical School at Houston and Memorial Hermann Hospital (K.L.G., N.P.J., R.L.K., S.S.); Division of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA (S.K.); Cardiovascular Research Foundation, New York, NY (G.S.M.); Department of Medicine, Cardiovascular Disease, New York Presbyterian Hospital, The University Hospital of Columbia and Cornell, New
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Diaz-Zamudio M, Dey D, Schuhbaeck A, Nakazato R, Gransar H, Slomka PJ, Narula J, Berman DS, Achenbach S, Min JK, Doh JH, Koo BK. Automated Quantitative Plaque Burden from Coronary CT Angiography Noninvasively Predicts Hemodynamic Significance by using Fractional Flow Reserve in Intermediate Coronary Lesions. Radiology 2015; 276:408-15. [PMID: 25897475 DOI: 10.1148/radiol.2015141648] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE To evaluate the utility of multiple automated plaque measurements from coronary computed tomographic (CT) angiography in determining hemodynamic significance by using invasive fractional flow reserve (FFR) in patients with intermediate coronary stenosis. MATERIALS AND METHODS The study was approved by the institutional review board. All patients provided written informed consent. Fifty-six intermediate lesions (with 30%-69% diameter stenosis) in 56 consecutive patients (mean age, 62 years; range, 46-88 years), who subsequently underwent invasive coronary angiography with assessment of FFR (values ≤0.80 were considered hemodynamically significant) were analyzed at coronary CT angiography. Coronary CT angiography images were quantitatively analyzed with automated software to obtain the following measurements: volume and burden (plaque volume × 100 per vessel volume) of total, calcified, and noncalcified plaque; low-attenuation (<30 HU) noncalcified plaque; diameter stenosis; remodeling index; contrast attenuation difference (maximum percent difference in attenuation per unit area with respect to the proximal reference cross section); and lesion length. Logistic regression adjusted for potential confounding factors, receiver operating characteristics, and integrated discrimination improvement were used for statistical analysis. RESULTS FFR was 0.80 or less in 21 (38%) of the 56 lesions. Compared with nonischemic lesions, ischemic lesions had greater diameter stenosis (65% vs 52%, P = .02) and total (49% vs 37%, P = .0003), noncalcified (44% vs 33%, P = .0004), and low-attenuation noncalcified (9% vs 4%, P < .0001) plaque burden. Calcified plaque and remodeling index were not significantly different. In multivariable analysis, only total, noncalcified, and low-attenuation noncalcified plaque burden were significant predictors of ischemia (P < .015). For predicting ischemia, the area under the receiver operating characteristics curve was 0.83 for total plaque burden versus 0.68 for stenosis (P = .04). CONCLUSION Compared with stenosis grading, automatic quantification of total, noncalcified, and low-attenuation noncalcified plaque burden substantially improves determination of lesion-specific hemodynamic significance by FFR in patients with intermediate coronary lesions.
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Affiliation(s)
- Mariana Diaz-Zamudio
- From the Department of Imaging and Medicine, Division of Nuclear Medicine (M.D.Z., R.N., H.G., P.J.S., D.S.B.), and Biomedical Imaging Research Institute (D.D.), Cedars-Sinai Medical Center, 8700 Beverly Blvd, S. Mark Taper Building A238, Los Angeles, CA 90048; Department of Internal Medicine 2, University of Erlangen, Erlangen, Germany (A.S., S.A.); Cardiovascular Institute, Mount Sinai Medical Center, New York, NY (J.N.); Department of Radiology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY (J.K.M.); Department of Medicine, Inje University Ilsan-Paik Hospital, Goyang, South Korea (J.H.D.); and Department of Medicine, Seoul National University Hospital, Seoul, South Korea (B.K.K.)
| | - Damini Dey
- From the Department of Imaging and Medicine, Division of Nuclear Medicine (M.D.Z., R.N., H.G., P.J.S., D.S.B.), and Biomedical Imaging Research Institute (D.D.), Cedars-Sinai Medical Center, 8700 Beverly Blvd, S. Mark Taper Building A238, Los Angeles, CA 90048; Department of Internal Medicine 2, University of Erlangen, Erlangen, Germany (A.S., S.A.); Cardiovascular Institute, Mount Sinai Medical Center, New York, NY (J.N.); Department of Radiology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY (J.K.M.); Department of Medicine, Inje University Ilsan-Paik Hospital, Goyang, South Korea (J.H.D.); and Department of Medicine, Seoul National University Hospital, Seoul, South Korea (B.K.K.)
| | - Annika Schuhbaeck
- From the Department of Imaging and Medicine, Division of Nuclear Medicine (M.D.Z., R.N., H.G., P.J.S., D.S.B.), and Biomedical Imaging Research Institute (D.D.), Cedars-Sinai Medical Center, 8700 Beverly Blvd, S. Mark Taper Building A238, Los Angeles, CA 90048; Department of Internal Medicine 2, University of Erlangen, Erlangen, Germany (A.S., S.A.); Cardiovascular Institute, Mount Sinai Medical Center, New York, NY (J.N.); Department of Radiology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY (J.K.M.); Department of Medicine, Inje University Ilsan-Paik Hospital, Goyang, South Korea (J.H.D.); and Department of Medicine, Seoul National University Hospital, Seoul, South Korea (B.K.K.)
