1
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Benenati S, De Maria GL, Kotronias R, Porto I, Banning AP. Why percutaneous revascularisation might not reduce the risk of myocardial infarction and mortality in patients with stable CAD? Open Heart 2023; 10:e002343. [PMID: 37890892 PMCID: PMC10619108 DOI: 10.1136/openhrt-2023-002343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 08/07/2023] [Indexed: 10/29/2023] Open
Abstract
Percutaneous coronary intervention (PCI) is widely adopted to treat chronic coronary artery disease. Numerous randomised trials have been conducted to test whether PCI may provide any prognostic advantage over oral medical therapy (OMT) alone, without definitive results. This has maintained the paradigm of OMT as the first-line standard of care for patients, reserving PCI for symptom control. In this review, we discuss the current evidence in favour and against PCI in stable coronary syndromes and highlight the pitfalls of the available studies. We offer a critical appraisal of the possible reasons why the existing data does not provide evidence supporting the role of PCI in improving clinical outcomes in patients with stable coronary syndromes.
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Affiliation(s)
- Stefano Benenati
- Cardiovascular Disease Chair, Department of Internal Medicine (Di.M.I.), University of Genova, Genova, Italy
- Oxford Heart Centre, John Radcliffe Hospital, Oxford, UK
| | | | | | - Italo Porto
- Cardiovascular Disease Chair, Department of Internal Medicine (Di.M.I.), University of Genova, Genova, Italy
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, IRCCS, Genova, Italy
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2
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Ekmejian A, Sritharan H, Selvakumar D, Venkateshka V, Allahwala U, Ward M, Bhindi R. Outcomes of deferred revascularisation following negative fractional flow reserve in diabetic and non-diabetic patients: a meta-analysis. Cardiovasc Diabetol 2023; 22:22. [PMID: 36717847 PMCID: PMC9887893 DOI: 10.1186/s12933-023-01751-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 01/23/2023] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Fractional Flow Reserve (FFR) is a widely applied invasive physiological assessment, endorsed by major guidelines to aid in the decision to perform or defer revascularisation. While a threshold of > 0.8 has been applied universally, clinical outcomes may be affected by numerous factors, including the presence of diabetes. This meta-analysis aims to investigate the outcomes of diabetic versus non-diabetic patients in whom revascularisation was deferred based on negative FFR. METHODS We performed a meta-analysis investigating the outcomes of diabetic and non-diabetic patients in whom revascularisation was deferred based on negative FFR. A search was performed on MEDLINE, PubMed and EMBASE, and peer-reviewed studies that reported MACE for diabetic and non-diabetic patients with deferred revascularisation based on FFR > 0.8 were included. The primary end point was MACE. RESULTS The meta-analysis included 7 studies in which 4275 patients had revascularisation deferred based on FFR > 0.8 (1250 diabetic). Follow up occurred over a mean of 3.2 years. Diabetes was associated with a higher odds of MACE (OR = 1.66, 95% CI 1.35-2.04, p = < 0.001), unplanned revascularisation (OR = 1.48, 95% CI 1.06-2.06, p = 0.02), all-cause mortality (OR = 1.74, 95% CI 1.20-2.52, p = 0.004) and cardiovascular mortality (OR = 2.08, 95% CI 1.07-4.05, p = 0.03). CONCLUSIONS For patients with stable coronary syndromes and deferred revascularisation based on FFR > 0.8, the presence of diabetes portends an increased long-term risk of MACE compared to non-diabetic patients. Trail registration URL: https://www.crd.york.ac.uk/PROSPERO/ ; Unique identifier: CRD42022367312.
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Affiliation(s)
- Avedis Ekmejian
- Department of Cardiology, Interventional Cardiologist, Royal North Shore Hospital, Reserve Rd, St Leonards, Sydney, 2065, Australia. .,University of Sydney, Camperdown, Australia.
| | - Hari Sritharan
- grid.412703.30000 0004 0587 9093Department of Cardiology, Interventional Cardiologist, Royal North Shore Hospital, Reserve Rd, St Leonards, Sydney, 2065 Australia ,grid.1013.30000 0004 1936 834XUniversity of Sydney, Camperdown, Australia
| | - Dinesh Selvakumar
- grid.412703.30000 0004 0587 9093Department of Cardiology, Interventional Cardiologist, Royal North Shore Hospital, Reserve Rd, St Leonards, Sydney, 2065 Australia
| | - Venkateshka Venkateshka
- grid.482157.d0000 0004 0466 4031Northern Sydney Local Health District Executive, Hornsby, Australia
| | - Usaid Allahwala
- grid.412703.30000 0004 0587 9093Department of Cardiology, Interventional Cardiologist, Royal North Shore Hospital, Reserve Rd, St Leonards, Sydney, 2065 Australia ,grid.1013.30000 0004 1936 834XUniversity of Sydney, Camperdown, Australia
| | - Michael Ward
- grid.412703.30000 0004 0587 9093Department of Cardiology, Interventional Cardiologist, Royal North Shore Hospital, Reserve Rd, St Leonards, Sydney, 2065 Australia ,grid.1013.30000 0004 1936 834XUniversity of Sydney, Camperdown, Australia
| | - Ravinay Bhindi
- grid.412703.30000 0004 0587 9093Department of Cardiology, Interventional Cardiologist, Royal North Shore Hospital, Reserve Rd, St Leonards, Sydney, 2065 Australia ,grid.1013.30000 0004 1936 834XUniversity of Sydney, Camperdown, Australia
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3
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Geng L, Shi X, Yuan Y, Du P, Gao L, Wang Y, Li J, Guo W, Huang Y, Zhang Q. Anatomical and Functional Discrepancy in Diabetic Patients With Intermediate Coronary Lesions - An Intravascular Ultrasound and Quantitative Flow Ratio Study. Circ J 2023; 87:320-328. [PMID: 36104251 DOI: 10.1253/circj.cj-22-0238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Data regarding the performance of computational fractional flow reserve in patients with diabetes mellitus (DM) remain scarce. This study sought to explore the impact of DM on quantitative flow ratio (QFR) and its association with intravascular ultrasound (IVUS)-derived anatomical references. METHODS AND RESULTS IVUS and QFR were retrospectively analyzed in 237 non-diabetic and 93 diabetic patients with 250 and 102 intermediate lesions, respectively. Diabetics were further categorized based on adequate (HbA1c <7.0%: 47 patients with 53 lesions) or poor (HbA1c ≥7.0%: 46 patients with 49 lesions) glycemic control. Lesions with QFR ≤0.8 or minimum lumen area (MLA) ≤4.0 mm2and plaque burden (PB, %) ≥70 were considered functionally or anatomically significant, respectively. PB increased, and MLA decreased stepwise across non-diabetics, diabetics with adequate glycemic control and those with poor glycemic control. In contrast, QFR was similar among the 3 groups. PB correlated significantly with the QFR for lesions in non-diabetics, but not for lesions in diabetics. DM was independently correlated with the functionally non-significant lesions (QFR >0.8) with high-risk IVUS features (MLA ≤4.0 mm2and PB ≥70; OR 2.053, 95% CI: 1.137-3.707, P=0.017). When considering the effect of glycemic control, HbA1c was an independent predictor of anatomical-functional discordance (OR 1.347, 95% CI: 1.089-1.667, P=0.006). CONCLUSIONS Anatomical-functional discordance of intermediate coronary lesions assessed by IVUS and QFR is exacerbated in patients with diabetes, especially when glycemia is poorly controlled.
