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Dahdal J, Bakker F, Svanerud J, Danad I, Driessen RS, Raijmakers PG, Harms HJ, Lammertsma AA, van de Hoef TP, Appelman Y, van Royen N, Knaapen P, de Waard GA. Validation of resting full-cycle ratio and diastolic pressure ratio with [ 15O]H 2O positron emission tomography myocardial perfusion. Heart Vessels 2024; 39:299-309. [PMID: 38367040 PMCID: PMC10920410 DOI: 10.1007/s00380-023-02356-4] [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: 06/13/2023] [Accepted: 10/18/2023] [Indexed: 02/19/2024]
Abstract
Fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) are invasive techniques used to evaluate the hemodynamic significance of coronary artery stenosis. These methods have been validated through perfusion imaging and clinical trials. New invasive pressure ratios that do not require hyperemia have recently emerged, and it is essential to confirm their diagnostic efficacy. The aim of this study was to validate the resting full-cycle ratio (RFR) and the diastolic pressure ratio (dPR), against [15O]H2O positron emission tomography (PET) imaging. A total of 129 symptomatic patients with an intermediate risk of coronary artery disease (CAD) were included. All patients underwent cardiac [15O]H2O PET with quantitative assessment of resting and hyperemic myocardial perfusion. Within a 2 week period, coronary angiography was performed. Intracoronary pressure measurements were obtained in 320 vessels and RFR, dPR, and FFR were computed. PET derived regional hyperemic myocardial blood flow (hMBF) and myocardial perfusion reserve (MPR) served as reference standards. In coronary arteries with stenoses (43%, 136 of 320), the overall diagnostic accuracies of RFR, dPR, and FFR did not differ when PET hyperemic MBF < 2.3 ml min-1 (69.9%, 70.6%, and 77.1%, respectively) and PET MPR < 2.5 (70.6%, 71.3%, and 66.9%, respectively) were considered as the reference for myocardial ischemia. Non-significant differences between the areas under the receiver operating characteristic (ROC) curve were found between the different indices. Furthermore, the integration of FFR with RFR (or dPR) does not enhance the diagnostic information already achieved by FFR in the characterization of ischemia via PET perfusion. In conclusion, the novel non-hyperemic pressure ratios, RFR and dPR, have a diagnostic performance comparable to FFR in assessing regional myocardial ischemia. These findings suggest that RFR and dPR may be considered as an FFR alternative for invasively guiding revascularization treatment in symptomatic patients with CAD.
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Affiliation(s)
- Jorge Dahdal
- Department of Cardiology, Amsterdam University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
- Department of Cardiology, Hospital Del Salvador, Salvador 364, 7500922, Santiago, Chile
| | - Frank Bakker
- Department of Cardiology, Amsterdam University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Johan Svanerud
- Coroventis Research AB, Ulls Väg 29A, 75651, Uppsala, Sweden
| | - Ibrahim Danad
- Utrecht University Medical Center, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Roel S Driessen
- Department of Cardiology, Amsterdam University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Pieter G Raijmakers
- Department of Radiology and Nuclear Medicine, VU University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Hendrik J Harms
- Clinical Institute, Aarhus University, Palle Juul-Jensens Blvd. 82, 8200, Aarhus, Denmark
| | - Adriaan A Lammertsma
- Department of Radiology and Nuclear Medicine, VU University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Tim P van de Hoef
- Utrecht University Medical Center, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Yolande Appelman
- Department of Cardiology, Amsterdam University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Niels van Royen
- Department of Cardiology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - Paul Knaapen
- Department of Cardiology, Amsterdam University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Guus A de Waard
- Department of Cardiology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands.
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2
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de Winter RW, van Diemen PA, Schumacher SP, Jukema RA, Somsen YBO, Hoek R, van Rossum AC, Twisk JWR, de Waard GA, Nap A, Raijmakers PG, Driessen RS, Knaapen P, Danad I. Hemodynamic Insights into Combined Fractional Flow Reserve and Instantaneous Wave-Free Ratio Assessment Through Quantitative [ 15O]H 2O PET Myocardial Perfusion Imaging. J Nucl Med 2024; 65:279-286. [PMID: 38176722 DOI: 10.2967/jnumed.123.265973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 11/01/2023] [Indexed: 01/06/2024] Open
Abstract
In patients evaluated for obstructive coronary artery disease (CAD), guidelines recommend using either fractional flow reserve (FFR) or instantaneous wave-free ratio (iFR) to guide coronary revascularization decision-making. The hemodynamic significance of lesions with discordant FFR and iFR measurements is debated. This study compared [15O]H2O PET-derived absolute myocardial perfusion between vessels with concordant and discordant FFR and iFR measurements. Methods: We included 197 patients suspected of obstructive CAD who had undergone [15O]H2O PET perfusion imaging and combined FFR/iFR interrogation in 468 vessels. Resting myocardial blood flow (MBF), hyperemic MBF, and coronary flow reserve (CFR) were compared among 4 groups: FFR low/iFR low (n = 79), FFR high/iFR low (n = 22), FFR low/iFR high (n = 22), and FFR high/iFR high (n = 345). Predefined [15O]H2O PET thresholds for ischemia were 2.3 mL·min-1·g-1 or less for hyperemic MBF and 2.5 or less for CFR. Results: Hyperemic MBF was lower in the concordant low (2.09 ± 0.67 mL·min-1·g-1), FFR high/iFR low (2.41 ± 0.80 mL·min-1·g-1), and FFR low/iFR high (2.40 ± 0.69 mL·min-1·g-1) groups compared with the concordant high group (2.91 ± 0.84 mL·min-1·g-1) (P < 0.001, P = 0.004, and P < 0.001, respectively). A lower CFR was observed in the concordant low (2.37 ± 0.76) and FFR high/iFR low (2.64 ± 0.84) groups compared with the concordant high group (3.35 ± 1.07, P < 0.01 for both). However, for vessels with either low FFR or low iFR, quantitative hyperemic MBF and CFR values exceeded the ischemic threshold in 38% and 49%, respectively. In addition, resting MBF exhibited a negative correlation with iFR (P < 0.001) and was associated with FFR low/iFR high discordance compared with concordant low FFR/low iFR measurements, independent of clinical and angiographic characteristics, as well as hyperemic MBF (odds ratio [OR], 0.41; 95% CI, 0.26-0.65; P < 0.001). Conclusion: We found reduced myocardial perfusion in vessels with concordant low and discordant FFR/iFR measurements. However, FFR/iFR combinations often inaccurately classified vessels as either ischemic or nonischemic when compared with hyperemic MBF and CFR. Furthermore, a lower resting MBF was associated with a higher iFR and the occurrence of FFR low/iFR high discordance. Our study showed that although combined FFR/iFR assessment can be useful to estimate the hemodynamic significance of coronary lesions, these pressure-derived indices provide a limited approximation of [15O]H2O PET-derived quantitative myocardial perfusion as the physiologic standard of CAD severity.