| | - Ryo Nakazato
- From the Department of Imaging and Medicine, Division of Nuclear Medicine (M.D.Z., R.N., H.G., P.J.S., D.S.B.), and Biomedical Imaging Research Institute (D.D.), Cedars-Sinai Medical Center, 8700 Beverly Blvd, S. Mark Taper Building A238, Los Angeles, CA 90048; Department of Internal Medicine 2, University of Erlangen, Erlangen, Germany (A.S., S.A.); Cardiovascular Institute, Mount Sinai Medical Center, New York, NY (J.N.); Department of Radiology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY (J.K.M.); Department of Medicine, Inje University Ilsan-Paik Hospital, Goyang, South Korea (J.H.D.); and Department of Medicine, Seoul National University Hospital, Seoul, South Korea (B.K.K.)
| | - Heidi Gransar
- From the Department of Imaging and Medicine, Division of Nuclear Medicine (M.D.Z., R.N., H.G., P.J.S., D.S.B.), and Biomedical Imaging Research Institute (D.D.), Cedars-Sinai Medical Center, 8700 Beverly Blvd, S. Mark Taper Building A238, Los Angeles, CA 90048; Department of Internal Medicine 2, University of Erlangen, Erlangen, Germany (A.S., S.A.); Cardiovascular Institute, Mount Sinai Medical Center, New York, NY (J.N.); Department of Radiology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY (J.K.M.); Department of Medicine, Inje University Ilsan-Paik Hospital, Goyang, South Korea (J.H.D.); and Department of Medicine, Seoul National University Hospital, Seoul, South Korea (B.K.K.)
| | - Piotr J Slomka
- From the Department of Imaging and Medicine, Division of Nuclear Medicine (M.D.Z., R.N., H.G., P.J.S., D.S.B.), and Biomedical Imaging Research Institute (D.D.), Cedars-Sinai Medical Center, 8700 Beverly Blvd, S. Mark Taper Building A238, Los Angeles, CA 90048; Department of Internal Medicine 2, University of Erlangen, Erlangen, Germany (A.S., S.A.); Cardiovascular Institute, Mount Sinai Medical Center, New York, NY (J.N.); Department of Radiology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY (J.K.M.); Department of Medicine, Inje University Ilsan-Paik Hospital, Goyang, South Korea (J.H.D.); and Department of Medicine, Seoul National University Hospital, Seoul, South Korea (B.K.K.)
| | - Jagat Narula
- From the Department of Imaging and Medicine, Division of Nuclear Medicine (M.D.Z., R.N., H.G., P.J.S., D.S.B.), and Biomedical Imaging Research Institute (D.D.), Cedars-Sinai Medical Center, 8700 Beverly Blvd, S. Mark Taper Building A238, Los Angeles, CA 90048; Department of Internal Medicine 2, University of Erlangen, Erlangen, Germany (A.S., S.A.); Cardiovascular Institute, Mount Sinai Medical Center, New York, NY (J.N.); Department of Radiology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY (J.K.M.); Department of Medicine, Inje University Ilsan-Paik Hospital, Goyang, South Korea (J.H.D.); and Department of Medicine, Seoul National University Hospital, Seoul, South Korea (B.K.K.)
| | - Daniel S Berman
- From the Department of Imaging and Medicine, Division of Nuclear Medicine (M.D.Z., R.N., H.G., P.J.S., D.S.B.), and Biomedical Imaging Research Institute (D.D.), Cedars-Sinai Medical Center, 8700 Beverly Blvd, S. Mark Taper Building A238, Los Angeles, CA 90048; Department of Internal Medicine 2, University of Erlangen, Erlangen, Germany (A.S., S.A.); Cardiovascular Institute, Mount Sinai Medical Center, New York, NY (J.N.); Department of Radiology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY (J.K.M.); Department of Medicine, Inje University Ilsan-Paik Hospital, Goyang, South Korea (J.H.D.); and Department of Medicine, Seoul National University Hospital, Seoul, South Korea (B.K.K.)
| | - Stephan Achenbach
- From the Department of Imaging and Medicine, Division of Nuclear Medicine (M.D.Z., R.N., H.G., P.J.S., D.S.B.), and Biomedical Imaging Research Institute (D.D.), Cedars-Sinai Medical Center, 8700 Beverly Blvd, S. Mark Taper Building A238, Los Angeles, CA 90048; Department of Internal Medicine 2, University of Erlangen, Erlangen, Germany (A.S., S.A.); Cardiovascular Institute, Mount Sinai Medical Center, New York, NY (J.N.); Department of Radiology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY (J.K.M.); Department of Medicine, Inje University Ilsan-Paik Hospital, Goyang, South Korea (J.H.D.); and Department of Medicine, Seoul National University Hospital, Seoul, South Korea (B.K.K.)
