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Cortigiani L, Rigo F, Bovenzi F, Sicari R, Picano E. The Prognostic Value of Coronary Flow Velocity Reserve in Two Coronary Arteries During Vasodilator Stress Echocardiography. J Am Soc Echocardiogr 2019; 32:81-91. [DOI: 10.1016/j.echo.2018.09.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Indexed: 10/28/2022]
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Ciampi Q, Rigo F, Grolla E, Picano E, Cortigiani L. Dual imaging stress echocardiography versus computed tomography coronary angiography for risk stratification of patients with chest pain of unknown origin. Cardiovasc Ultrasound 2015; 13:21. [PMID: 25896850 PMCID: PMC4409769 DOI: 10.1186/s12947-015-0013-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Accepted: 04/01/2015] [Indexed: 01/07/2023] Open
Abstract
Background Dual imaging stress echocardiography, combining the evaluation of wall motion and coronary flow reserve (CFR) on the left anterior descending artery (LAD), and computed tomography coronary angiography (CTCA) are established techniques for assessing prognosis in chest pain patients. In this study we compared the prognostic value of the two methods in a cohort of patients with chest pain having suspected coronary artery disease (CAD). Methods A total of 131 patients (76 men; age 68 ± 9 years) with chest pain of unknown origin underwent dipyridamole (up to 0.84 mg/kg over 6 min) stress echo with CFR assessment of LAD by Doppler and CTCA. A CFR ≤ 1.9 was considered abnormal, while > 50% lumen diameter reduction was the criterion for significant CAD at CTCA. Results Of 131 patients, 34 (26%) had ischemia at stress echo (new wall motion abnormalities), and 56 (43%) had reduced CFR on LAD. Significant coronary stenosis at CTCA was found in 69 (53%) patients. Forty-six patients (84%) with abnormal CFR on LAD showed significant CAD at CTCA (p < 0.001). Calcium score was higher in patients with reduced than in those with normal CFR (265 ± 404 vs 131 ± 336, p = 0.04). During a median follow-up of 7 months (1st to 3rd quartile: 5–13 months), there were 45 major cardiac events (4 deaths, 11 nonfatal myocardial infarctions, and 30 late [≥6 months] coronary revascularizations). At Cox analysis, independent prognostic indicators were calcium score > 100 (HR 2.84, 95% CI 1.33-6.07, p = 0.007), significant CAD at CTCA (HR 2.68, 95% CI 1.23-5.82, p = 0.013), and inducible ischemia or CFR <1.9R on LAD on dual imaging stress echo (HR 2.25, 95% CI 1.05-4.84, p = 0.038). Conclusions Functional and anatomical evaluation using, respectively, dual imaging stress echocardiography and CTCA are both effective modalities to risk stratify patients with chest pain of unknown origin, yielding independent and comparable prognostic value. Compared to CTCA, however, stress echocardiography has the advantage of lower cost and of being free of radiations.
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Affiliation(s)
- Quirino Ciampi
- Division of Cardiology, Fatebenefratelli Hospital, Viale Principe di Napoli, 12 I-82100, Benevento, Italy. .,CNR Institute of Clinical Physiology, Pisa, Italy.
| | - Fausto Rigo
- Department of Cardiology, dell'Angelo Hospital, Mestre-Venice, Italy.
| | - Elisabetta Grolla
- Department of Cardiology, dell'Angelo Hospital, Mestre-Venice, Italy.