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Affiliation(s)
- Ruben W de Winter
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Pepijn A van Diemen
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Stefan P Schumacher
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Ruurt A Jukema
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Yvemarie B O Somsen
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Roel Hoek
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Albert C van Rossum
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Jos W R Twisk
- Department of Epidemiology and Data Science, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands; and
| | - Guus A de Waard
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Alexander Nap
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Pieter G Raijmakers
- Department of Radiology, Nuclear Medicine, and PET Research, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Roel S Driessen
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Paul Knaapen
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands;
| | - Ibrahim Danad
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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Ohtani H, Ueshima D, Kawakami T, Hanyu Y, Yoshioka K, Mizukami A, Matsumura A, Sasano T. A novel coronary angiographic index for predicting correlation between fractional flow reserve and resting full-cycle ratio. Coron Artery Dis 2023; 34:545-554. [PMID: 37865863 DOI: 10.1097/mca.0000000000001301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2023]
Abstract
OBJECTIVES The discordant results between fractional flow reserve (FFR) and resting full-cycle ratio (RFR) and the influence of angiographic characteristics on their correlation have not been sufficiently investigated. We aimed to identify angiographic characteristics that can predict FFR and RFR correlations using a novel angiographic scoring system. METHODS This retrospective analysis included 220 patients with 252 intermediate coronary lesions assessed using FFR and RFR. Each branch distal to the target lesion was scored based on the vessel diameter (0 points: < 1.5 mm, 1 point: 1.5-2.0 mm, and 2 points: > 2.0 mm) measured using quantitative coronary angiography. The angiographic score was calculated by adding these scores. RESULTS In a propensity score-matched cohort including 84 lesions (42 lesions in each low-and high-angiographic score group), the correlation between FFR and RFR in the high-angiographic score group (>4) was weaker than that in the low-score group (≤4) (Spearman's correlation: r = 0.44 vs. r = 0.80, P < 0.01). Considering a threshold of functional myocardial ischemia as FFR ≤ 0.80 and RFR ≤ 0.89, the low-angiographic score group showed a significantly lower discordance rate of abnormal FFR/normal RFR than the high-angiographic score group (7.1% vs. 23.8%, P = 0.03), whereas the discordance rates of normal FFR/abnormal RFR were similar in both groups (7.1% vs. 9.5%, P = 0.69). CONCLUSION This retrospective analysis highlights the influence of angiographic characteristics on the correlation between FFR and RFR. Our simple angiographic assessment method may be useful for interpreting physiological evaluations in daily clinical practice.
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Affiliation(s)
- Hirofumi Ohtani
- Department of Cardiology, Kameda Medical Center, Chiba
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | | | | | | | | | | | | | - Tetsuo Sasano
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
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Eftekhari A, Holck EN, Westra J, Olsen NT, Bruun NH, Jensen LO, Engstrøm T, Christiansen EH. Instantaneous wave free ratio vs. fractional flow reserve and 5-year mortality: iFR SWEDEHEART and DEFINE FLAIR. Eur Heart J 2023; 44:4376-4384. [PMID: 37634144 DOI: 10.1093/eurheartj/ehad582] [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: 07/07/2023] [Revised: 08/18/2023] [Accepted: 08/24/2023] [Indexed: 08/29/2023] Open
Abstract
BACKGROUND AND AIMS Guidelines recommend revascularization of intermediate epicardial artery stenosis to be guided by evidence of ischaemia. Fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) are equally recommended. Individual 5-year results of two major randomized trials comparing FFR with iFR-guided revascularization suggested increased all-cause mortality following iFR-guided revascularization. The aim of this study was a study-level meta-analysis of the 5-year outcome data in iFR-SWEDEHEART (NCT02166736) and DEFINE-FLAIR (NCT02053038). METHODS Composite of major adverse cardiovascular events (MACE) and its individual components [all-cause death, myocardial infarction (MI), and unplanned revascularisation] were analysed. Raw Kaplan-Meier estimates, numbers at risk, and number of events were extracted at 5-year follow-up and analysed using the ipdfc package (Stata version 18, StataCorp, College Station, TX, USA). RESULTS In total, iFR and FFR-guided revascularization was performed in 2254 and 2257 patients, respectively. Revascularization was more often deferred in the iFR group [n = 1128 (50.0%)] vs. the FFR group [n = 1021 (45.2%); P = .001]. In the iFR-guided group, the number of deaths, MACE, unplanned revascularization, and MI was 188 (8.3%), 484 (21.5%), 235 (10.4%), and 123 (5.5%) vs. 143 (6.3%), 420 (18.6%), 241 (10.7%), and 123 (5.4%) in the FFR group. Hazard ratio [95% confidence interval (CI)] estimates for MACE were 1.18 [1.04; 1.34], all-cause mortality 1.34 [1.08; 1.67], unplanned revascularization 0.99 [0.83; 1.19], and MI 1.02 [0.80; 1.32]. CONCLUSIONS Five-year all-cause mortality and MACE rates were increased with revascularization guided by iFR compared to FFR. Rates of unplanned revascularization and MI were equal in the two groups.
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Affiliation(s)
- Ashkan Eftekhari
- Department Cardiology, Aalborg University Hospital, Hobrovej 18-22, 9000 Aalborg, Denmark
| | - Emil Nielsen Holck
- Department Cardiology, Aarhus University Hospital, Denmark
- Department Clinical Medicine, Health, Aarhus University, Denmark
| | - Jelmer Westra
- Department Cardiology, Aarhus University Hospital, Denmark
- Department Cardiology, Linköping University Hospital, Sweden
| | | | | | | | | | - Evald Høj Christiansen
- Department Cardiology, Aarhus University Hospital, Denmark
- Department Clinical Medicine, Health, Aarhus University, Denmark
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5
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López-Palop R, Carrillo P, Lozano Í. Non-hyperemic, non pressure wire, coronary physiology. A further step towards the generalization of physiology in the cath-lab? Int J Cardiol 2023; 380:1-3. [PMID: 36841291 DOI: 10.1016/j.ijcard.2023.02.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 02/22/2023] [Indexed: 02/26/2023]
Affiliation(s)
- Ramón López-Palop
- Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain.
| | - Pilar Carrillo
- Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Íñigo Lozano
- Servicio de Cardiología, Hospital Universitario de Cabueñes, Gijón, Spain; Instituto de Investigación Sanitaria del Principado de Asturias, ISPA, Oviedo, Spain; Universidad de Oviedo, Spain
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6
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Faria D, Mejia‐Renteria H, Lee JM, Lee SH, Travieso A, Jung J, Doh J, Nam C, Shin E, Hoshino M, Sugiyama T, Kanaji Y, Gonzalo N, Kakuta T, Koo B, Escaned J. Age-related changes in the coronary microcirculation influencing the diagnostic performance of invasive pressure-based indices and long-term patient prognosis. Catheter Cardiovasc Interv 2022; 100:1195-1205. [PMID: 36273417 PMCID: PMC10092817 DOI: 10.1002/ccd.30445] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 09/07/2022] [Accepted: 10/09/2022] [Indexed: 01/04/2023]
Abstract
OBJECTIVES Investigate age-related changes in coronary microvascular function, its effect on hyperemic and non-hyperemic indices of stenosis relevance, and its prognostic implications. BACKGROUND Evidence assessing the effect of age on fractional flow reserve (FFR), resting mean distal intracoronary pressure/mean aortic pressure (Pd/Pa), and microcirculatory function remains scarce. METHODS This is a post hoc study of a large prospective international registry (NCT03690713) including 1134 patients (1326 vessels) with coronary stenoses interrogated with pressure and flow guidewires. Age-dependent correlations with functional indices were analyzed. Prevalences of FFR, resting Pd/Pa, and coronary flow reserve (CFR) classification agreement were assessed. At 5 years follow-up, the relation between resting Pd/Pa, CFR, and their age-dependent implications on FFR-guided percutaneous coronary intervention (PCI) deferral (deferred if FFR > 0.80) were investigated using vessel-oriented composite outcomes (VOCO) composed of death, myocardial infarction, and repeated revascularization. RESULTS Age correlated positively with FFR (r = 0.08, 95% confidence interval [CI]: 0.03 to 0.13, p = 0.005), but not with resting Pd/Pa (r = -0.03, 95% CI:-0.09 to 0.02, p = 0.242). CFR correlated negatively with age (r = -0.15, 95% CI: -0.21 to -0.10, p < 0.001) due to a significant decrease in maximal hyperemic flow in older patients. Patients over 60 years of age with FFR-guided deferred-PCI abnormal resting Pd/Pa or abnormal CFR had increased risk of VOCO (hazard ratio [HR]: 2.10, 95% CI: 1.15 to 4.36, p = 0.048; HR: 2.46, 95% CI:1.23 to 4.96, p = 0.011; respectively). CONLUSIONS Aging is associated with decrease in microcirculatory vasodilation, as assessed with adenosine-based methods like CFR. In patients older than 60 years in whom PCI is deferred according to FFR > 0.80, CFR and resting Pd/Pa have an incremental value in predicting future vessel-oriented patient outcomes.