| | - James K Min
- From the Department of Imaging and Medicine, Division of Nuclear Medicine (M.D.Z., R.N., H.G., P.J.S., D.S.B.), and Biomedical Imaging Research Institute (D.D.), Cedars-Sinai Medical Center, 8700 Beverly Blvd, S. Mark Taper Building A238, Los Angeles, CA 90048; Department of Internal Medicine 2, University of Erlangen, Erlangen, Germany (A.S., S.A.); Cardiovascular Institute, Mount Sinai Medical Center, New York, NY (J.N.); Department of Radiology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY (J.K.M.); Department of Medicine, Inje University Ilsan-Paik Hospital, Goyang, South Korea (J.H.D.); and Department of Medicine, Seoul National University Hospital, Seoul, South Korea (B.K.K.)
| | - Joon-Hyung Doh
- From the Department of Imaging and Medicine, Division of Nuclear Medicine (M.D.Z., R.N., H.G., P.J.S., D.S.B.), and Biomedical Imaging Research Institute (D.D.), Cedars-Sinai Medical Center, 8700 Beverly Blvd, S. Mark Taper Building A238, Los Angeles, CA 90048; Department of Internal Medicine 2, University of Erlangen, Erlangen, Germany (A.S., S.A.); Cardiovascular Institute, Mount Sinai Medical Center, New York, NY (J.N.); Department of Radiology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY (J.K.M.); Department of Medicine, Inje University Ilsan-Paik Hospital, Goyang, South Korea (J.H.D.); and Department of Medicine, Seoul National University Hospital, Seoul, South Korea (B.K.K.)
| | - Bon-Kwon Koo
- From the Department of Imaging and Medicine, Division of Nuclear Medicine (M.D.Z., R.N., H.G., P.J.S., D.S.B.), and Biomedical Imaging Research Institute (D.D.), Cedars-Sinai Medical Center, 8700 Beverly Blvd, S. Mark Taper Building A238, Los Angeles, CA 90048; Department of Internal Medicine 2, University of Erlangen, Erlangen, Germany (A.S., S.A.); Cardiovascular Institute, Mount Sinai Medical Center, New York, NY (J.N.); Department of Radiology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY (J.K.M.); Department of Medicine, Inje University Ilsan-Paik Hospital, Goyang, South Korea (J.H.D.); and Department of Medicine, Seoul National University Hospital, Seoul, South Korea (B.K.K.)
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Jin XJ, Tahk SJ, Yang HM, Lim HS, Yoon MH, Choi SY, Choi BJ, Hwang GS, Seo KW, Shin JS, Lee YH, Choi YW, Park SJ, Park JS, Shin JH. The relationship between intravascular ultrasound-derived percent total atheroma volume and fractional flow reserve in the intermediate stenosis of proximal or middle left anterior descending coronary artery. Int J Cardiol 2015; 185:56-61. [DOI: 10.1016/j.ijcard.2015.03.048] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Revised: 10/25/2014] [Accepted: 03/03/2015] [Indexed: 11/29/2022]
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188
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He WM, Li CL, Sun Y, Zhou Z, Mai YF. Safety and Efficacy of a Novel Technique in the Use of Fractional Flow Reserve in Complex Coronary Artery Lesions. Chin Med J (Engl) 2015; 128:822-5. [PMID: 25758280 PMCID: PMC4833990 DOI: 10.4103/0366-6999.152664] [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] [Indexed: 11/19/2022] Open
Abstract
Background: Fractional flow reserve (FFR) has become an increasingly important index when making decisions with respect to revascularization of coronary artery stenosis. However, the pressure guidewire used in obtaining FFR measurements is difficult to control and manipulate in certain complex coronary artery lesions, resulting in increased fluoroscopy time and contrast dye usage. This study examined a novel (NOV) technique for obtaining FFR measurements in hope of easing the difficulties associated with evaluating and treating complex coronary artery lesions. Methods: Fifty-six patients with complex coronary artery lesions were assigned to a conventional (CON) FFR technique group or a NOV FFR technique group. The NOV technique involved the use of a balloon and wire exchange within the coronary artery. The fluoroscopy time, contrast dye usage, and FFR-related complications were assessed after completing the FFR measurement procedure for each patient. Results: The median time required for fluoroscopy in the NOV technique group was significantly less than that in the CON technique group; additionally, lesser amounts of contrast dye were used in the NOV technique group (both P < 0.05). The NOV technique was successfully performed in thirty patients, without any FFR-related complications. However, the CON technique failed in three patients, including two who experienced coronary artery spasms (P > 0.05). Conclusions: Compared to the CON technique used for measuring FFR, the new technique reduced the fluoroscopy time and amount of contrast dye used when evaluating complex coronary artery lesions. The new technique did not increase the risk of operation or decrease the success rate.