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Ascione L, Carlomagno G, Sordelli C, Iengo R, Monda V, Severino S, Merenda R, D'Andrea A, Caso P. Dipyridamole coronary flow reserve stratifies prognosis in acute coronary syndrome patients without left anterior descending disease. Eur Heart J Cardiovasc Imaging 2013; 14:858-64. [DOI: 10.1093/ehjci/jes305] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Assessment of Coronary Flow During Stress Testing: Does it Add Diagnostic and Prognostic Value? CURRENT CARDIOVASCULAR IMAGING REPORTS 2011. [DOI: 10.1007/s12410-011-9101-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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D'Andrea A, Nistri S, Castaldo F, Galderisi M, Mele D, Agricola E, Losi MA, Mondillo S, Marino PN. The relationship between early left ventricular myocardial alterations and reduced coronary flow reserve in non-insulin-dependent diabetic patients with microvascular angina. Int J Cardiol 2010; 154:250-5. [PMID: 21035209 DOI: 10.1016/j.ijcard.2010.09.044] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2010] [Accepted: 09/10/2010] [Indexed: 12/21/2022]
Abstract
AIMS To evaluate left ventricular (LV) systolic and diastolic myocardial function, and their relation to coronary flow reserve in patients with non-insulin-dependent diabetes mellitus (DM) and microvascular angina. METHODS AND RESULTS We selected a population of 45 normotensive patients with DM (56.3 ± 8.2 years; 25 males) with LV ejection fraction >50% and microvascular angina (anginal pain, positive imaging stress test and normal coronary angiography). Thirty-five age- and sex-matched healthy controls were also enrolled. All the patients underwent standard echocardiography, Tissue Doppler (TDI), two-dimensional strain (2DSE) imaging, and coronary flow reserve (CFR) measurement. LV myocardial early diastolic peak velocities (E(m)) and peak systolic 2DSE were reduced in both interventricular septum (IVS) and LV lateral wall (p<0.01) in DM, as well as CFR (1.89 ± 0.7 vs 2.55 ± 0.56, p<0.0001) compared with controls. By multivariate analysis, the independent determinants of E(m) were glycated haemoglobin (β coefficient=-0.36; p<0.01) and age (β=-0.46, p<0.001), while global longitudinal strain was predicted by glycated haemoglobin (β=0.48, P<0.001) and by the duration of the disease (β=0.38, P<0.005). An independent association between LV global longitudinal strain and CFR (β coefficient=-0.47, p<0.001) in DM patients was also evidenced. CONCLUSIONS TDI, 2DSE and CFR are valuable non-invasive and easy-repeatable tools for detecting LV myocardial and coronary function in DM patients with microvascular angina.
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Implication of the continuous prognostic spectrum of Doppler echocardiographic derived coronary flow reserve on left anterior descending artery. Am J Cardiol 2010; 105:158-62. [PMID: 20102911 DOI: 10.1016/j.amjcard.2009.08.669] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2009] [Revised: 08/25/2009] [Accepted: 08/25/2009] [Indexed: 11/20/2022]
Abstract
The additive prognostic value of coronary flow reserve (CFR) over regional wall motion has been established, but there is more than a binary (normal-abnormal) response in CFR, which can be continuously titrated. We assessed the prognostic value of quartiles of CFR, evaluated by transthoracic Doppler of the left anterior descending coronary artery (LAD), in patients with known or suspected coronary artery disease (CAD). One thousand six hundred twenty patients (1,006 men, 64 +/- 11 years of age) underwent dipyridamole (up to 0.84 mg/kg over 6 minutes) stress echocardiography with CFR evaluation of LAD by Doppler and coronary angiography. Patients were followed up for a median of 19 months. Mean CFR in the entire population was 2.25 +/- 0.65. Stress echocardiogram was positive for ischemia in 480 patients (30%). Obstructive (>or=70% vessel stenosis) CAD at angiography was present in 650 patients (40%). During follow-up, there were 298 events (42 deaths, 73 ST-elevation myocardial infarctions, and 183 non-ST-elevation myocardial infarctions). Patients (n = 399) undergoing revascularization were censored. With the Kaplan-Meier method, the first quartile of CFR (<or=1.80) was associated with a worse (p <0.0001) event rate than other quartiles in the entire population and in patients with no ischemia at stress echocardiography. Furthermore, the second quartile of CFR (1.81 to 2.16) was predictive of increased (p <0.0001) risk compared to the higher quartiles. In conclusion, Doppler echocardiographically derived CFR in LAD is a strong and independent prognostic predictor in patients with known or suspected CAD, but the spectrum of prognostic stratifications is expanded if the response is titrated according to a continuous scale rather than artificially dichotomized.