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Affiliation(s)
- Liang Geng
- Department of Cardiology, Shanghai East Hospital, Tongji University
- Department of Cardiology, JI'AN Hospital, Shanghai East Hospital
| | - Xibao Shi
- Department of Cardiovascular Medicine, Ruijin Hospital, Shanghai Jiaotong University School of Medicine
| | - Yuan Yuan
- Department of Cardiology, Shanghai East Hospital, Tongji University
| | - Peizhao Du
- Department of Cardiology, Baoshan Hospital of Integrated Traditional Chinese and Western Medicine
| | - Liming Gao
- Department of Cardiology, Shanghai East Hospital, Tongji University
| | - Yunkai Wang
- Department of Cardiology, Shanghai East Hospital, Tongji University
| | - Jiming Li
- Department of Cardiology, Shanghai East Hospital, Tongji University
| | - Wei Guo
- Department of Cardiology, Shanghai East Hospital, Tongji University
| | - Ying Huang
- Department of Cardiology, Shanghai East Hospital, Tongji University
| | - Qi Zhang
- Department of Cardiology, Shanghai East Hospital, Tongji University
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4
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Marin F, Scarsini R, Terentes-Printzios D, Kotronias RA, Ribichini F, Banning AP, De Maria GL. The Role of Coronary Physiology in Contemporary Percutaneous Coronary Interventions. Curr Cardiol Rev 2022; 18:e080921196264. [PMID: 34521331 PMCID: PMC9241117 DOI: 10.2174/1573403x17666210908114154] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 02/21/2021] [Accepted: 03/02/2021] [Indexed: 01/10/2023] Open
Abstract
Invasive assessment of coronary physiology has radically changed the paradigm of myocardial revascularization in patients with coronary artery disease. Despite the prognostic improvement associated with ischemia-driven revascularization strategy, functional assessment of angiographic intermediate epicardial stenosis remains largely underused in clinical practice. Multiple tools have been developed or are under development in order to reduce the invasiveness, cost, and extra procedural time associated with the invasive assessment of coronary physiology. Besides epicardial stenosis, a growing body of evidence highlights the role of coronary microcirculation in regulating coronary flow with consequent pathophysiological and clinical and prognostic implications. Adequate assessment of coronary microcirculation function and integrity has then become another component of the decision-making algorithm for optimal diagnosis and treatment of coronary syndromes. This review aims at providing a comprehensive description of tools and techniques currently available in the catheterization laboratory to obtain a thorough and complete functional assessment of the entire coronary tree (both for the epicardial and microvascular compartments).
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Affiliation(s)
- Federico Marin
- Division of Cardiology, University of Verona, Verona, Italy.,Oxford Heart Centre, Oxford University Hospitals, Oxford, United Kingdom
| | | | | | - Rafail A Kotronias
- Oxford Heart Centre, Oxford University Hospitals, Oxford, United Kingdom
| | | | - Adrian P Banning
- Oxford Heart Centre, Oxford University Hospitals, Oxford, United Kingdom
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5
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Van Belle E, Cosenza A, Baptista SB, Vincent F, Henderson J, Santos L, Ramos R, Pouillot C, Calé R, Cuisset T, Jorge E, Teiger E, Machado C, Belle L, Costa M, Barreau D, Oliveira E, Hanssen M, Costa J, Besnard C, Nunes L, Dallongeville J, Sideris G, Bretelle C, Fonseca N, Lhoest N, Guardado J, Silva B, Sousa MJ, Barnay P, Silva JC, Leborgne L, Rodrigues A, Porouchani S, Seca L, Fernandes R, Dupouy P, Raposo L. Usefulness of Routine Fractional Flow Reserve for Clinical Management of Coronary Artery Disease in Patients With Diabetes. JAMA Cardiol 2021; 5:272-281. [PMID: 31913433 DOI: 10.1001/jamacardio.2019.5097] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Approximately one-third of patients considered for coronary revascularization have diabetes, which is a major determinant of clinical outcomes, often influencing the choice of the revascularization strategy. The usefulness of fractional flow reserve (FFR) to guide treatment in this population is understudied and has been questioned. Objective To evaluate the usefulness and rate of major adverse cardiovascular events (MACE) of integrating FFR in management decisions for patients with diabetes who undergo coronary angiography. Design, Setting, and Participants This cross-sectional study used data from the PRIME-FFR study derived from the merger of the POST-IT study (Portuguese Study on the Evaluation of FFR-Guided Treatment of Coronary Disease [March 2012-November 2013]) and R3F study (French Study of FFR Integrated Multicenter Registries Implementation of FFR in Routine Practice [October 2008-June 2010]), 2 prospective multicenter registries that shared a common design. A population of all-comers for whom angiography disclosed ambiguous lesions was analyzed for rates, patterns, and outcomes associated with management reclassification, including revascularization deferral, in patients with vs without diabetes. Data analysis was performed from June to August 2018. Main Outcomes and Measures Death from any cause, myocardial infarction, or unplanned revascularization (MACE) at 1 year. Results Among 1983 patients (1503 [77%] male; mean [SD] age, 65 [10] years), 701 had diabetes, and FFR was performed for 1.4 lesions per patient (58.2% of lesions in the left anterior descending artery; mean [SD] stenosis, 56% [11%]; mean [SD] FFR, 0.81 [0.01]). Reclassification by FFR was high and similar in patients with and without diabetes (41.2% vs 37.5%, P = .13), but reclassification from medical treatment to revascularization was more frequent in the former (142 of 342 [41.5%] vs 230 of 730 [31.5%], P = .001). There was no statistical difference between the 1-year rates of MACE in reclassified (9.7%) and nonreclassified patients (12.0%) (P = .37). Among patients with diabetes, FFR-based deferral identified patients with a lower risk of MACE at 12 months (25 of 296 [8.4%]) compared with those undergoing revascularization (47 of 257 [13.1%]) (P = .04), and the rate was of the same magnitude of the observed rate among deferred patients without diabetes (7.9%, P = .87). Status of insulin treatment had no association with outcomes. Patients (6.6% of the population) in whom FFR was disregarded had the highest MACE rates regardless of diabetes status. Conclusions and Relevance Routine integration of FFR for the management of coronary artery disease in patients with diabetes may be associated with a high rate of treatment reclassification. Management strategies guided by FFR, including revascularization deferral, may be useful for patients with diabetes.