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Affiliation(s)
- Daniel Faria
- Interventional Cardiology, Hospital Clinico San Carlos IDISCCComplutense University of MadridMadridSpain
- Hospital Professor Doutor Fernando FonsecaAmadoraPortugal
| | - Hernan Mejia‐Renteria
- Interventional Cardiology, Hospital Clinico San Carlos IDISCCComplutense University of MadridMadridSpain
| | - Joo Myung Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical CenterSungkyunkwan University School of MedicineSeoulKorea
| | - Seung Hun Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical CenterSungkyunkwan University School of MedicineSeoulKorea
| | - Alejandro Travieso
- Interventional Cardiology, Hospital Clinico San Carlos IDISCCComplutense University of MadridMadridSpain
| | - Ji‐Hyun Jung
- Department of Internal Medicine and Cardiovascular CenterSeoul National University HospitalSeoulKorea
| | - Joon‐Hyung Doh
- Department of MedicineInje University Ilsan Paik HospitalGoyangKorea
| | - Chang‐Wook Nam
- Department of Medicine and Cardiovascular CenterKeimyung University Dongsan Medical CenterDaeguKorea
| | - Eun‐Seok Shin
- Department of Cardiology, Ulsan University HospitalUniversity of Ulsan College of MedicineUlsanKorea
| | - Masahiro Hoshino
- Division of Cardiovascular MedicineTsuchiura Kyodo General HospitalIbarakiJapan
| | - Tomoyo Sugiyama
- Division of Cardiovascular MedicineTsuchiura Kyodo General HospitalIbarakiJapan
| | - Yoshihisa Kanaji
- Division of Cardiovascular MedicineTsuchiura Kyodo General HospitalIbarakiJapan
| | - Nieves Gonzalo
- Interventional Cardiology, Hospital Clinico San Carlos IDISCCComplutense University of MadridMadridSpain
| | - Tsunekazu Kakuta
- Division of Cardiovascular MedicineTsuchiura Kyodo General HospitalIbarakiJapan
| | - Bon‐Kwon Koo
- Department of Internal Medicine and Cardiovascular CenterSeoul National University HospitalSeoulKorea
- Institute on AgingSeoul National UniversitySeoulKorea
| | - Javier Escaned
- Interventional Cardiology, Hospital Clinico San Carlos IDISCCComplutense University of MadridMadridSpain
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Jeremias A, Nijjer S, Davies J, DiMario C. Physiologic Assessment and Guidance in the Cardiac Catheterization Laboratory. Interv Cardiol 2022. [DOI: 10.1002/9781119697367.ch7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
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Faria D, Lee J, van der Hoef T, Mejía-Rentería H, Echavarria-Pinto M, Baptista S, Cerrato E, Garcia-Garcia H, Davies J, Onuma Y, Samady H, Piek JJ, Serruys PW, Lerman A, Escaned J. Age and functional relevance of coronary stenosis: a post hoc analysis of the ADVISE II trial. EUROINTERVENTION 2021; 17:757-764. [PMID: 33720019 PMCID: PMC9724935 DOI: 10.4244/eij-d-20-01163] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND The influence of age-dependent changes on fractional flow reserve (FFR) or instantaneous wave-free ratio (iFR) and the response to pharmacological hyperaemia has not been investigated. AIMS We investigated the impact of age on these indices. METHODS This is a post hoc analysis of the ADVISE II trial, including a total of 690 pressure recordings (in 591 patients). Age-dependent correlations with FFR and iFR were calculated and adjusted for stenosis severity. Patients were stratified into three age terciles. The hyperaemic response to adenosine, calculated as the difference between resting and hyperaemic pressure ratios, and the prevalence of FFR-iFR discordance were assessed. RESULTS Age correlated positively with FFR (r=0.08, 95% CI: 0.01 to 0.15, p=0.015), but not with iFR (r=-0.03, 95% CI: -0.11 to 0.04, p=0.411). The hyperaemic response to adenosine decreased with patient age (0.12±0.07, 0.11±0.06, 0.09±0.05, for the 1st [33-58 years], 2nd [59-69 years] and 3rd [70-94 years] age tertiles, respectively, p<0.001) and showed significant correlation with age (r=-0.14, 95% CI: -0.21 to -0.06, p<0.001). The proportion of patients with FFR ≤0.80+iFR >0.89 discordance doubled in the first age tercile (14.1% vs 7.1% vs 7.0%, p=0.005). CONCLUSIONS The hyperaemic response of the microcirculation to adenosine administration is age dependent. FFR values increase with patient age, while iFR values remain constant across the age spectrum. These findings contribute to explaining differences observed in functional stenosis classification with hyperaemic and non-hyperaemic coronary indices.