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Lee BK, Lim HS, Fearon WF, Yong AS, Yamada R, Tanaka S, Lee DP, Yeung AC, Tremmel JA. Invasive evaluation of patients with angina in the absence of obstructive coronary artery disease. Circulation 2015; 131:1054-60. [PMID: 25712205 DOI: 10.1161/circulationaha.114.012636] [Citation(s) in RCA: 258] [Impact Index Per Article: 28.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND More than 20% of patients presenting to the cardiac catheterization laboratory with angina have no angiographic evidence of coronary artery disease. Despite a "normal" angiogram, these patients often have persistent symptoms, recurrent hospitalizations, a poor functional status, and adverse cardiovascular outcomes, without a clear diagnosis. METHODS AND RESULTS In 139 patients with angina in the absence of obstructive coronary artery disease (no diameter stenosis >50%), endothelial function was assessed; the index of microcirculatory resistance, coronary flow reserve, and fractional flow reserve were measured; and intravascular ultrasound was performed. There were no complications. The average age was 54.0±11.4 years, and 107 (77%) were women. All patients had at least some evidence of atherosclerosis based on an intravascular ultrasound examination of the left anterior descending artery. Endothelial dysfunction (a decrease in luminal diameter of >20% after intracoronary acetylcholine) was present in 61 patients (44%). Microvascular impairment (an index of microcirculatory resistance ≥25) was present in 29 patients (21%). Seven patients (5%) had a fractional flow reserve ≤0.80. A myocardial bridge was present in 70 patients (58%). Overall, only 32 patients (23%) had no coronary explanation for their angina, with normal endothelial function, normal coronary physiological assessment, and no myocardial bridging. CONCLUSIONS The majority of patients with angina in the absence of obstructive coronary artery disease have occult coronary abnormalities. A comprehensive invasive assessment of these patients at the time of coronary angiography can be performed safely and provides important diagnostic information that may affect treatment and outcomes.
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Affiliation(s)
- Bong-Ki Lee
- From Division of Cardiovascular Medicine, Stanford University Medical Center, Stanford, CA (B.-K.L., H.-S.L., W.F.F., A.S.Y., R.Y., S.T., D.P.L., A.C.Y., J.A.T.); Division of Cardiology, Kangwon National University School of Medicine, Chuncheon, Republic of Korea (B.-K.L.); and Department of Cardiology, Ajou University School of Medicine, Suwon, Republic of Korea (H.-S.L.)
| | - Hong-Seok Lim
- From Division of Cardiovascular Medicine, Stanford University Medical Center, Stanford, CA (B.-K.L., H.-S.L., W.F.F., A.S.Y., R.Y., S.T., D.P.L., A.C.Y., J.A.T.); Division of Cardiology, Kangwon National University School of Medicine, Chuncheon, Republic of Korea (B.-K.L.); and Department of Cardiology, Ajou University School of Medicine, Suwon, Republic of Korea (H.-S.L.)
| | - William F Fearon
- From Division of Cardiovascular Medicine, Stanford University Medical Center, Stanford, CA (B.-K.L., H.-S.L., W.F.F., A.S.Y., R.Y., S.T., D.P.L., A.C.Y., J.A.T.); Division of Cardiology, Kangwon National University School of Medicine, Chuncheon, Republic of Korea (B.-K.L.); and Department of Cardiology, Ajou University School of Medicine, Suwon, Republic of Korea (H.-S.L.).
| | - Andy S Yong
- From Division of Cardiovascular Medicine, Stanford University Medical Center, Stanford, CA (B.-K.L., H.-S.L., W.F.F., A.S.Y., R.Y., S.T., D.P.L., A.C.Y., J.A.T.); Division of Cardiology, Kangwon National University School of Medicine, Chuncheon, Republic of Korea (B.-K.L.); and Department of Cardiology, Ajou University School of Medicine, Suwon, Republic of Korea (H.-S.L.)
| | - Ryotaro Yamada
- From Division of Cardiovascular Medicine, Stanford University Medical Center, Stanford, CA (B.-K.L., H.-S.L., W.F.F., A.S.Y., R.Y., S.T., D.P.L., A.C.Y., J.A.T.); Division of Cardiology, Kangwon National University School of Medicine, Chuncheon, Republic of Korea (B.-K.L.); and Department of Cardiology, Ajou University School of Medicine, Suwon, Republic of Korea (H.-S.L.)
| | - Shigemitsu Tanaka
- From Division of Cardiovascular Medicine, Stanford University Medical Center, Stanford, CA (B.-K.L., H.-S.L., W.F.F., A.S.Y., R.Y., S.T., D.P.L., A.C.Y., J.A.T.); Division of Cardiology, Kangwon National University School of Medicine, Chuncheon, Republic of Korea (B.-K.L.); and Department of Cardiology, Ajou University School of Medicine, Suwon, Republic of Korea (H.-S.L.)
| | - David P Lee
- From Division of Cardiovascular Medicine, Stanford University Medical Center, Stanford, CA (B.-K.L., H.-S.L., W.F.F., A.S.Y., R.Y., S.T., D.P.L., A.C.Y., J.A.T.); Division of Cardiology, Kangwon National University School of Medicine, Chuncheon, Republic of Korea (B.-K.L.); and Department of Cardiology, Ajou University School of Medicine, Suwon, Republic of Korea (H.-S.L.)