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Affiliation(s)
- Eric Van Belle
- Département de Cardiologie, Institut Coeur-Poumon, Centre Hospitalier Universitaire de Lille, Lille, France.,Institut national de la santé et de la recherche médicale INSERM U1011, Lille-II-University, Lille, France
| | - Alessandro Cosenza
- Département de Cardiologie, Institut Coeur-Poumon, Centre Hospitalier Universitaire de Lille, Lille, France.,Institut national de la santé et de la recherche médicale INSERM U1011, Lille-II-University, Lille, France
| | - Sergio Bravo Baptista
- Serviço de Cardiologia, Hospital Prof Doutor Fernando da Fonseca, Amadora, Portugal.,University Clinic of Cardiology-Faculty of Medicine at University of Lisbon, Lisbon, Portugal
| | - Flavien Vincent
- Département de Cardiologie, Institut Coeur-Poumon, Centre Hospitalier Universitaire de Lille, Lille, France.,Institut national de la santé et de la recherche médicale INSERM U1011, Lille-II-University, Lille, France
| | - John Henderson
- Statistical Department, St. Jude Medical Inc, St Paul, Minnesota
| | - Lino Santos
- Serviço de Cardiologie, Centro Hospitalar Vila Nova de Gaia, Vila Nova de Gaia, Portugal
| | - Ruben Ramos
- Serviço de Cardiologia, Hospital Santa Marta-Centro Hospitalar Lisboa Central, Lisboa, Portugal
| | - Christophe Pouillot
- Department de Cardiologia, Clinique Sainte Clotilde, Saint Denis de la Réunion, France
| | - Rita Calé
- Serviço de Cardiologia, Hospital Garcia de Orta, Almada, Portugal
| | - Thomas Cuisset
- Department de Cardiologie, Centre Hospitalar Universitaire, La Timone, Marseille, France
| | - Elisabete Jorge
- Serviço de Cardiologia, Centro Hospitalar Universitário, Coimbra, Coimbra, Portugal
| | - Emmanuel Teiger
- Department of Cardiologie, Centre Hospitalar Universitaire Mondor, Créteil, France
| | - Carina Machado
- Serviço de Cardiologia, Hospital Divino Espirito Santo, Ponta Delgada, Portugal
| | - Loic Belle
- Department de Cardiologie, Centre Hospitalier d'Annecy, Annecy, France
| | - Marco Costa
- Serviço de Cardiologia, Hospital Geral dos Covões-Centro Hospitalar Coimbra, Coimbra, Portugal
| | - Didier Barreau
- Department of Cardiologie, Centre Hospitalier Intercommunal Toulon La Seyne sur Mer-Hôpital Sainte Musse, Toulon, France
| | - Eduardo Oliveira
- Serviço de Cardiologia, Hospital Santa Maria-Centro Hospitalar Lisboa Norte, Lisboa, Portugal
| | - Michel Hanssen
- Department de Cardiologie, Centre Hospitalier Haguenau, Haguenau, France
| | - João Costa
- Serviço de Cardiologia, Hospital de Braga, Braga, Portugal
| | - Cyril Besnard
- Department of Cardiologie, Hôpital de la Croix-Rousse, Lyon, France
| | - Luis Nunes
- Serviço de Cardiologia, Hospital São Teotónio, Viseu, Portugal
| | - Jean Dallongeville
- Institut Pasteur de Lille, Institut national de la santé et de la recherche médicale INSERM, Lille, France
| | | | | | - Nuno Fonseca
- Serviço de Cardiologia, Centro Hospitalar Setúbal, Setúbal, Portugal
| | - Nicolas Lhoest
- Department of Cardiologie, Hôpital Albert Schweizer, Colmar, France
| | - Jorge Guardado
- Serviço de Cardiologia, Hospital Santo André-Centro Hospitalar Leiria-Pombal, Leiria, Portugal
| | - Bruno Silva
- Serviço de Cardiologia, Hospital Dr Nélio Mendonça, Funchal, Portugal
| | - Maria-João Sousa
- Serviço de Cardiologia, Hospital Geral Santo António-Centro Hospitalar do Porto, Porto, Portugal
| | - Pierre Barnay
- Department of Cardiologie, Centre Hospitalier La Durance, Avignon, France
| | | | - Laurent Leborgne
- Department of Cardiologie, Centre Hospitalier Amiens Sud, Amiens, France
| | - Alberto Rodrigues
- Serviço de Cardiologia, Centro Hospitalar Tâmega e Sousa, Penafiel, Portugal
| | - Sina Porouchani
- Département de Cardiologie, Institut Coeur-Poumon, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Luís Seca
- Serviço de Cardiologia, Centro Hospitalar Trás-os-Montes e Alto Douro-Unidade Hospitalar Vila Real, Vila Real, Portugal
| | - Renato Fernandes
- Serviço de Cardiologia, Hospital Espírito Santo, Évora, Portugal
| | - Patrick Dupouy
- Department of Cardiologie, Hôpital Privé d'Antony, Antony, France
| | - Luís Raposo
- Serviço de Cardiologia, Hospital de Santa Cruz-Centro Hospitalar de Lisboa Ocidental, Carnaxide, Portugal
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6
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Di Gioia G, Soto Flores N, Franco D, Colaiori I, Sonck J, Gigante C, Kodeboina M, Bartunek J, Vanderheyden M, Van Praet F, Casselman F, Degriek I, Stockman B, Barbato E, Collet C, De Bruyne B. Coronary Artery Bypass Grafting or Fractional Flow Reserve–Guided Percutaneous Coronary Intervention in Diabetic Patients With Multivessel Disease. Circ Cardiovasc Interv 2020; 13:e009157. [DOI: 10.1161/circinterventions.120.009157] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background:
In diabetic patients with multivessel coronary artery disease, coronary artery bypass grafting (CABG) has shown long-term benefits over percutaneous coronary intervention (PCI). Physiology-guided PCI has shown to improve clinical outcomes in multivessel coronary artery disease, though its impact in diabetic patients has never been investigated. We evaluated long-term clinical outcomes of diabetic patients with multivessel coronary artery disease treated with fractional flow reserve (FFR)–guided PCI compared with CABG.
Methods:
From 2010 to 2018, 4622 diabetic patients undergoing coronary angiography were screened for inclusion. The inclusion criterion was the presence of at least 2-vessel disease defined as with diameter stenosis ≥50%, in which at least 1 intermediate stenosis (diameter stenosis, 30%–70%) was treated or deferred according to FFR. Inverse probability of treatment weighting analysis was used to account for baseline differences with a contemporary cohort of patients treated with CABG. The primary end point was major adverse cardiovascular and cerebrovascular events, defined as all-cause death, myocardial infarction, revascularization, or stroke.