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Affiliation(s)
- Daniel Faria
- Interventional Cardiology Unit, Hospital Clinico San Carlos IDISSC, Complutense University of Madrid, Madrid, Spain,Department of Cardiology, Hospital Professor Doutor Fernando Fonseca, Amadora, Portugal
| | - Joo Lee
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Tim van der Hoef
- Amsterdam UMC, University of Amsterdam, Heart Center, Department of Interventional Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Hernán Mejía-Rentería
- Interventional Cardiology Unit, Hospital Clinico San Carlos IDISSC, Complutense University of Madrid, Madrid, Spain
| | - Mauro Echavarria-Pinto
- Interventional Cardiology Unit, Hospital Clinico San Carlos IDISSC, Complutense University of Madrid, Madrid, Spain,Hospital General ISSSTE Querétaro, Facultad de Medicina, Universidad Autónoma de Querétaro, Santiago de Querétaro, México
| | - Sérgio Baptista
- Department of Cardiology, Hospital Professor Doutor Fernando Fonseca, Amadora, Portugal,University Clinic of Cardiology, Faculty of Medicine at University of Lisbon, Lisbon, Portugal
| | - Enrico Cerrato
- Interventional Cardiology Unit, San Luigi Gonzaga University Hospital, Orbassano, Italy,Rivoli Infermi Hospital, Turin, Italy
| | - Hector Garcia-Garcia
- Interventional Cardiology, Medstar Washington Hospital Center, Washington, DC, USA
| | - Justin Davies
- Faculty of Medicine, National Heart & Lung Institute, Imperial College London, London, United Kingdom
| | - Yoshinobu Onuma
- Department of Interventional Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Habib Samady
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Jan J. Piek
- Amsterdam UMC, University of Amsterdam, Heart Center, Department of Interventional Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Patrick W. Serruys
- Department of Cardiology, National University of Ireland, Galway, Ireland
| | - Amir Lerman
- Department of Cardiovascular Disease, Mayo Clinic, Rochester, MN, USA
| | - Javier Escaned
- Interventional Cardiology, Hospital Clinico San Carlos, Calle del Prof Martín Lagos, 28040 Madrid, Spain
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9
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Manabe O, Aikawa T, Naya M, Miura S, Oyama-Manabe N. Functional Assessment of Coronary Artery Disease by Myocardial Flow Reserve Versus Pressure-wire Based Assessment. ANNALS OF NUCLEAR CARDIOLOGY 2021; 7:57-62. [PMID: 36994131 PMCID: PMC10040938 DOI: 10.17996/anc.21-00144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 08/02/2021] [Indexed: 11/19/2022]
Abstract
Positron emission tomography (PET) permits the noninvasive quantification of myocardial blood flow (MBF). Myocardial flow reserve (MFR), calculated by dividing stress MBF by rest MBF is a reliable index for the functional information of coronary artery disease. A pressure-derived physiological index, such as fractional flow reserve (FFR) is also an important measurement. Both MFR and FFR values are used to evaluate coronary physiology; however, but they are not interchangeable because each test has certain discrepancies. In this systematic review, we provide an overview of coronary physiology with PET compared to pressure-derived physiological indices.
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Affiliation(s)
- Osamu Manabe
- Department of Radiology, Jichi Medical University Saitama Medical Center
| | - Tadao Aikawa
- Department of Radiology, Jichi Medical University Saitama Medical Center
| | - Masanao Naya
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine
| | - Shiro Miura
- Department of Cardiology, Hokkaido Ohno Memorial Hospital
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10
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Coronary Microvascular Dysfunction: PET, CMR and CT Assessment. J Clin Med 2021; 10:jcm10091848. [PMID: 33922841 PMCID: PMC8123021 DOI: 10.3390/jcm10091848] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 04/16/2021] [Accepted: 04/21/2021] [Indexed: 01/05/2023] Open
Abstract
Microvascular dysfunction is responsible for chest pain in various kinds of patients, including those with obstructive coronary artery disease and persistent symptoms despite revascularization, or those with myocardial disease without coronary stenosis. Its diagnosis can be performed with an advanced imaging technique such as positron emission tomography, which represents the gold standard for diagnosing microvascular abnormalities. In recent years, cardiovascular magnetic resonance and cardiac computed tomography have demonstrated to be emerging modalities for microcirculation assessment. The identification of microvascular disease represents a fundamental step in the characterization of patients with chest pain and no epicardial coronary disease: its identification is important to manage medical strategies and improve prognosis. The present overview summarizes the main techniques and current evidence of these advanced imaging strategies in assessing microvascular dysfunction and, if present, their relationship with invasive evaluation.
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11
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Westra J, Eftekhari A, Tu S, Campo G, Escaned J, Winther S, Matsuo H, Qu X, Koltowski L, Chang Y, Liu T, Yang J, Andersen BK, Wijns W, Böttcher M, Christiansen EH, Xu B, Holm NR. Resting distal to aortic pressure ratio and fractional flow reserve discordance affects the diagnostic performance of quantitative flow ratio: Results from an individual patient data meta-analysis. Catheter Cardiovasc Interv 2021; 97:825-832. [PMID: 32478462 DOI: 10.1002/ccd.28976] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 04/06/2020] [Accepted: 05/04/2020] [Indexed: 01/10/2023]
Abstract
OBJECTIVE To evaluate the diagnostic performance of quantitative flow ratio (QFR) related to fractional flow reserve (FFR) and resting distal-to-aortic pressure ratio (resting Pd/Pa) concordance. BACKGROUND QFR is a method for computation of FFR based on standard coronary angiography. It is unclear how QFR is performed in patients with discordance between FFR and resting pressure ratios (distal-to-aortic pressure ratio [Pd/Pa]). MATERIALS AND METHODS The main comparison was the diagnostic performance of QFR with FFR as reference stratified by correspondence between FFR and resting Pd/Pa. Secondary outcome measures included distribution of clinical or procedural characteristics stratified by FFR and resting Pd/Pa correspondence. RESULTS Four prospective studies matched the inclusion criteria. Analysis was performed on patient level data reaching a total of 759 patients and 887 vessels with paired FFR, QFR, and resting Pd/Pa. Median FFR was 0.85 (IQR: 0.77-0.90). Diagnostic accuracy of QFR with FFR as reference was higher if FFR corresponded to resting Pd/Pa: accuracy 90% (95% CI: 88-92) versus 72% (95% CI: 64-80), p < .001, and sAUC 0.95 (95% CI: 0.92-0.96) versus 0.73 (95% CI: 0.69-0.77), p < .001. Resting Pd/Pa and FFR discordance were related to age, sex, hypertension, and lesion severity. CONCLUSION Diagnostic performance of QFR with FFR as reference is reduced for lesions with discordant FFR (≤0.80) and resting Pd/Pa (≤0.92) measurements.
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Affiliation(s)
- Jelmer Westra
- Department of Cardiology, Aarhus University Hospital, Skejby, Denmark
| | - Ashkan Eftekhari
- Department of Cardiology, Aarhus University Hospital, Skejby, Denmark
| | - Shengxian Tu
- School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Gianluca Campo
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Cona, Italy.,Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
| | - Javier Escaned
- Department of Cardiology, Hospital Clinico San Carlos, Madrid, Spain
| | - Simon Winther
- Department of Cardiology, Aarhus University Hospital, Skejby, Denmark
| | - Hitoshi Matsuo
- Department of Cardiovascular Medicine, Gifu Heart Center, Gifu City, Japan
| | - Xinkai Qu
- Huadong Hospital, Fudan University, Shanghai, China
| | - Lukasz Koltowski
- 1st Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Yunxiao Chang
- School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Tommy Liu
- Department of Cardiology, Hagaziesskenhuis, The Hague, The Netherlands
| | - Junqing Yang
- Department of Cardiology, Guangdong General Hospital, Guangzhou, China
| | | | - William Wijns
- The Lambe Institute for Translational Medicine and Curam, National University of Ireland Galway, Galway, Ireland
| | - Morten Böttcher
- Department of Cardiology, Hospital Unit West Jutland, Herning, Denmark
| | | | - Bo Xu
- National Clinical Research Center for Cardiovascular Diseases, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing, China
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12
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Tahir H, Livesay J, Fogelson B, Baljepally R. Effect of Elevated Left Ventricular End Diastolic Pressure on Instantaneous Wave-Free Ratio and Fractional Flow Reserve Discordance. Cardiol Res 2021; 12:117-125. [PMID: 33738015 PMCID: PMC7935642 DOI: 10.14740/cr1230] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 02/09/2021] [Indexed: 01/22/2023] Open
Abstract
Background Instantaneous wave-free ratio (iFR)-guided physiological assessment has been shown to be non-inferior to fractional flow reserve (FFR)-guided assessment for deciding best treatment strategy for angiographically intermediate stenosis. The diagnostic accuracy of iFR compared to FFR reported in various studies is around 80%. Many factors can lead to iFR/FFR discordance, though underlying physiological mechanism of discordance and its associated factors have not been fully evaluated. The effect of left ventricle end diastolic pressure (LVEDP) on iFR/FFR discordance is unknown and needs further evaluation. Methods We performed a single center, non-randomized, both retrospective and prospective study. A total of 65 patients with intermediate coronary stenosis undergoing physiological assessment were included in the study. Patients were assigned to two groups (normal LVEDP and high LVEDP group) based on LVEDP cutoff of 15 mm Hg. iFR and FFR were measured for each patient and iFR/FFR results were compared between the two groups. Results A significantly large number of patients in elevated LVEDP group had iFR/FFR discordance compared to normal LVEDP group (42.8% vs. 6.7%, P = 0.001). More patients with acute coronary syndrome (ACS) had discordance compared to stale coronary artery disease (CAD) patients (53% vs. 15%, P = 0.003). Conclusions Elevated LVEDP can affect iFR and FFR measurements and can lead to discordance. Further studies are required to determine effect of elevated LVEDP on iFR/FFR discordance and whether such discordance is clinically relevant. “Normal range” iFR results should be cautiously interpreted in patients with elevated LVEDP, especially those with ACS.