| | - Alan C Yeung
- From Division of Cardiovascular Medicine, Stanford University Medical Center, Stanford, CA (B.-K.L., H.-S.L., W.F.F., A.S.Y., R.Y., S.T., D.P.L., A.C.Y., J.A.T.); Division of Cardiology, Kangwon National University School of Medicine, Chuncheon, Republic of Korea (B.-K.L.); and Department of Cardiology, Ajou University School of Medicine, Suwon, Republic of Korea (H.-S.L.)
| | - Jennifer A Tremmel
- From Division of Cardiovascular Medicine, Stanford University Medical Center, Stanford, CA (B.-K.L., H.-S.L., W.F.F., A.S.Y., R.Y., S.T., D.P.L., A.C.Y., J.A.T.); Division of Cardiology, Kangwon National University School of Medicine, Chuncheon, Republic of Korea (B.-K.L.); and Department of Cardiology, Ajou University School of Medicine, Suwon, Republic of Korea (H.-S.L.)
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Nørgaard BL, Jensen JM, Leipsic J. Fractional flow reserve derived from coronary CT angiography in stable coronary disease: a new standard in non-invasive testing? Eur Radiol 2015; 25:2282-90. [DOI: 10.1007/s00330-015-3619-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Revised: 01/07/2015] [Accepted: 01/20/2015] [Indexed: 10/24/2022]
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Rajabi-Jaghargh E, Banerjee RK. Combined functional and anatomical diagnostic endpoints for assessing arteriovenous fistula dysfunction. World J Nephrol 2015; 4:6-18. [PMID: 25664243 PMCID: PMC4317629 DOI: 10.5527/wjn.v4.i1.6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2014] [Revised: 08/26/2014] [Accepted: 11/19/2014] [Indexed: 02/06/2023] Open
Abstract
Failure of arteriovenous fistulas (AVF) to mature and thrombosis in matured fistulas have been the major causes of morbidity and mortality in hemodialysis patients. Stenosis, which occurs due to adverse remodeling in AVFs, is one of the major underlying factors under both scenarios. Early diagnosis of a stenosis in an AVF can provide an opportunity to intervene in a timely manner for either assisting the maturation process or avoiding the thrombosis. The goal of surveillance strategies was to supplement the clinical evaluation (i.e., physical examination) of the AVF for better and earlier diagnosis of a developing stenosis. Surveillance strategies were mainly based on measurement of functional hemodynamic endpoints, including blood flow (Qa) to the vascular access and venous access pressure (VAP). As the changes in arterial pressure (MAP) affects the level of VAP, the ratio of VAP to MAP (VAPR = VAP/MAP) was used for diagnosis. A Qa < 400-500 mL/min or a VAPR > 0.55 is considered sign of significant stenosis, which requires immediate intervention. However, due to the complex nature of AVFs, the surveillance strategies have failed to consistently detect stenosis under different scenarios. VAPR has been primarily developed to detect outflow stenosis in arteriovenous grafts, and it hasn’t been successful in accurate diagnosis of outflow lesions in AVFs. Similarly, AVFs can maintain relatively high blood flow despite the presence of a significant outflow stenosis and thus, Qa has been found to be a better predictor of only inflow lesions. Similar shortcomings have been reported in the detection of functional severity of coronary stenosis using diagnostic endpoints that were based on either flow or pressure. This limitation has been associated with the fact that both pressure and flow change in the presence of a stenosis and thus, hemodynamic diagnostic endpoints that employ only one of these parameters are inherently prone to inaccuracies. Recent attempts have resulted in development of new diagnostic endpoints that can combine the effects of pressure and flow. These new hemodynamic diagnostic endpoints have shown to be better predictors of functional severity of lesions as compared to either flow or pressure based counterparts. In this review article, we discussed the advantages and limitations of current functional and anatomical diagnostic endpoints in AVFs.