Results:
A total of 418 patients were included in the analysis. Among them, 209 patients underwent CABG and 209 FFR-guided PCI. At 5 years, the incidence of major adverse cardiovascular and cerebrovascular events was higher in the FFR-guided PCI versus the CABG group (44.5% versus 31.9%; hazard ratio, 1.60 [95% CI, 1.15–2.22];
P
=0.005). No difference was found in the composite of all-cause death, myocardial infarction, or stroke (28.8% versus 27.5%; hazard ratio, 1.05 [95% CI, 0.72–1.53];
P
=0.81). Repeat revascularization was more frequent with FFR-guided PCI (24.9% versus 8.2%; hazard ratio, 3.51 [95% CI, 1.93–6.40];
P
<0.001).
Conclusions:
In diabetic patients with multivessel coronary artery disease, CABG was associated with a lower rate of major adverse cardiovascular and cerebrovascular events compared with FFR-guided PCI, driven by a higher rate of repeat revascularization. At 5-year follow-up, no difference was observed in the composite of all-cause death, myocardial infarction, or stroke between CABG and FFR-guided PCI.
Graphic Abstract:
A
graphic abstract
is available for this article.
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Affiliation(s)
- Giuseppe Di Gioia
- Cardiovascular Center Aalst, OLV Clinic, Belgium (G.D.G., N.S.F., I.C., J.S., C.G., M.K., J.B., M.V., F.V.P., F.C., I.D., B.S., E.B., C.C., B.D.B.)
- Division of Cardiology, Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy (G.D.G., D.F., J.S.)
| | - Nina Soto Flores
- Cardiovascular Center Aalst, OLV Clinic, Belgium (G.D.G., N.S.F., I.C., J.S., C.G., M.K., J.B., M.V., F.V.P., F.C., I.D., B.S., E.B., C.C., B.D.B.)
| | - Danilo Franco
- Division of Cardiology, Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy (G.D.G., D.F., J.S.)
| | - Iginio Colaiori
- Cardiovascular Center Aalst, OLV Clinic, Belgium (G.D.G., N.S.F., I.C., J.S., C.G., M.K., J.B., M.V., F.V.P., F.C., I.D., B.S., E.B., C.C., B.D.B.)
| | - Jeroen Sonck
- Cardiovascular Center Aalst, OLV Clinic, Belgium (G.D.G., N.S.F., I.C., J.S., C.G., M.K., J.B., M.V., F.V.P., F.C., I.D., B.S., E.B., C.C., B.D.B.)
- Division of Cardiology, Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy (G.D.G., D.F., J.S.)
| | - Carlo Gigante
- Cardiovascular Center Aalst, OLV Clinic, Belgium (G.D.G., N.S.F., I.C., J.S., C.G., M.K., J.B., M.V., F.V.P., F.C., I.D., B.S., E.B., C.C., B.D.B.)
| | - Monika Kodeboina
- Cardiovascular Center Aalst, OLV Clinic, Belgium (G.D.G., N.S.F., I.C., J.S., C.G., M.K., J.B., M.V., F.V.P., F.C., I.D., B.S., E.B., C.C., B.D.B.)
| | - Jozef Bartunek
- Cardiovascular Center Aalst, OLV Clinic, Belgium (G.D.G., N.S.F., I.C., J.S., C.G., M.K., J.B., M.V., F.V.P., F.C., I.D., B.S., E.B., C.C., B.D.B.)
| | - Marc Vanderheyden
- Cardiovascular Center Aalst, OLV Clinic, Belgium (G.D.G., N.S.F., I.C., J.S., C.G., M.K., J.B., M.V., F.V.P., F.C., I.D., B.S., E.B., C.C., B.D.B.)
| | - Frank Van Praet
- Cardiovascular Center Aalst, OLV Clinic, Belgium (G.D.G., N.S.F., I.C., J.S., C.G., M.K., J.B., M.V., F.V.P., F.C., I.D., B.S., E.B., C.C., B.D.B.)
| | - Filip Casselman
- Cardiovascular Center Aalst, OLV Clinic, Belgium (G.D.G., N.S.F., I.C., J.S., C.G., M.K., J.B., M.V., F.V.P., F.C., I.D., B.S., E.B., C.C., B.D.B.)
| | - Ivan Degriek
- Cardiovascular Center Aalst, OLV Clinic, Belgium (G.D.G., N.S.F., I.C., J.S., C.G., M.K., J.B., M.V., F.V.P., F.C., I.D., B.S., E.B., C.C., B.D.B.)
| | - Bernard Stockman
- Cardiovascular Center Aalst, OLV Clinic, Belgium (G.D.G., N.S.F., I.C., J.S., C.G., M.K., J.B., M.V., F.V.P., F.C., I.D., B.S., E.B., C.C., B.D.B.)
| | - Emanuele Barbato
- Cardiovascular Center Aalst, OLV Clinic, Belgium (G.D.G., N.S.F., I.C., J.S., C.G., M.K., J.B., M.V., F.V.P., F.C., I.D., B.S., E.B., C.C., B.D.B.)
| | - Carlos Collet
- Cardiovascular Center Aalst, OLV Clinic, Belgium (G.D.G., N.S.F., I.C., J.S., C.G., M.K., J.B., M.V., F.V.P., F.C., I.D., B.S., E.B., C.C., B.D.B.)
| | - Bernard De Bruyne
- Cardiovascular Center Aalst, OLV Clinic, Belgium (G.D.G., N.S.F., I.C., J.S., C.G., M.K., J.B., M.V., F.V.P., F.C., I.D., B.S., E.B., C.C., B.D.B.)
- Cardiology Department, Lausanne University Center Hospital, Switzerland (B.D.B.)
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7
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Lehto HR, Pietilä A, Niiranen TJ, Lommi J, Salomaa V. Clinical practice patterns in revascularization of diabetic patients with coronary heart disease: nationwide register study. Ann Med 2020; 52:225-232. [PMID: 32429711 PMCID: PMC7877943 DOI: 10.1080/07853890.2020.1771757] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Aims: To compare diabetic patients with coronary heart disease (CHD) needing revascularization to corresponding non-diabetic patients in terms of revascularization methods, comorbidities and urgency of procedure. We also examined the impact of patient characteristics and comorbidities on the revascularization method.Methods: We identified all diabetic (n = 33,018) and non-diabetic (n = 106,224) patients with first-ever, percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) from electronic health records in Finland between 2000 and 2015.Results: Overall, PCI was the most common revascularization method. PCI outnumbered CABG in women and men both in diabetic and non-diabetic patients. However, diabetic patients were more likely to undergo CABG than PCI (OR 1.30; 95% CI 1.27-1.34, adjusted for age, gender, region of residence and procedure year). Moreover, 26.9% of diabetic patients' urgent procedures were CABG compared to 21.6% in non-diabetic patients (p<.001). Among diabetic patients, prior myocardial infarction was associated with increased odds of CABG, whereas female gender, atrial fibrillation, congestive heart failure, hypertension and later procedure year were associated with lower odds of CABG.Conclusions: CABG has been performed more frequently in diabetic than in non-diabetic CHD patients. Nevertheless, PCI was the dominant revascularization method over CABG both in diabetic and non-diabetic patients. KEY MESSAGESPCI was the dominant revascularization method in both diabetic and non-diabetic patients. Diabetic patients were more likely to undergo CABG than PCI when compared to non-diabetic patients (OR: 1.30; CI 1.27-1.34).Diabetic patients underwent urgent CABG procedures more often than non-diabetic patients and had more comorbidities compared to non-diabetic patients.