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Affiliation(s)
- Hassan Tahir
- Department of Cardiology, Heart Lung Vascular Institute, University of Tennessee Medical Center, Knoxville, TN, USA
| | - James Livesay
- Department of Cardiology, Heart Lung Vascular Institute, University of Tennessee Medical Center, Knoxville, TN, USA
| | - Benjamin Fogelson
- Department of Cardiology, Heart Lung Vascular Institute, University of Tennessee Medical Center, Knoxville, TN, USA
| | - Raj Baljepally
- Department of Cardiology, Heart Lung Vascular Institute, University of Tennessee Medical Center, Knoxville, TN, USA
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13
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Kayaert P, Coeman M, Gevaert S, De Pauw M, Haine S. Physiology-Based Revascularization of Left Main Coronary Artery Disease. J Interv Cardiol 2021; 2021:4218769. [PMID: 33628144 PMCID: PMC7892248 DOI: 10.1155/2021/4218769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 01/12/2021] [Accepted: 01/22/2021] [Indexed: 01/10/2023] Open
Abstract
It is of critical importance to correctly assess the significance of a left main lesion. Underestimation of significance beholds the risk of inappropriate deferral of revascularization, whereas overestimation may trigger major but unnecessary interventions. This article addresses the invasive physiological assessment of left main disease and its role in deciding upon revascularization. It mainly focuses on the available evidence for fractional flow reserve and instantaneous wave-free ratio, their interpretation, and limitations. We also discuss alternative invasive physiological indices and imaging, as well as the link between physiology, ischemia, and prognosis.
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Affiliation(s)
- Peter Kayaert
- Department of Cardiology, Ghent University Hospital, Ghent, Belgium
| | - Mathieu Coeman
- Department of Cardiology, Jan Yperman Ziekenhuis, Ypres, Belgium
| | - Sofie Gevaert
- Department of Cardiology, Ghent University Hospital, Ghent, Belgium
| | - Michel De Pauw
- Department of Cardiology, Ghent University Hospital, Ghent, Belgium
| | - Steven Haine
- Department of Cardiology, Antwerp University Hospital, Antwerp, Belgium
- Department of Cardiovascular Diseases, University of Antwerp, Antwerp, Belgium
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14
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Beg F, Rehman H, Chamsi-Pasha MA, Nabi F, Chang SM, Mahmarian JJ, Al-Mallah MH. Association Between FFR CT and Instantaneous Wave-Free Ratio (iFR) of Intermediate Lesions on Coronary Computed Tomography Angiography. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2020; 31:57-60. [PMID: 33272881 DOI: 10.1016/j.carrev.2020.11.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 11/18/2020] [Accepted: 11/23/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND New data suggests long term outcomes of coronary revascularization based on instantaneous wave free ratio (iFR) are equivalent to invasive fractional flow reserve (FFR). We aimed to evaluate the correlation between non-invasive FFR derived from cardiac CT (FFRCT) and iFR. METHODS Data from 21 patients with 26 vessels, who underwent both FFRCT computation and invasive iFR measurement, were analysed. We evaluated diagnostic performance of FFRCT according to two cut-off values of ≤0.80 and ≤0.70 with iFR ≤0.89 as the reference standard. RESULTS In a per vessel analysis, the average diameter stenosis was 59%, mean FFRCT was 0.81 while mean iFR was 0.90. Using an FFRCT cut-off of 0.80, the sensitivity, specificity, positive predictive value, negative predictive value and overall accuracy for FFRCT were 86%, 84%, 67%, 94%, and 85% respectively. When the cut-off was lowered to 0.70, the sensitivity, specificity, positive predictive value, negative predictive value and overall accuracy for FFRCT were 57%, 100%, 100%, 86% and 88% respectively. CONCLUSION FFRCT correlates well with iFR in this small retrospective study. Larger studies are required to confirm this finding.
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Affiliation(s)
- Faheemullah Beg
- Section of Interventional & Structural Cardiology, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Hasan Rehman
- Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, TX, United States of America
| | - Mohammed A Chamsi-Pasha
- Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, TX, United States of America
| | - Faisal Nabi
- Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, TX, United States of America
| | - Su-Min Chang
- Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, TX, United States of America
| | - John J Mahmarian
- Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, TX, United States of America
| | - Mouaz H Al-Mallah
- Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, TX, United States of America.
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15
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Comparison of Instantaneous Wave-Free Ratio (iFR) and Fractional Flow Reserve (FFR) with respect to Their Sensitivities to Cardiovascular Factors: A Computational Model-Based Study. J Interv Cardiol 2020; 2020:4094121. [PMID: 32508540 PMCID: PMC7240797 DOI: 10.1155/2020/4094121] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 01/18/2020] [Accepted: 02/27/2020] [Indexed: 02/06/2023] Open
Abstract
While coronary revascularization strategies guided by instantaneous wave-free ratio (iFR) are, in general, noninferior to those guided by fractional flow reserve (FFR) with respect to the rate of major adverse cardiac events at one-year follow-up in patients with stable angina or an acute coronary syndrome, the overall accuracy of diagnosis with iFR in large patient cohorts is about 80% compared with the diagnosis with FFR. So far, it remains incompletely understood what factors contribute to the discordant diagnosis between iFR and FFR. In this study, a computational method was used to systemically investigate the respective effects of various cardiovascular factors on FFR and iFR. The results showed that deterioration in aortic valve disease (e.g., regurgitation or stenosis) led to a marked decrease in iFR and a mild increase in FFR given fixed severity of coronary artery stenosis and that increasing coronary microvascular resistance caused a considerable increase in both iFR and FFR, but the degree of increase in iFR was lower than that in FFR. These findings suggest that there is a high probability of discordant diagnosis between iFR and FFR in patients with severe aortic valve disease or coronary microcirculation dysfunction.