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Stuijfzand WJ, Uusitalo V, Kero T, Danad I, Rijnierse MT, Saraste A, Raijmakers PG, Lammertsma AA, Harms HJ, Heymans MW, Huisman MC, Marques KM, Kajander SA, Pietilä M, Sörensen J, Royen NV, Knuuti J, Knaapen P. Relative Flow Reserve Derived From Quantitative Perfusion Imaging May Not Outperform Stress Myocardial Blood Flow for Identification of Hemodynamically Significant Coronary Artery Disease. Circ Cardiovasc Imaging 2015; 8:CIRCIMAGING.114.002400. [DOI: 10.1161/circimaging.114.002400] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Wijnand J. Stuijfzand
- From the Departments of Cardiology (W.J.S., I.D., M.T.R., K.M.M., N.v.R., P.K.), Radiology and Nuclear Medicine (P.G.R., A.A.L, H.J.H., M.C.H.), Department of Epidemiology and Biostatistics (M.W.H.), VU University Medical Center, Amsterdam, The Netherlands; Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland (V.U., A.S., S.A.K, M.P., J.K.); and Department of Nuclear Medicine and PET, Institution of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala
| | - Valtteri Uusitalo
- From the Departments of Cardiology (W.J.S., I.D., M.T.R., K.M.M., N.v.R., P.K.), Radiology and Nuclear Medicine (P.G.R., A.A.L, H.J.H., M.C.H.), Department of Epidemiology and Biostatistics (M.W.H.), VU University Medical Center, Amsterdam, The Netherlands; Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland (V.U., A.S., S.A.K, M.P., J.K.); and Department of Nuclear Medicine and PET, Institution of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala
| | - Tanja Kero
- From the Departments of Cardiology (W.J.S., I.D., M.T.R., K.M.M., N.v.R., P.K.), Radiology and Nuclear Medicine (P.G.R., A.A.L, H.J.H., M.C.H.), Department of Epidemiology and Biostatistics (M.W.H.), VU University Medical Center, Amsterdam, The Netherlands; Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland (V.U., A.S., S.A.K, M.P., J.K.); and Department of Nuclear Medicine and PET, Institution of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala
| | - Ibrahim Danad
- From the Departments of Cardiology (W.J.S., I.D., M.T.R., K.M.M., N.v.R., P.K.), Radiology and Nuclear Medicine (P.G.R., A.A.L, H.J.H., M.C.H.), Department of Epidemiology and Biostatistics (M.W.H.), VU University Medical Center, Amsterdam, The Netherlands; Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland (V.U., A.S., S.A.K, M.P., J.K.); and Department of Nuclear Medicine and PET, Institution of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala
| | - Mischa T. Rijnierse
- From the Departments of Cardiology (W.J.S., I.D., M.T.R., K.M.M., N.v.R., P.K.), Radiology and Nuclear Medicine (P.G.R., A.A.L, H.J.H., M.C.H.), Department of Epidemiology and Biostatistics (M.W.H.), VU University Medical Center, Amsterdam, The Netherlands; Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland (V.U., A.S., S.A.K, M.P., J.K.); and Department of Nuclear Medicine and PET, Institution of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala
| | - Antti Saraste
- From the Departments of Cardiology (W.J.S., I.D., M.T.R., K.M.M., N.v.R., P.K.), Radiology and Nuclear Medicine (P.G.R., A.A.L, H.J.H., M.C.H.), Department of Epidemiology and Biostatistics (M.W.H.), VU University Medical Center, Amsterdam, The Netherlands; Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland (V.U., A.S., S.A.K, M.P., J.K.); and Department of Nuclear Medicine and PET, Institution of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala
| | - Pieter G. Raijmakers
- From the Departments of Cardiology (W.J.S., I.D., M.T.R., K.M.M., N.v.R., P.K.), Radiology and Nuclear Medicine (P.G.R., A.A.L, H.J.H., M.C.H.), Department of Epidemiology and Biostatistics (M.W.H.), VU University Medical Center, Amsterdam, The Netherlands; Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland (V.U., A.S., S.A.K, M.P., J.K.); and Department of Nuclear Medicine and PET, Institution of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala
| | - Adriaan A. Lammertsma
- From the Departments of Cardiology (W.J.S., I.D., M.T.R., K.M.M., N.v.R., P.K.), Radiology and Nuclear Medicine (P.G.R., A.A.L, H.J.H., M.C.H.), Department of Epidemiology and Biostatistics (M.W.H.), VU University Medical Center, Amsterdam, The Netherlands; Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland (V.U., A.S., S.A.K, M.P., J.K.); and Department of Nuclear Medicine and PET, Institution of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala
| | - Hans J. Harms
- From the Departments of Cardiology (W.J.S., I.D., M.T.R., K.M.M., N.v.R., P.K.), Radiology and Nuclear Medicine (P.G.R., A.A.L, H.J.H., M.C.H.), Department of Epidemiology and Biostatistics (M.W.H.), VU University Medical Center, Amsterdam, The Netherlands; Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland (V.U., A.S., S.A.K, M.P., J.K.); and Department of Nuclear Medicine and PET, Institution of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala
| | - Martijn W. Heymans
- From the Departments of Cardiology (W.J.S., I.D., M.T.R., K.M.M., N.v.R., P.K.), Radiology and Nuclear Medicine (P.G.R., A.A.L, H.J.H., M.C.H.), Department of Epidemiology and Biostatistics (M.W.H.), VU University Medical Center, Amsterdam, The Netherlands; Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland (V.U., A.S., S.A.K, M.P., J.K.); and Department of Nuclear Medicine and PET, Institution of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala
| | - Marc C. Huisman
- From the Departments of Cardiology (W.J.S., I.D., M.T.R., K.M.M., N.v.R., P.K.), Radiology and Nuclear Medicine (P.G.R., A.A.L, H.J.H., M.C.H.), Department of Epidemiology and Biostatistics (M.W.H.), VU University Medical Center, Amsterdam, The Netherlands; Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland (V.U., A.S., S.A.K, M.P., J.K.); and Department of Nuclear Medicine and PET, Institution of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala