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Affiliation(s)
| | - Arto Pietilä
- THL - Finnish Institute for Health and Welfare, Helsinki, Finland
| | - Teemu J Niiranen
- THL - Finnish Institute for Health and Welfare, Helsinki, Finland.,Department of Medicine, Turku University Hospital and University of Turku, Turku, Finland
| | - Jyri Lommi
- Division of Cardiology, Heart and Lung Center, Helsinki University Central Hospital, Helsinki, Finland
| | - Veikko Salomaa
- THL - Finnish Institute for Health and Welfare, Helsinki, Finland
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8
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Alkhalil M, McCune C, McClenaghan L, Mailey J, Collins P, Kearney A, Todd M, McKavanagh P. Clinical Outcomes of Deferred Revascularisation Using Fractional Flow Reserve in Diabetic Patients. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2019; 21:897-902. [PMID: 31883978 DOI: 10.1016/j.carrev.2019.12.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Revised: 12/10/2019] [Accepted: 12/13/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Fractional flow reserve (FFR) is used to assess the functional significance of coronary artery lesions. Diabetic patients are associated with high burden of atherosclerosis and microvascular dysfunction. We studied the clinical outcomes of diabetic patients who underwent FFR-guided deferred revascularisation. METHODS Consecutive patients from a single large volume centre who underwent FFR assessment were included. Clinical endpoints were prospectively collected using the national electronic care records system. The primary endpoint was defined as the four-year risk of the vessel-oriented composite outcome of cardiac death, vessel-related myocardial infarction (VMI), and vessel-related urgent revascularisation (VUR). Absolute FFR values groups (0.81 to 0.85; 0.86 to 0.90; and >0.90) were used to further stratify patient outcomes. RESULTS FFR-guided deferred revascularisation occurred in 860 patients (63%), of whom 159 were diabetic. The primary endpoint was significantly higher in the diabetic compared to the non-diabetic group [HR 1.76 (95%CI 1.08 to 2.88), P = 0.024]. The difference was driven from cardiac death (6.3% vs. 3.0%, P = 0.044) and VMI (5.0% vs. 1.7%, P = 0.012) but not VUR (8.8% vs. 5.1%, P = 0.07). There was a significant decrease in the incidence of the primary endpoint in the diabetic group according to FFR groups (23.6%, 12.3%, 2.4%, P = 0.001) with comparable clinical outcomes in the non-diabetic group (11.8%, 6.4%, 7.4%, P = 0.085). CONCLUSIONS Our study demonstrated an increased risk of death and target vessel MI in diabetic patients undergoing FFR-guided deferred revascularisation compared to non-diabetic group. Nonetheless, FFR remained a useful tool to identify those at future risk, mainly in diabetic patients.
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Affiliation(s)
| | - Claire McCune
- Department of Cardiology, Royal Victoria Hospital, Belfast, UK
| | | | - Jonathan Mailey
- Department of Cardiology, Royal Victoria Hospital, Belfast, UK
| | - Patrick Collins
- Department of Cardiology, Royal Victoria Hospital, Belfast, UK
| | - Aileen Kearney
- Department of Cardiology, Royal Victoria Hospital, Belfast, UK
| | - Matthew Todd
- Department of Cardiology, Royal Victoria Hospital, Belfast, UK
| | - Peter McKavanagh
- Department of Cardiology, Royal Victoria Hospital, Belfast, UK; Department of Cardiology, Ulster Hospital, Belfast, UK
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9
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Nous FMA, Coenen A, Boersma E, Kim YH, Kruk MBP, Tesche C, de Geer J, Yang DH, Kepka C, Schoepf UJ, Persson A, Kurata A, Budde RPJ, Nieman K. Comparison of the Diagnostic Performance of Coronary Computed Tomography Angiography-Derived Fractional Flow Reserve in Patients With Versus Without Diabetes Mellitus (from the MACHINE Consortium). Am J Cardiol 2019; 123:537-543. [PMID: 30553510 DOI: 10.1016/j.amjcard.2018.11.024] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 10/28/2018] [Accepted: 11/01/2018] [Indexed: 02/05/2023]
Abstract
Coronary computed tomography angiography-derived fractional flow reserve (CT-FFR) is a noninvasive application to evaluate the hemodynamic impact of coronary artery disease by simulating invasively measured FFR based on CT data. CT-FFR is based on the assumption of a normal coronary microvascular response. We assessed the diagnostic performance of a machine-learning based application for on-site computation of CT-FFR in patients with and without diabetes mellitus with suspected coronary artery disease. The study population included 75 diabetic and 276 nondiabetic patients who were enrolled in the MACHINE consortium. The overall diagnostic performance of coronary CT angiography alone and in combination with CT-FFR were analyzed with direct invasive FFR comparison in 110 coronary vessels of the diabetic group and in 415 coronary vessels of the nondiabetic group. Per-vessel discrimination of lesion-specific ischemia by CT-FFR was assessed by the area under the receiver operating characteristic curves. The overall diagnostic accuracy of CT-FFR in diabetic patients was 83% and in nondiabetic patients 75% (p = 0.088), showing improvement over the diagnostic accuracy of coronary CT angiography, which was 58% and 65% (p = 0.223), respectively. In addition, the diagnostic accuracy of CT-FFR was similar between diabetic and nondiabetic patients per stratified CT-FFR group (CT-FFR < 0.6, 0.6 to 0.69, 0.7 to 0.79, 0.8 to 0.89, ≥0.9). The area under the curves for diabetic and nondiabetic patients were also comparable, 0.88 and 0.82 (p = 0.113), respectively. In conclusion, on-site machine-learning CT-FFR analysis improved the diagnostic performance of coronary CT angiography and accurately discriminated lesion-specific ischemia in both diabetic and nondiabetic patients suspected of coronary artery disease.