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D'Andrea A, Severino S, Mita C, Riegler L, Cocchia R, Gravino R, Castaldo F, Scarafile R, Salerno G, Pirone S, Calabrò P, Bigazzi MC, Citro R, Cuomo S, Caso P, Calabrò R. Clinical Outcome in Patients with Intermediate Stenosis of Left Anterior Descending Coronary Artery after Deferral of Revascularization on the Basis of Noninvasive Coronary Flow Reserve Measurement. Echocardiography 2009; 26:431-40. [DOI: 10.1111/j.1540-8175.2008.00807.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Shiina Y, Funabashi N, Lee K, Murayama T, Nakamura K, Wakatsuki Y, Daimon M, Komuro I. Acute effect of oral flavonoid-rich dark chocolate intake on coronary circulation, as compared with non-flavonoid white chocolate, by transthoracic Doppler echocardiography in healthy adults. Int J Cardiol 2009; 131:424-9. [DOI: 10.1016/j.ijcard.2007.07.131] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2007] [Accepted: 07/07/2007] [Indexed: 10/22/2022]
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Prognostic value of coronary flow reserve in medically treated patients with left anterior descending coronary disease with stenosis 51% to 75% in diameter. Am J Cardiol 2007; 100:1527-31. [PMID: 17996513 DOI: 10.1016/j.amjcard.2007.06.060] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2007] [Revised: 06/17/2007] [Accepted: 06/17/2007] [Indexed: 12/12/2022]
Abstract
According to American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions 2005 guidelines on percutaneous intervention, intracoronary physiologic measurement in the assessment of effects of intermediate coronary stenoses in patients with anginal symptoms is a class IIa indication. This study assessed the additional prognostic value of Doppler echocardiographically derived coronary flow reserve (CFR) in patients with single-vessel disease and intermediate stenosis severity. We enrolled 86 patients (44 men; 66 +/- 10 years of age) with angiographically assessed single-vessel coronary artery disease of the left anterior descending coronary artery (LAD) with quantitatively assessed diameter stenosis severity 50% to 75%. All patients underwent dipyridamole (up to 0.84 mg/kg over 6 minutes) stress echocardiography with wall motion analysis by 2-dimensional echocardiography and CFR evaluation of the affected artery by Doppler. All patients were followed up for a median of 14 months (first quartile 10, third quartile 18) after diagnostic coronary angiography (without percutaneous intervention for a clinically driven decision). Mean diameter stenosis of the LAD was 58 +/- 10%. Mean CFR of the LAD was 2.09 +/- 0.5. Regional wall motion abnormality at peak stress was present in 17 patients. During follow-up, 24 events occurred: 6 nonfatal ST-elevation myocardial infarctions and 18 non-ST-elevation myocardial infarctions. Thirty-month spontaneous event-free survival was higher in patients with normal CFR and lower in patients with decreased CFR (86% vs 30%, p = 0.0001). At Cox analysis, a CFR <2 (hazard ratio 24.2, 95% confidence interval 3.2 to 179.7, p = 0.002) was the only independent prognostic predictor of outcome. In conclusion, in medically treated patients with single-vessel disease of intermediate severity, decreased CFR is associated with a worse outcome.
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D'Andrea A, Stisi S, Caso P, Uccio FSD, Bellissimo S, Salerno G, Scarafile R, Riegler L, Cuomo S, Citro R, Scherillo M, Calabrò R. Associations between left ventricular myocardial involvement and endothelial dysfunction in systemic sclerosis: noninvasive assessment in asymptomatic patients. Echocardiography 2007; 24:587-97. [PMID: 17584198 DOI: 10.1111/j.1540-8175.2007.00436.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES Systemic sclerosis (SSc) is a multisystem disorder characterized by widespread vascular lesions and fibrosis of skin and distinct internal organs. Cardiac involvement is a common finding in SSc, but often clinically occult. AIM OF THE STUDY To analyze possible associations of left ventricular (LV) myocardial function with coronary flow reserve (CFR) and endothelial function in asymptomatic patients with SSc. METHODS 30 healthy patients and 33 age- and sex-comparable asymptomatic patients classified as having either diffuse (18 patients) or limited form (15 patients) of SSc underwent standard Doppler Echo, Doppler myocardial imaging, Strain rate imaging of interventricular septum and LV lateral wall, transthoracic CFR of left anterior descending coronary vessel (after dipyridamole infusion), and brachial artery vasodilatation measurement (Vivid 7, GE Medical Systems Inc). RESULTS LV diameters and ejection fraction were comparable between the two groups, while systolic pulmonary pressure (P < 0.001) was increased in SSc. By chest-CT, 15 SSc patients showed interstitial pulmonary fibrosis. Serological antibodies analysis detected anti-centromere pattern in 14 SSc patients, and anti Scl-70 in 19 patients. In SSc, LV myocardial early diastolic peak velocity, peak systolic strain rate and strain were both reduced in basal and middle interventricular septum, and in basal and middle LV lateral wall. Both CFR (P < 0.0001) and endothelial flow-mediated dilatation (P < 0.001) were significantly lower in SSc patients. By stepwise forward multivariate analyses, CFR (P < 0.001) and endothelial function (P < 0.001) were powerful independent determinants of middle LV strain. CONCLUSIONS Strain rate imaging, transthoracic CFR, and brachial artery flow-mediated dilatation are valuable noninvasive and easily repeatable tools for detecting LV myocardial and vascular involvement caused by SSc. Their combined use may be therefore useful for early identifying patients with more diffused and severe form of SSc, ideally in asymptomatic cases prior to the development of severe vasculopathy, when it may be most feasible to modify the disease process by new potential therapies.