| | - Koen M. Marques
- From the Departments of Cardiology (W.J.S., I.D., M.T.R., K.M.M., N.v.R., P.K.), Radiology and Nuclear Medicine (P.G.R., A.A.L, H.J.H., M.C.H.), Department of Epidemiology and Biostatistics (M.W.H.), VU University Medical Center, Amsterdam, The Netherlands; Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland (V.U., A.S., S.A.K, M.P., J.K.); and Department of Nuclear Medicine and PET, Institution of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala
| | - Sami A. Kajander
- From the Departments of Cardiology (W.J.S., I.D., M.T.R., K.M.M., N.v.R., P.K.), Radiology and Nuclear Medicine (P.G.R., A.A.L, H.J.H., M.C.H.), Department of Epidemiology and Biostatistics (M.W.H.), VU University Medical Center, Amsterdam, The Netherlands; Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland (V.U., A.S., S.A.K, M.P., J.K.); and Department of Nuclear Medicine and PET, Institution of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala
| | - Mikko Pietilä
- From the Departments of Cardiology (W.J.S., I.D., M.T.R., K.M.M., N.v.R., P.K.), Radiology and Nuclear Medicine (P.G.R., A.A.L, H.J.H., M.C.H.), Department of Epidemiology and Biostatistics (M.W.H.), VU University Medical Center, Amsterdam, The Netherlands; Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland (V.U., A.S., S.A.K, M.P., J.K.); and Department of Nuclear Medicine and PET, Institution of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala
| | - Jens Sörensen
- From the Departments of Cardiology (W.J.S., I.D., M.T.R., K.M.M., N.v.R., P.K.), Radiology and Nuclear Medicine (P.G.R., A.A.L, H.J.H., M.C.H.), Department of Epidemiology and Biostatistics (M.W.H.), VU University Medical Center, Amsterdam, The Netherlands; Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland (V.U., A.S., S.A.K, M.P., J.K.); and Department of Nuclear Medicine and PET, Institution of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala
| | - Niels van Royen
- From the Departments of Cardiology (W.J.S., I.D., M.T.R., K.M.M., N.v.R., P.K.), Radiology and Nuclear Medicine (P.G.R., A.A.L, H.J.H., M.C.H.), Department of Epidemiology and Biostatistics (M.W.H.), VU University Medical Center, Amsterdam, The Netherlands; Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland (V.U., A.S., S.A.K, M.P., J.K.); and Department of Nuclear Medicine and PET, Institution of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala
| | - Juhani Knuuti
- From the Departments of Cardiology (W.J.S., I.D., M.T.R., K.M.M., N.v.R., P.K.), Radiology and Nuclear Medicine (P.G.R., A.A.L, H.J.H., M.C.H.), Department of Epidemiology and Biostatistics (M.W.H.), VU University Medical Center, Amsterdam, The Netherlands; Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland (V.U., A.S., S.A.K, M.P., J.K.); and Department of Nuclear Medicine and PET, Institution of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala
| | - Paul Knaapen
- From the Departments of Cardiology (W.J.S., I.D., M.T.R., K.M.M., N.v.R., P.K.), Radiology and Nuclear Medicine (P.G.R., A.A.L, H.J.H., M.C.H.), Department of Epidemiology and Biostatistics (M.W.H.), VU University Medical Center, Amsterdam, The Netherlands; Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland (V.U., A.S., S.A.K, M.P., J.K.); and Department of Nuclear Medicine and PET, Institution of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala
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Yang S, Wang DZ, Zhang HX, He W, Chen BX. Echo-tracking technology assessment of carotid artery stiffness in patients with coronary slow flow. ULTRASOUND IN MEDICINE & BIOLOGY 2015; 41:72-76. [PMID: 25438843 DOI: 10.1016/j.ultrasmedbio.2014.08.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Revised: 08/13/2014] [Accepted: 08/17/2014] [Indexed: 06/04/2023]
Abstract
Coronary slow flow (CSF) in coronary angiography (CAG) is a well-recognized clinical entity. Previous studies have suggested that microvascular abnormalities and endothelial dysfunction are responsible for CSF. Accordingly, we hypothesized that the CSF phenomenon is a form of atherosclerosis including both small vessels and epicardial coronary arteries. The echo-tracking (ET) technique is a non-invasive detection method for early prediction of arterial atherosclerosis. Therefore, we investigated carotid elasticity with the ET technique in patients with CSF. Fifty patients with CSF and 50 patients with normal coronary artery blood flow, as determined by CAG, with a similar distribution of risk factors were recruited. The stiffness parameter (β), pressure-strain elastic modulus (Ep), arterial compliance (AC), augmentation index (AIx) and local pulse-wave velocity (PWV) were determined at the level of the bilateral common carotid artery (CCA) with using the ET technique. Levels of serum high-sensitivity C-reactive protein (hs-HSCRP) were determined for the two groups. β, Ep and PWV were significantly higher in the CSF group than in the control group (β: 11.4 ± 3.76 vs. 9.22 ± 3.28, p < 0.01; Ep: 153.44 ± 47.85 vs. 126.40 ± 43.32, p < 0.01; PWV: 7.26 ± 1.10 vs. 6.55 ± 1.02, p < 0.01), but AC was lower in the CSF group than in the control group (0.62 ± 0.20 vs. 0.74 ± 0.24, p < 0.01). The elasticity parameters of the bilateral common carotid artery did not significantly differ. The level of hs-HSCRP was correlated positively with β (r = 0.306, p = 0.015), Ep (r = 0.358, p = 0.005) and PWV (r = 0.306, p = 0.015), but negatively with AC (r = -0.236, p = 0.049). In conclusion, the ET technique is a simple practical method for evaluating carotid artery elasticity, and there is a significant correlation between carotid artery stiffness and level of hs-HSCRP in patients with CSF.