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Affiliation(s)
- Fay M A Nous
- Department of Radiology & Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands.
| | - Adriaan Coenen
- Department of Radiology & Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Eric Boersma
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Young-Hak Kim
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Mariusz B P Kruk
- Coronary Disease and Structural Heart Diseases Department, Institute of Cardiology, Warsaw, Poland
| | - Christian Tesche
- Department of Radiology and Radiological Science, Heart & Vascular Center, Medical University of South Carolina, Charleston, South Carolina
| | - Jakob de Geer
- Department of Radiology and Department of Medical and Health Sciences, Center for Medical Image Science and Visualization, CMIV, Linköping University, Linköping, Sweden
| | - Dong Hyun Yang
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Cezary Kepka
- Coronary Disease and Structural Heart Diseases Department, Institute of Cardiology, Warsaw, Poland
| | - U Joseph Schoepf
- Department of Radiology and Radiological Science, Heart & Vascular Center, Medical University of South Carolina, Charleston, South Carolina
| | - Anders Persson
- Department of Radiology and Department of Medical and Health Sciences, Center for Medical Image Science and Visualization, CMIV, Linköping University, Linköping, Sweden
| | - Akira Kurata
- Department of Radiology & Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Radiology, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Ricardo P J Budde
- Department of Radiology & Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Koen Nieman
- Department of Radiology & Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands; Stanford University School of Medicine, Cardiovascular Institute, Stanford, California
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10
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Garcia D, Harbaoui B, van de Hoef TP, Meuwissen M, Nijjer SS, Echavarria-Pinto M, Davies JE, Piek JJ, Lantelme P. Relationship between FFR, CFR and coronary microvascular resistance - Practical implications for FFR-guided percutaneous coronary intervention. PLoS One 2019; 14:e0208612. [PMID: 30616240 PMCID: PMC6322913 DOI: 10.1371/journal.pone.0208612] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 11/20/2018] [Indexed: 01/09/2023] Open
Abstract
Objective The aim was threefold: 1) expound the independent physiological parameters that drive FFR, 2) elucidate contradictory conclusions between fractional flow reserve (FFR) and coronary flow reserve (CFR), and 3) highlight the need of both FFR and CFR in clinical decision making. Simple explicit theoretical models were supported by coronary data analyzed retrospectively. Methodology FFR was expressed as a function of pressure loss coefficient, aortic pressure and hyperemic coronary microvascular resistance. The FFR-CFR relationship was also demonstrated mathematically and was shown to be exclusively dependent upon the coronary microvascular resistances. The equations were validated in a first series of 199 lesions whose pressures and distal velocities were monitored. A second dataset of 75 lesions with pre- and post-PCI measures of FFR and CFR was also analyzed to investigate the clinical impact of our hemodynamic reasoning. Results Hyperemic coronary microvascular resistance and pressure loss coefficient had comparable impacts (45% and 49%) on FFR. There was a good concordance (y = 0.96 x − 0.02, r2 = 0.97) between measured CFR and CFR predicted by FFR and coronary resistances. In patients with CFR < 2 and CFR/FFR ≥ 2, post-PCI CFR was significantly >2 (p < 0.001), whereas it was not (p = 0.94) in patients with CFR < 2 and CFR/FFR < 2. Conclusion The FFR behavior and FFR-CFR relationship are predictable from basic hemodynamics. Conflicting conclusions between FFR and CFR are explained from coronary vascular resistances. As confirmed by our results, FFR and CFR are complementary; they could jointly contribute to better PCI guidance through the CFR-to-FFR ratio in patients with coronary artery disease.
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Affiliation(s)
- Damien Garcia
- CREATIS, INSERM U1206, Université Lyon 1, INSA Lyon, Villeurbanne, France
- * E-mail: ,
| | - Brahim Harbaoui
- CREATIS, INSERM U1206, Université Lyon 1, INSA Lyon, Villeurbanne, France
- Department of Cardiology, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, France
| | - Tim P. van de Hoef
- AMC Heart Center, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Department of Cardiology, Tergooi Hospital, Blaricum, The Netherlands
| | | | | | - Mauro Echavarria-Pinto
- AMC Heart Center, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Justin E. Davies
- Department of Cardiology, Tergooi Hospital, Blaricum, The Netherlands
| | - Jan J. Piek
- AMC Heart Center, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Pierre Lantelme
- CREATIS, INSERM U1206, Université Lyon 1, INSA Lyon, Villeurbanne, France
- Department of Cardiology, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, France
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11
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Abstract
PURPOSE OF REVIEW To provide an update on the management of patients with diabetes mellitus and requiring coronary revascularization. RECENT FINDINGS Evidence continues to show that patients with diabetes mellitus and ischemic heart disease represent a very high-risk group of patients. Choice of stent appears important for minimizing target lesion and target vessel adverse events with everolimus eluting stents having the best performance, particularly in patients being treated with insulin. The higher risk of adverse angioplasty results in patients with diabetes appears most related to the disease state per se and not necessarily to anatomical complexities. Interestingly, physiologic documentation of nonischemia producing lesions with use of fractional flow reserve appears less reassuring in this setting of aggressive and rapid atherosclerosis progression, particularly if myocardial infarction has occurred previously, than in patients without diabetes. Coronary artery bypass surgery in patients with appropriate anatomy and diabetes continues to emerge in many analyzes as the optimal, long-term therapy. IMPLICATIONS The treatment of diabetes per se, advances in stent technology and optimization of coronary artery bypass techniques are all occurring in parallel making it very critical for the design of modern era trials that keep pace with these advances. Currently, in patients with appropriate anatomy who are willing candidates, bypass surgery remains the optimal, long-term therapeutic option.
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12
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Benenati S, De Maria GL, Scarsini R, Porto I, Banning AP. Invasive “in the cath-lab” assessment of myocardial ischemia in patients with coronary artery disease: When does the gold standard not apply? CARDIOVASCULAR REVASCULARIZATION MEDICINE 2018; 19:362-372. [DOI: 10.1016/j.carrev.2018.01.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Accepted: 01/16/2018] [Indexed: 02/08/2023]
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13
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Kennedy MW, Fabris E, Suryapranata H, Kedhi E. Is ischemia the only factor predicting cardiovascular outcomes in all diabetes mellitus patients? Cardiovasc Diabetol 2017; 16:51. [PMID: 28427383 PMCID: PMC5397766 DOI: 10.1186/s12933-017-0533-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 04/08/2017] [Indexed: 02/06/2023] Open
Abstract
Diabetes mellitus (DM) is associated with an excess in cardiovascular morbidity and mortality, and is characterized by increased rates of coronary artery disease. Furthermore, once atherosclerosis is established, this is associated with an increased extent, complexity and a more rapid progression than seen in non-DM patients. Ischemia is the single most important predictor of future hard cardiac events and ischemia correction remains the cornerstone of current revascularization strategies. However recent data suggests that, in DM patients, coronary atherosclerosis despite the absence of ischemia, detected by either invasive or non-invasive methods, may not be associated with the same low risk of future cardiac events as seen in non-DM patients. This review seeks to examine the current evidence supporting an ischemia driven revascularization strategy, and to challenge the notion that ischemia is the only clinically relevant factor in the prediction of cardiovascular outcomes in all-comer DM patients. Specifically, we examine whether in DM patients certain characteristics beyond ischemia, such as microvascular disease, coronary atherosclerosis burden, progression and plaque composition, may need to be considered for a more refined risk stratification in these high-risk patients.