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16
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Rivero F, Antuña P, García-Guimaraes M, Jiménez C, Cuesta J, Bastante T, Alfonso F. Correlation between fractional flow reserve and instantaneous wave-free ratio with morphometric assessment by optical coherence tomography in diabetic patients. Int J Cardiovasc Imaging 2020; 36:1193-1201. [PMID: 32221772 DOI: 10.1007/s10554-020-01819-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 03/18/2020] [Indexed: 10/24/2022]
Abstract
Currently there is lack of data regarding the use of optical coherence tomography (OCT) to depict the hemodynamic relevance of coronary stenoses in diabetic patients. We sought to assess the diagnostic accuracy of OCT-derived morphologic assessment in identifying hemodynamically significant coronary lesions as determined by both, the resting instantaneous wave-free ratio (iFR) and the hyperemic fractional flow reserve (FFR) in diabetic patients. Diabetic patients presenting with at least one intermediate coronary lesion were prospectively and consecutively enrolled. All lesions were systematically assessed by iFR, FFR and OCT. A total of 41 intermediate lesions were analysed. Mean iFR and FFR values were 0.90 ± 0.04 and 0.81 ± 0.06, respectively (intra-class correlation coefficient 0.49; 95% CI 0.22-0.79). A moderate correlation between iFR and OCT derived minimal lumen diameter (MLD, r = 0.49) and minimal lumen area (MLA, r = 0.50) was found. Conversely, there was a poor correlation between FFR and OCT-derived MLD (r = 0.34) and MLA (r = 0.32). The diagnostic efficiency of MLA and MLD to identify iFR significant stenoses showed an AUC of 0.82 (95% CI 0.69-0.95) for MLD and 0.83 (95% CI 0.71-0.96) for MLA. A worse diagnostic efficiency was found when FFR was used as the reference with an AUC of 0.71 (95% CI 0.54-0.87) for MLD and 0.70 (95% CI 0.53-0.87). OCT-derived MLA and MLD were the strongest independent anatomic predictors of abnormal iFR and FFR values. In diabetic patients, OCT-derived MLA and MLD showed a moderate diagnostic efficiency in identifying functionally significant coronary stenoses by FFR or iFR. In diabetics, anatomic OCT measurements better predicted resting than FFR-determined physiologically significant lesions.
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Affiliation(s)
- Fernando Rivero
- Cardiology Department, Hospital Universitario de La Princesa, IIS-IP, CIBERCV, C/ Diego de Leon 62, 28006, Madrid, Spain
| | - Paula Antuña
- Cardiology Department, Hospital Universitario de La Princesa, IIS-IP, CIBERCV, C/ Diego de Leon 62, 28006, Madrid, Spain
| | - Marcos García-Guimaraes
- Cardiology Department, Hospital Universitario de La Princesa, IIS-IP, CIBERCV, C/ Diego de Leon 62, 28006, Madrid, Spain
| | - César Jiménez
- Cardiology Department, Hospital Universitario de La Princesa, IIS-IP, CIBERCV, C/ Diego de Leon 62, 28006, Madrid, Spain
| | - Javier Cuesta
- Cardiology Department, Hospital Universitario de La Princesa, IIS-IP, CIBERCV, C/ Diego de Leon 62, 28006, Madrid, Spain
| | - Teresa Bastante
- Cardiology Department, Hospital Universitario de La Princesa, IIS-IP, CIBERCV, C/ Diego de Leon 62, 28006, Madrid, Spain
| | - Fernando Alfonso
- Cardiology Department, Hospital Universitario de La Princesa, IIS-IP, CIBERCV, C/ Diego de Leon 62, 28006, Madrid, Spain.
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17
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Quantitative flow ratio and instantaneous wave-free ratio for the assessment of the functional severity of intermediate coronary artery stenosis. Coron Artery Dis 2019; 29:611-617. [PMID: 29965837 DOI: 10.1097/mca.0000000000000650] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVE Quantitative flow ratio (QFR) is a novel physiological index of the severity of coronary stenosis. The aim of the present study was to investigate the relationship between QFR and the instantaneous wave-free ratio (iFR). PATIENTS AND METHODS We analyzed contrast-flow QFR, iFR, and fractional flow reserve (FFR) in 100 coronary arteries with intermediate stenosis. RESULTS There was a high correlation (r=0.71, P<0.001) and a good agreement (mean difference: -0.09±0.11) between QFR and iFR. Both QFR and iFR were correlated significantly with FFR (r=0.89, P<0.001 and r=0.76, P<0.001, respectively). The mean absolute difference between FFR and QFR was significantly smaller than that between FFR and iFR (-0.01±0.07 vs. -0.08±0.09, P<0.001). The diagnostic accuracy of QFR less than or equal to 0.80 for predicting FFR less than or equal to 0.80 was numerically higher than that of iFR less than or equal to 0.89 for predicting FFR less than or equal to 0.80 [QFR: 94% (95% confidence interval: 85-97%) vs. iFR: 74% (95% confidence interval: 65-81%)]. CONCLUSION QFR was correlated highly with iFR as well as FFR. Like FFR and iFR, QFR might be reliable for assessing the physiological severity of coronary stenosis in the angiographic intermediate lesions.
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18
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Lee SH, Choi KH, Lee JM, Hwang D, Rhee TM, Park J, Kim HK, Cho YK, Yoon HJ, Park J, Song YB, Hahn JY, Doh JH, Nam CW, Shin ES, Hur SH, Koo BK. Physiologic Characteristics and Clinical Outcomes of Patients With Discordance Between FFR and iFR. JACC Cardiovasc Interv 2019; 12:2018-2031. [PMID: 31563683 DOI: 10.1016/j.jcin.2019.06.044] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 06/12/2019] [Accepted: 06/18/2019] [Indexed: 01/10/2023]
Abstract
OBJECTIVES This study evaluated the physiologic characteristics of discordant lesions between instantaneous wave-free ratio (iFR) and fractional flow reserve (FFR) and the prognosis at 5 years. BACKGROUND FFR or iFR have been standard methods for assessing the functional significance of coronary artery stenosis. However, limited data exist about the physiologic characteristics of discordant lesions and the prognostic implications resulting from these lesions. METHODS A total of 840 vessels from 596 patients were classified according to iFR and FFR; high iFR-high FFR (n = 580), low iFR-high FFR (n = 40), high iFR-low FFR (n = 69), and low iFR-low FFR (n = 128) groups, which were compared with a control group (n = 23). The differences in coronary circulatory indices including the coronary flow reserve (CFR), index of microcirculatory resistance (IMR), and resistance reserve ratio (RRR) (resting distal arterial pressure × mean transit time / hyperemic distal arterial pressure × hyperemic mean transit time), which reflect the vasodilatory capacity of coronary microcirculation, were compared. Patient-oriented composite outcomes (POCO) at 5 years including all-cause death, any myocardial infarction, and any revascularization were compared among patients with deferred lesions. RESULTS In the low iFR-high FFR group, CFR, RRR, and IMR measurements were similar to the low iFR-low FFR group: CFR 2.71 versus 2.43 (p = 0.144), RRR 3.36 versus 3.68 (p = 0.241), and IMR 18.51 versus 17.38 (p = 0.476). In the high iFR-low FFR group, the CFR, RRR, and IMR measurements were similar to the control group: CFR 2.95 versus 3.29 (p = 0.160), RRR 4.28 versus 4.00 (p = 0.414), and IMR 17.44 versus 17.06 (p = 0.818). Among the 4 groups, classified by iFR and FFR, CFR and RRR were all significantly different, except for IMR. However, there were no significant differences in the rates of POCO, regardless of discordance between the iFR and FFR. Only the low iFR-low FFR group had a higher POCO rate compared with the high iFR-high FFR group (adjusted hazard ratio: 2.46; 95% confidence interval: 1.17 to 5.16; p = 0.018). CONCLUSIONS Differences in coronary circulatory function were found, especially in the vasodilatory capacity between the low iFR-high FFR and high iFR-low FFR groups. FFR-iFR discordance was not related to an increased risk of POCO among patients with deferred lesions at 5 years. (Clinical, Physiological and Prognostic Implication of Microvascular Status;NCT02186093; Physiologic Assessment of Microvascular Function in Heart Transplant Patients; NCT02798731).