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Affiliation(s)
- Song Yang
- Department of Ultrasonography, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - De-Zhao Wang
- Department of Cardiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
| | - Hong-Xia Zhang
- Department of Ultrasonography, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Wen He
- Department of Ultrasonography, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
| | - Bu-Xing Chen
- Department of Cardiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Clinical Cardiac Positron Emission Tomography. Coron Artery Dis 2015. [DOI: 10.1007/978-1-4471-2828-1_12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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196
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Longitudinal myocardial blood flow gradient and CAD detection. Curr Cardiol Rep 2014; 17:550. [PMID: 25417123 DOI: 10.1007/s11886-014-0550-z] [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] [Indexed: 01/18/2023]
Abstract
Conventional myocardial perfusion scintigraphy with SPECT/CT or with PET/CT has been established as pivotal clinical imaging modality for the identification of hemodynamically obstructive coronary artery disease (CAD) and risk stratification of patients with suspected or known CAD. While the assessment of the relative distribution of radiotracer uptake in the left-ventricular (LV) myocardium during vasomotor stress identifies the "culprit" or most severe CAD lesion in multivessel disease, flow-limiting effects of remaining but less severe epicardial lesions may be missed. This limitation principally may be overcome by the possibility of PET/CT with radiotracer-kinetic modeling to concurrently assess left-ventricular (LV) myocardial blood flow (MBF) in ml/g/min at rest and during vasomotor stress and the resulting myocardial flow reserve (MFR). While a stress-induced regional reduction in radiotracer uptake or perfusion identifies the most advanced epicardial lesion, flow-limiting effects of the other epicardial lesions may principally be identified by regional reductions in MFR. Conversely, reductions in MFR in CAD may be appreciated as suboptimal as they reflect not only the consequences of flow-limiting effects of epicardial stenosis but also of microvascular dysfunction. The relatively low specificity of a reduced therefore MFR may hamper a clear identification of the downstream hemodynamic effects of an epicardial lesion on hyperemic coronary flow increases. In this scenario, there is increasing evidence that the PET assessment of an abnormal decrease in MBF from the base to the apex of the LV during hyperemic flows, a so-called longitudinal flow gradient, is primarily related to fluid dynamic consequences of CAD-induced diffuse luminal and/or focal narrowing of the epicardial artery. The combined evaluation of the MFR and corresponding longitudinal MBF gradient could emerge as new a novel analytic concept to further optimize the identification and characterization of hemodynamic CAD burden in multivessel disease, which, however, warrants further clinical validation.
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Alghamdi A, Balgaith M, Alkhaldi A. Influence of the length of coronary artery lesions on fractional flow reserve across intermediate coronary obstruction. Eur Heart J Suppl 2014. [DOI: 10.1093/eurheartj/suu010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Ito T, Tani T, Fujita H, Ohte N. Relationship between fractional flow reserve and residual plaque volume and clinical outcomes after optimal drug-eluting stent implantation: Insight from intravascular ultrasound volumetric analysis. Int J Cardiol 2014; 176:399-404. [DOI: 10.1016/j.ijcard.2014.07.115] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2014] [Revised: 07/06/2014] [Accepted: 07/26/2014] [Indexed: 11/30/2022]
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Schindler TH, Quercioli A, Valenta I, Ambrosio G, Wahl RL, Dilsizian V. Quantitative Assessment of Myocardial Blood Flow—Clinical and Research Applications. Semin Nucl Med 2014; 44:274-93. [DOI: 10.1053/j.semnuclmed.2014.04.002] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Abstract
Coronary blood flow is tightly autoregulated but is subject to epicardial and microvascular obstruction, primarily owing to coronary atherosclerosis. Because coronary flow limitation underlies ischemic heart disease, an understanding of coronary physiology is paramount. Measurement of coronary blood flow, once relegated to the research laboratory is now easily performed in the cardiac catheterization laboratory. In particular, the measurement of fractional flow reserve has been extensively studied and is an important adjunct to clinical decision making. Measurement of coronary flow informs clinicians of prognosis, guides revascularization therapy, and forms the basis of ongoing research in treatment of complex myocardial disease processes. Newer methods of assessing coronary flow measurements are undergoing validation for clinical use and should further enhance our ability to assess the importance of coronary flow in clinical disease.
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