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Affiliation(s)
- Mark W Kennedy
- Isala Hartcentrum, Docter van Heesweg 2, Zwolle, The Netherlands.,Diagram CRO, Zwolle, The Netherlands
| | - Enrico Fabris
- Isala Hartcentrum, Docter van Heesweg 2, Zwolle, The Netherlands.,Diagram CRO, Zwolle, The Netherlands
| | - Harry Suryapranata
- Isala Hartcentrum, Docter van Heesweg 2, Zwolle, The Netherlands.,Diagram CRO, Zwolle, The Netherlands
| | - Elvin Kedhi
- Isala Hartcentrum, Docter van Heesweg 2, Zwolle, The Netherlands.
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14
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Kennedy MW, Fabris E, Hermanides RS, Kaplan E, Borren N, Berta B, Koopmans PC, Ottervanger JP, Suryapranata H, Kedhi E. Factors associated with deferred lesion failure following fractional flow reserve assessment in patients with diabetes mellitus. Catheter Cardiovasc Interv 2017; 90:1077-1083. [PMID: 28303683 DOI: 10.1002/ccd.27002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 01/30/2017] [Accepted: 02/04/2017] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To explore the predictors of deferred lesion failure (DLF) in patients with diabetes mellitus (DM) and lesions with a fractional flow reserve (FFR) >0.80 and to examine whether a predictive relationship between negative FFR values (>0.80-1.00) and DLF exists. BACKGROUND DM is associated with rapidly progressive atherosclerosis and predictors of DLF in FFR negative lesions in this high-risk group are unknown. METHODS All DM patients who underwent FFR-assessment between 1/01/2010 and 31/12/2013 were included, and followed until 1/7/2015. Patients carrying ≥1 FFR negative lesion(s) were assessed for DLF, and multivariate models used to identify independent factors associated with DLF. RESULTS A total of 205 patients with 252 FFR >0.80 lesions were identified. At a mean follow-up of 3.1 ± 1.4 years, DLF occurred in 29/205 (14.1%) patients, 31/252 (12.3%) lesions. Using marginal Cox regression multivariate analysis, insulin requiring DM [HR 2.24 (95%CI; 1.01-4.95), P = 0.046] and prior revascularization [HR 2.70 (95%CI 1.21-6.01), P = 0.015] were identified as being associated with a higher incidence of DLF. Absolute FFR values in FFR negative lesions in DM patients are not predictive of DLF (receiver operating characteristics curve analysis: area under the curve: 0.57 ± 0.06, 95%CI 0.46-0.69). CONCLUSIONS In DM patients with FFR negative lesions, insulin requiring DM and prior revascularization are predictors for DLF. In contrast to non-DM patients, no predictive relationship between absolute negative FFR values (ranging >0.80-1.00) and the risk of DLF exists in DM patients. © 2017 Wiley Periodicals, Inc.
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Affiliation(s)
- Mark W Kennedy
- Isala Hartcentrum, Zwolle, The Netherlands.,Diagram CRO, Zwolle, The Netherlands
| | - Enrico Fabris
- Isala Hartcentrum, Zwolle, The Netherlands.,Diagram CRO, Zwolle, The Netherlands
| | | | | | | | - Balazs Berta
- Isala Hartcentrum, Zwolle, The Netherlands.,Diagram CRO, Zwolle, The Netherlands
| | | | | | - Harry Suryapranata
- Isala Hartcentrum, Zwolle, The Netherlands.,Diagram CRO, Zwolle, The Netherlands
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15
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Use of fractional flow reserve in patients with coronary artery disease: The right choice for the right outcome. Trends Cardiovasc Med 2017; 27:106-120. [DOI: 10.1016/j.tcm.2016.06.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Revised: 06/21/2016] [Accepted: 06/23/2016] [Indexed: 01/15/2023]
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16
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Gargiulo G, Stabile E, Ferrone M, Barbato E, Zimmermann FM, Adjedj J, Hennigan B, Matsumura M, Johnson NP, Fearon WF, Jeremias A, Trimarco B, Esposito G. Diabetes does not impact the diagnostic performance of contrast-based fractional flow reserve: insights from the CONTRAST study. Cardiovasc Diabetol 2017; 16:7. [PMID: 28086778 PMCID: PMC5237130 DOI: 10.1186/s12933-016-0494-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2016] [Accepted: 12/30/2016] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Adenosine-free coronary pressure wire metrics have been proposed to test the functional significance of coronary artery lesions, but it is unexplored whether their diagnostic performance might be altered in patients with diabetes. METHODS We performed a post-hoc analysis of the CONTRAST study, which prospectively enrolled an international cohort of patients undergoing routine fractional flow reserve (FFR) assessment for standard indications. Paired, repeated measurements of all physiology metrics (Pd/Pa, iFR, contrast-based FFR, and FFR) were made. A central core laboratory analyzed blinded pressure tracings in a standardized fashion. RESULTS Of 763 subjects enrolled at 12 international centers, 219 (29%) had diabetes. The two groups were well-balanced for age, clinical presentation (stable or unstable), coronary vessel studied, volume and type of intracoronary contrast, and volume of intracoronary adenosine. A binary threshold of cFFR ≤ 0.83 produced an accuracy superior to both Pd/Pa and iFR when compared with FFR ≤ 0.80 in the absence of significant interaction with diabetes status; indeed, accuracy in subgroups of patients with or without diabetes was similar for cFFR (86.7 vs 85.4% respectively; p = 0.76), iFR (84.2 vs 80.0%, p = 0.29) and Pd/Pa (81.3 vs 78.9%, p = 0.55). There was no significant heterogeneity between patients with or without diabetes in terms of sensitivity and specificity of all metrics. The area under the receiver operating characteristic (ROC) curve was largest for cFFR compared with Pd/Pa and iFR which were equivalent (cFFR 0.961 and 0.928; Pd/Pa 0.916 and 0.870; iFR 0.911 and 0.861 in diabetic and non-diabetic patients respectively). CONCLUSIONS cFFR provides superior diagnostic performance compared with Pd/Pa or iFR for predicting FFR irrespective of diabetes (clinicaltrials.gov identifier NCT02184117).