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MESH Headings
- Blood Flow Velocity
- Blood Pressure
- Brachial Artery/diagnostic imaging
- Brachial Artery/physiopathology
- Coronary Circulation
- Echocardiography, Doppler/methods
- Echocardiography, Doppler, Pulsed/methods
- Endothelium, Vascular/diagnostic imaging
- Endothelium, Vascular/physiopathology
- Female
- Heart Ventricles/diagnostic imaging
- Heart Ventricles/physiopathology
- Humans
- Male
- Middle Aged
- Reference Values
- Reproducibility of Results
- Scleroderma, Systemic/complications
- Scleroderma, Systemic/physiopathology
- Stroke Volume
- Vasodilation
- Ventricular Dysfunction, Left/complications
- Ventricular Dysfunction, Left/diagnosis
- Ventricular Dysfunction, Left/physiopathology
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D'Andrea A, Caso P, Cuomo S, Scotto di Uccio F, Scarafile R, Salerno G, Romano S, Stisi S, Scherillo M, Calabrò R. Myocardial and vascular dysfunction in systemic sclerosis: The potential role of noninvasive assessment in asymptomatic patients. Int J Cardiol 2007; 121:298-301. [PMID: 17156866 DOI: 10.1016/j.ijcard.2006.08.119] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2006] [Accepted: 08/12/2006] [Indexed: 11/17/2022]
Abstract
Systemic sclerosis (SSc) is a multi-system disorder characterized by widespread vascular lesions and fibrosis of skin and distinct internal organs. The aim of the present study was to analyze possible associations of left ventricular (LV) myocardial function with coronary flow reserve (CFR) and endothelial function in asymptomatic patients with SSc. Thirty healthy subjects and 33 age- and sex-comparable asymptomatic SSc patients underwent standard Doppler Myocardial Imaging, Strain Rate (SR) Imaging of interventricular septum (IVS) and LV lateral wall, transthoracic CFR of left anterior descending coronary vessel, and brachial artery vasodilatation measurement. In SSc patients, LV myocardial early diastolic peak velocity, peak systolic SR and strain were both reduced in basal and middle IVS, and in basal and middle LV lateral wall (p<0.001). In addition, both CFR (p<0.0001) and endothelial flow-mediated dilatation (p<0.001) were significantly lower in SSc patients. By stepwise forward multivariate analyses, CFR (p<0.001) and endothelial function (p<0.001) were powerful independent determinants of middle LV strain of SSc patients. In conclusion, SR Imaging, transthoracic CFR and brachial artery flow-mediated dilatation are valuable non-invasive and easy-repeatable tools for detecting early LV myocardial and vascular involvement caused by SSc.