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Affiliation(s)
- Seung Hun Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ki Hong Choi
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joo Myung Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
| | - Doyeon Hwang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Tae-Min Rhee
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Jonghanne Park
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea; Department of Internal Medicine, Naju National Hospital, Ministry of Health and Welfare, Naju, Korea
| | - Hyun Kuk Kim
- Department of Internal Medicine and Cardiovascular Center, Chosun University Hospital, University of Chosun College of Medicine, Gwangju, Korea
| | - Yun-Kyeong Cho
- Department of Medicine, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Hyuck-Jun Yoon
- Department of Medicine, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Jinhyoung Park
- Department of Biomedical Engineering, Sungkyunkwan University, Suwon, Korea
| | - Young Bin Song
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joo-Yong Hahn
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joon-Hyung Doh
- Department of Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Chang-Wook Nam
- Department of Medicine, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Eun-Seok Shin
- Division of Cardiology, Ulsan Hospital, Ulsan, Korea; Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Seung-Ho Hur
- Department of Medicine, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Bon-Kwon Koo
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea; Institute on Aging, Seoul National University, Seoul, Korea
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19
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Lee JM, Rhee TM, Choi KH, Park J, Hwang D, Kim J, Park J, Kim HY, Jung HW, Cho YK, Yoon HJ, Song YB, Hahn JY, Nam CW, Shin ES, Doh JH, Hur SH, Koo BK. Clinical Outcome of Lesions With Discordant Results Among Different Invasive Physiologic Indices - Resting Distal Coronary to Aortic Pressure Ratio, Resting Full-Cycle Ratio, Diastolic Pressure Ratio, Instantaneous Wave-Free Ratio, and Fractional Flow Reserve. Circ J 2019; 83:2210-2221. [PMID: 31484836 DOI: 10.1253/circj.cj-19-0230] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND We evaluated the 2-year clinical outcomes of deferred lesions with discordant results between resting and hyperemic pressure-derived physiologic indices, including resting distal to aortic coronary pressure (resting Pd/Pa), instantaneous wave-free ratio (iFR), resting full-cycle ratio (RFR), diastolic pressure ratio (dPR), and fractional flow reserve (FFR).Methods and Results:The 2-year clinical outcomes of 1,024 vessels (435 patients) with available resting Pd/Pa, iFR, RFR, dPR, and FFR data were analyzed according to a 4-group classification using known cutoff values (resting Pd/Pa ≤0.92, iFR/RFR/dPR ≤0.89, and FFR ≤0.80): Group 1 (concordant normal), Group 2 (high resting index and low FFR), Group 3 (low resting index and high FFR), and Group 4 (concordance abnormal). The primary outcome was vessel-oriented composite outcomes (VOCO) in deferred vessels at 2 years. In the comparison of VOCO risk among 4 groups classified according to FFR and 4 resting physiologic indices, Group 4 consistently showed a significantly higher risk of VOCO than Group 1. Comparison of VOCO risk among 4 groups classified according to iFR and other resting physiologic indices also showed the same results. The presence of discordance, either between hyperemic and resting indices or among resting indices, was not an independent predictor for VOCO. CONCLUSIONS Discordant results between resting physiologic indices and FFR and among the resting indices were not associated with increased risk of VOCO in deferred lesions.
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Affiliation(s)
- Joo Myung Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Tae-Min Rhee
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital
| | - Ki Hong Choi
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Jonghanne Park
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital.,Department of Internal Medicine, Naju National Hospital, Ministry of Health and Welfare
| | - Doyeon Hwang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital
| | - Jinseob Kim
- Department of Epidemiology, School of Public Health, Seoul National University
| | - Jinhyoung Park
- Department of Biomedical Engineering, Sungkyunkwan University
| | - Hyung Yoon Kim
- Department of Cardiovascular Medicine, Chonnam National University Hospital
| | - Hae Won Jung
- Department of Cardiology, Daegu Catholic University Medical Center
| | - Yun-Kyeong Cho
- Department of Medicine, Keimyung University Dongsan Medical Center
| | - Hyuck-Jun Yoon
- Department of Medicine, Keimyung University Dongsan Medical Center
| | - Young Bin Song
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Joo-Yong Hahn
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Chang-Wook Nam
- Department of Medicine, Keimyung University Dongsan Medical Center
| | - Eun-Seok Shin
- Division of Cardiology, Ulsan Hospital.,Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine
| | - Joon-Hyung Doh
- Department of Medicine, Inje University Ilsan Paik Hospital
| | - Seung-Ho Hur
- Department of Medicine, Keimyung University Dongsan Medical Center
| | - Bon-Kwon Koo
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital.,Institute on Aging, Seoul National University
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20
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Lee HS, Lee JM, Nam CW, Shin ES, Doh JH, Dai N, Ng MKC, Yong ASC, Tresukosol D, Mullasari AS, Mathew R, Chandra P, Wang KT, Chen Y, Chen J, Yiu KH, Johnson NP, Koo BK. Consensus document for invasive coronary physiologic assessment in Asia-Pacific countries. Cardiol J 2019; 26:215-225. [PMID: 31225632 DOI: 10.5603/cj.a2019.0054] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Revised: 06/12/2019] [Accepted: 06/09/2019] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Currently, invasive physiologic assessment such as fractional flow reserve is widely used worldwide with different adoption rates around the globe. Patient characteristics and physician preferences often differ in the Asia-Pacific (APAC) region with respect to treatment strategy, techniques, lesion complexity, access to coronary physiology and imaging devices, as well as patient management. Thus, there is a need to construct a consensus document on recommendations for use of physiology-guided percutaneous coronary intervention (PCI) in APAC populations. This document serves as an overview of recommendations describing the best practices for APAC populations to achieve more consistent and optimal clinical outcomes. METHODS AND RESULTS A comprehensive multiple-choice questionnaire was provided to 20 interven- tional cardiologists from 10 countries in the APAC region. Clinical evidence, tips and techniques, and clinical situations for the use of physiology-guided PCI in APAC were reviewed and used to propose key recommendations. There are suggestions to continue to develop evidence for lesion and patient types that will benefit from physiology, develop directions for future research in health economics and local data, develop appropriate use criteria in different countries, and emphasize the importance of education of all stakeholders. A consensus recommendation to enhance the penetration of invasive physiology-based therapy was to adopt the 5E approach: Evidence, Education, Expand hardware, Economics and Expert consensus. CONCLUSIONS This consensus document and recommendations support interventional fellows and cardiologists, hospital administrators, patients, and medical device companies to build confidence and encourage wider implementation of invasive coronary physiology-guided therapy in the APAC region.