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Affiliation(s)
- Giuseppe Gargiulo
- Department of Advanced Biomedical Sciences, University of Naples Frederico II, Naples, Italy
| | - Eugenio Stabile
- Department of Advanced Biomedical Sciences, University of Naples Frederico II, Naples, Italy
| | - Marco Ferrone
- Department of Advanced Biomedical Sciences, University of Naples Frederico II, Naples, Italy
| | - Emanuele Barbato
- Department of Advanced Biomedical Sciences, University of Naples Frederico II, Naples, Italy.,Cardiovascular Center, OLV Clinic, Aalst, Belgium
| | | | | | - Barry Hennigan
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, Scotland, UK.,British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland, UK
| | | | - Nils P Johnson
- Division of Cardiology, Department of Medicine, Weatherhead PET Center, McGovern Medical School at UTHealth and Memorial Hermann Hospital, Houston, TX, USA
| | - William F Fearon
- Stanford University Medical Center, Stanford, USA.,The Palo Alto VA Health Care Systems, Palo Alto, CA, USA
| | - Allen Jeremias
- Cardiovascular Research Foundation (CRF), New York, NY, USA.,Division of Cardiovascular Medicine, Stony Brook University Medical Center, Stony Brook, NY, USA
| | - Bruno Trimarco
- Department of Advanced Biomedical Sciences, University of Naples Frederico II, Naples, Italy
| | - Giovanni Esposito
- Department of Advanced Biomedical Sciences, University of Naples Frederico II, Naples, Italy. .,Division of Cardiology-Department of Advanced Biomedical Sciences, Federico II University of Naples, Via Pansini 5, 80131, Naples, Italy.
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17
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Combined optical coherence tomography morphologic and fractional flow reserve hemodynamic assessment of non- culprit lesions to better predict adverse event outcomes in diabetes mellitus patients: COMBINE (OCT-FFR) prospective study. Rationale and design. Cardiovasc Diabetol 2016; 15:144. [PMID: 27724869 PMCID: PMC5057218 DOI: 10.1186/s12933-016-0464-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 09/30/2016] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Fractional flow reserve (FFR) is a widely used tool for the identification of ischaemia-generating stenoses and to guide decisions on coronary revascularisation. However, the safety of FFR-based decisions in high-risk subsets, such as patients with Diabetes Mellitus (DM) or vulnerable stenoses presenting thin-cap fibro-atheroma (TCFA), is unknown. This study will examine the impact of optical coherence tomography (OCT) plaque morphological assessment and the identification of TCFA, in combination with FFR to better predict clinical outcomes in DM patients. METHODS COMBINE (OCT-FFR) is a prospective, multi-centre study investigating the natural history of DM patients with ≥1 angiographically intermediate target lesion in three subgroups of patients; patients with FFR negative lesions without TCFA (group A) and patients with FFR negative lesions with TCFA (group B) as detected by OCT and to compare these two groups with each other, as well as to a third group with FFR-positive, PCI-treated intermediate lesions (group C). The study hypothesis is that DM patients with TCFA (group B) have a worse outcome than those without TCFA (group A) and also when compared to those patients with lesions FFR ≤0.80 who underwent complete revascularisation. The primary endpoint is the incidence of target lesion major adverse cardiac events (MACE); a composite of cardiac death, myocardial infarction or rehospitalisation for unstable/progressive angina in group B vs. group A. CONCLUSION COMBINE (OCT-FFR) is the first prospective study to examine whether the addition of OCT plaque morphological evaluation to FFR haemodynamic assessment of intermediate lesions in DM patients will better predict MACE and possibly lead to new revascularisation strategies. Trial Registration Netherlands Trial Register: NTR5376.
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von Haehling S, Hasenfuß G, Anker SD. Diabetes and Heart Failure. J Am Coll Cardiol 2016; 68:1417-1419. [DOI: 10.1016/j.jacc.2016.07.728] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 07/22/2016] [Accepted: 07/26/2016] [Indexed: 12/28/2022]
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19
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Kennedy MW, Kaplan E, Hermanides RS, Fabris E, Hemradj V, Koopmans PC, Dambrink JHE, Marcel Gosselink AT, Van't Hof AWJ, Ottervanger JP, Roolvink V, Remkes WS, van der Sluis A, Suryapranata H, Kedhi E. Clinical outcomes of deferred revascularisation using fractional flow reserve in patients with and without diabetes mellitus. Cardiovasc Diabetol 2016; 15:100. [PMID: 27431395 PMCID: PMC4950234 DOI: 10.1186/s12933-016-0417-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2016] [Accepted: 07/02/2016] [Indexed: 12/18/2022] Open
Abstract
Objective Deferred revascularisation based upon fractional flow reserve (FFR >0.80) is associated with a low incidence of target lesion failure (TLF). Whether deferred revascularisation is also as safe in diabetes mellitus (DM) patients is unknown. Methods All DM patients and the next consecutive Non-DM patients who underwent a FFR-assessment between 1/01/2010 and 31/12/2013 were included, and followed until 1/07/2015. Patients with lesions FFR >0.80 were analysed according to the presence vs. absence of DM, while patients who underwent index revascularisation in FFR-assessed or other lesions were excluded. The primary endpoint was the incidence of TLF; a composite of target lesion revascularisation (TLR) and target vessel myocardial infarction (TVMI). Results A total of 250 patients (122 DM, 128 non-DM) who underwent deferred revascularisation of all lesions (FFR >0.80) were compared. At a mean follow up of 39.8 ± 16.3 months, DM patients compared to non-DM had a higher TLF rate, 18.1 vs 7.5 %, logrank p ≤ 0.01, Cox regression-adjusted HR 3.65 (95 % CI 1.40–9.53, p < 0.01), which was largely driven by a higher incidence of TLR (17.2 vs. 7.5 %, HR 3.52, 95 % CI 1.34–9.30, p = 0.01), whilst a non-significant but numerically higher incidence of TVMI (6.1 vs. 2.0 %, HR 3.34, 95 % CI 0.64–17.30, p = 0.15) was observed. Conclusions This study, the largest to directly compare the clinical outcomes of FFR-guided deferred revascularisation in patients with and without DM, shows that DM patients are associated with a significantly higher TLF rate. Whether intravascular imaging, additional invasive haemodynamics or stringent risk factor modification may impact on this higher TLF rate remains unknown.
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Affiliation(s)
- Mark W Kennedy
- Isala Hartcentrum, Docter Van Heesweg 2, Zwolle, The Netherlands.,Diagram CRO, Zwolle, The Netherlands
| | - Eliza Kaplan
- Isala Hartcentrum, Docter Van Heesweg 2, Zwolle, The Netherlands
| | - Rik S Hermanides
- Isala Hartcentrum, Docter Van Heesweg 2, Zwolle, The Netherlands
| | - Enrico Fabris
- Isala Hartcentrum, Docter Van Heesweg 2, Zwolle, The Netherlands.,Diagram CRO, Zwolle, The Netherlands
| | - Veemal Hemradj
- Isala Hartcentrum, Docter Van Heesweg 2, Zwolle, The Netherlands
| | | | - Jan-Hank E Dambrink
- Isala Hartcentrum, Docter Van Heesweg 2, Zwolle, The Netherlands.,Diagram CRO, Zwolle, The Netherlands
| | | | | | | | - Vincent Roolvink
- Isala Hartcentrum, Docter Van Heesweg 2, Zwolle, The Netherlands
| | - Wouter S Remkes
- Isala Hartcentrum, Docter Van Heesweg 2, Zwolle, The Netherlands
| | | | | | - Elvin Kedhi
- Isala Hartcentrum, Docter Van Heesweg 2, Zwolle, The Netherlands.
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