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Cortigiani L, Rigo F, Gherardi S, Sicari R, Galderisi M, Bovenzi F, Picano E. Additional prognostic value of coronary flow reserve in diabetic and nondiabetic patients with negative dipyridamole stress echocardiography by wall motion criteria. J Am Coll Cardiol 2007; 50:1354-61. [PMID: 17903635 DOI: 10.1016/j.jacc.2007.06.027] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2007] [Revised: 06/06/2007] [Accepted: 06/20/2007] [Indexed: 01/30/2023]
Abstract
OBJECTIVES The aim of this prospective, multicenter, observational study was to compare the prognostic value of Doppler echocardiographic-derived coronary flow reserve (CFR) in diabetic and nondiabetic patients with known or suspected coronary artery disease and negative dipyridamole stress echocardiography. BACKGROUND The prognostic value of CFR in diabetic patients with negative stress echocardiography remains unknown. METHODS The study group consisted of 1,130 patients (207 diabetics) with known (n = 418) or suspected (n = 712) coronary artery disease and negative stress echocardiography by wall motion criteria. All underwent dipyridamole (up to 0.84 mg/kg over 6 min) echocardiography with CFR evaluation of left anterior descending artery by Doppler. A value of CFR < or =2.0 was considered abnormal. RESULTS Coronary flow reserve was abnormal in 309 (27%) patients. During a median follow-up of 16 months, 98 events (8 deaths, 24 ST-segment elevation myocardial infarctions, and 66 non-ST-segment elevation myocardial infarctions) occurred. In addition, 101 patients underwent revascularization and were censored. Multivariable prognostic indicators were abnormal CFR (p < 0.0001), anti-ischemic therapy at the time of testing (p = 0.002), age (p = 0.02), and resting wall motion abnormality (p = 0.05). The event rate was markedly higher (p < 0.0001) for both diabetic and nondiabetic patients with abnormal CFR as compared with diabetic and nondiabetic patients with normal CFR. Of note, a preserved CFR off therapy identified diabetic and nondiabetic patients with better survival and comparable yearly event rates (2.2% vs. 2.0%, p = 0.80). CONCLUSIONS Coronary flow reserve provides independent prognostic information in diabetic and nondiabetic patients with known or suspected coronary artery disease and negative dipyridamole stress echocardiography. In particular, a normal CFR off therapy is associated with better and similar survival in the 2 populations.
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Rigo F, Gherardi S, Galderisi M, Cortigiani L. Coronary flow reserve evaluation in stress-echocardiography laboratory. J Cardiovasc Med (Hagerstown) 2006; 7:472-9. [PMID: 16801808 DOI: 10.2459/01.jcm.0000234765.58207.b3] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The assessment of coronary flow reserve by transthoracic echocardiography has recently been introduced into clinical practice with good results for the diagnosis of left anterior descending artery disease and fairly promising results for posterior descending coronary artery disease. By looking at what is behind wall motion, we may realize a sonographer's dream and, in particular, the addition of coronary flow reserve to regional wall motion analysis allows us to have - in the same sitting - high specificity (regional wall motion) and a highly sensitive (coronary flow reserve) diagnostic marker, with an improvement in overall diagnostic accuracy. Coronary flow reserve evaluation may shift the balance of stress choice in favor of vasodilators, which are easier to perform with dual imaging than dobutamine or exercise coronary flow reserve evaluation and may shift the choice in favor of dipyridamole or adenosine stress tests, which are also easier to perform with dual imaging than those using dobutamine or exercise. Lastly, it adds quantitative support to the exquisitely qualitative assessment of wall motion analysis, thereby facilitating the communication of stress echo results to the cardiological world outside the echo laboratory.
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Affiliation(s)
- Fausto Rigo
- Department of Cardiology, Umberto I Hospital, Mestre-Venice, Italy.
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Rigo F. Coronary flow reserve in stress-echo lab. From pathophysiologic toy to diagnostic tool. Cardiovasc Ultrasound 2005; 3:8. [PMID: 15792499 PMCID: PMC1084250 DOI: 10.1186/1476-7120-3-8] [Citation(s) in RCA: 88] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2005] [Accepted: 03/25/2005] [Indexed: 12/12/2022] Open
Abstract
The assessment of coronary flow reserve by transthoracic echocardiography has recently been introduced into clinical practice with gratifying results for the diagnosis of left anterior descending artery disease simultaneously reported by several independent laboratories. This technological novelty is changing the practice of stress echo for 3 main reasons. First, adding coronary flow reserve to regional wall motion allows us to have - in the same sitting - high specificity (regional wall motion) and a high sensitivity (coronary flow reserve) diagnostic marker, with an obvious improvement in overall diagnostic accuracy. Second, the technicalities of coronary flow reserve shift the balance of stress choice in favour of vasodilators, which are a more robust hyperemic stress and are substantially easier to perform with dual imaging than dobutamine or exercise. Third, the coronary flow reserve adds a quantitative support to the exquisitely qualitative assessment of wall motion analysis, thereby facilitating the communication of stress echo results to the cardiological world outside the echo lab. The next challenges involve the need to expand the exploration of coronary flow reserve to the right and circumflex coronary artery and to prove the additional prognostic value - if any - of coronary flow reserve over regional wall motion analysis, which remains the cornerstone of clinically-driven diagnosis in the stress echo lab.
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Affiliation(s)
- Fausto Rigo
- Department of Cardiology Umberto I Hospital Mestre-Venice, Italy.
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