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Affiliation(s)
- Hak Seung Lee
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Joo Myung Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Chang-Wook Nam
- Department of Medicine, Keimyung University Dongsan Medical Center, Daegu, Republic of Korea
| | - Eun-Seok Shin
- Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Korea
| | - Joon-Hyung Doh
- Department of Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Neng Dai
- Department of Cardiology, Shanghai Institute of Cardiovascular Disease, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Martin K C Ng
- Department of Cardiology, Royal Prince Alfred Hospital, Camperdown, Australia
| | - Andy S C Yong
- Department of Cardiology, Concord Hospital, Sydney, Australia
| | - Damras Tresukosol
- Division of Cardiology, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Ajit S Mullasari
- Institute of Cardiovascular Diseases, The Madras Medical Mission, Chennai, India
| | | | | | - Kuang-Te Wang
- Division of Cardiology, Department of Internal Medicine, Mackay Memorial Hospital, Taitung Branch, Taiwan
| | - Yundai Chen
- Department of Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Jiyan Chen
- Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Kai-Hang Yiu
- Division of Cardiology, Department of Medicine, University of Hong Kong, Queen Mary Hospital, Hong Kong, China
| | - Nils P Johnson
- McGovern Medical School at UTHealth and Memorial Hermann Hospital, Houston, Texas, United States
| | - Bon-Kwon Koo
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Republic of Korea.
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21
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Low FFR equal to low ischemia: Really? Int J Cardiol 2018; 265:81. [PMID: 29885704 DOI: 10.1016/j.ijcard.2017.12.095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 12/23/2017] [Indexed: 11/23/2022]
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22
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Lee JM, Doh JH, Nam CW, Shin ES, Koo BK. Functional Approach for Coronary Artery Disease: Filling the Gap Between Evidence and Practice. Korean Circ J 2018; 48:179-190. [PMID: 29557104 PMCID: PMC5861310 DOI: 10.4070/kcj.2017.0393] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Accepted: 01/25/2018] [Indexed: 01/14/2023] Open
Abstract
The presence of myocardial ischemia is the most important prognostic factor in patients with coronary artery disease, and ischemia-directed revascularization has been a standard of care. Fractional flow reserve (FFR) is an invasive method used to detect the functionally significant epicardial coronary stenosis, and FFR-guided revascularization strategy has been proven to be superior to angiography-guided strategy. Recently, a hyperemia-free index, instantaneous wave free ratio (iFR), was developed and showed its non-inferiority for clinical outcomes compared with FFR-guided strategy. While evidence supporting the benefit of pressure wire assessment exists, there remain several unresolved issues, such as the mechanism of discordance between resting and hyperemic physiologic indices, clinical outcomes of patient/lesions with discordant results among the physiologic indices, role of physiologic indices beyond per-vessel decision tool, and the role of microvascular dysfunction in patient prognosis. The current article will review the recent studies performed to address these questions.
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Affiliation(s)
- Joo Myung Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joon Hyung Doh
- Department of Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Chang Wook Nam
- Department of Medicine, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Eun Seok Shin
- Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
- Division of Cardiology, Dietrich Bonhoeffer Hospital, Academic Teaching Hospital of University of Greifswald, Greifswald, Germany
| | - Bon Kwon Koo
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
- Institute on Aging, Seoul National University, Seoul, Korea.
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AL-Obaidi FR, Fearon WF, Yong AS. Invasive physiological indices to determine the functional significance of coronary stenosis. IJC HEART & VASCULATURE 2018; 18:39-45. [PMID: 29876502 PMCID: PMC5988484 DOI: 10.1016/j.ijcha.2018.02.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 02/13/2018] [Indexed: 01/10/2023]
Abstract
Physiological measurements are now commonly used to assess coronary lesions in the cardiac catheterisation laboratory, and this practice is evidence-based and supported by clinical guidelines. Fractional flow reserve is currently the gold standard method to determine whether coronary lesions are functionally significant, and is used to guide revascularization. There are however several other physiological measurements that have been proposed as alternatives to the fractional flow reserve. This review aims to comprehensively discuss physiological indices that can be used in the cardiac catheterisation laboratory to determine the functional significance of coronary lesions. We will focus on their advantages and disadvantages, and the current evidence supporting their use.
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Affiliation(s)
- Firas R. AL-Obaidi
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
- College of Medicine, University of Thi Qar, Iraq
| | - William F. Fearon
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Andy S.C. Yong
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
- ANZAC Research Institute, Concord Hospital, Sydney, Australia
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24
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Nanayakkara S, Marwick TH, Kaye DM. The ageing heart: the systemic and coronary circulation. Heart 2017; 104:370-376. [PMID: 29092917 DOI: 10.1136/heartjnl-2017-312114] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2017] [Revised: 09/27/2017] [Accepted: 09/28/2017] [Indexed: 12/22/2022] Open
Abstract
Most cardiovascular disease (CVD) occurs in patients over the age of 60. However, most evidence-based current cardiovascular guidelines lack evidence in an older population, due to the under-representation of older patients in randomised trials. Blood pressure rises with age due to increasing arterial stiffness, and stricter control results in improved outcomes. Myocardial ischaemia is also more common with increasing age, due to a combination of coronary artery disease and myocardial changes. However, despite higher rates of adverse outcomes, older patients are offered guideline-based therapy less frequently. Frailty is an independent predictor of mortality in adults over the age of 60, yet remains poorly assessed; slow gait speed is a key marker for the development of frailty and for adverse outcomes following intervention. Few trials have assessed frailty independent of age; however, there is evidence that non-frail older patients derive significant benefit from therapy, highlighting the urgent need to include frailty as a measure in clinical trials of treatment in CVD.In this review, the authors appraise the literature in regard to the cardiovascular changes with ageing, specifically in relation to the systemic and coronary circulation and with a particular emphasis on frailty and its implication in the evaluation and treatment of CVD.
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Affiliation(s)
- Shane Nanayakkara
- Heart Failure Research Group, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia.,Department of Cardiovascular Medicine, Alfred Hospital, Melbourne, Victoria, Australia.,Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Thomas H Marwick
- Department of Cardiovascular Medicine, Alfred Hospital, Melbourne, Victoria, Australia.,Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - David M Kaye
- Heart Failure Research Group, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia.,Department of Cardiovascular Medicine, Alfred Hospital, Melbourne, Victoria, Australia.,Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
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25
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Lee JM, Shin ES, Nam CW, Doh JH, Hwang D, Park J, Kim KJ, Zhang J, Koo BK. Discrepancy between fractional flow reserve and instantaneous wave-free ratio: Clinical and angiographic characteristics. Int J Cardiol 2017; 245:63-68. [PMID: 28789845 DOI: 10.1016/j.ijcard.2017.07.099] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2017] [Revised: 06/25/2017] [Accepted: 07/24/2017] [Indexed: 01/25/2023]
Abstract
BACKGROUND The invasive physiologic index such as fractional flow reserve (FFR) or instantaneous wave-free ratio (iFR) is used in clinical practice to identify ischemia-causing stenosis and to guide treatment strategy. We investigated clinical and angiographic characteristics of lesions with discrepancy between FFR and iFR. METHODS From the 3V FFR-FRIENDS study, 975 vessels (393 patients) with available pre-intervention FFR and iFR were included in this study. The vessels were classified according to FFR and iFR into: concordant normal (Group 1 [n=724]: FFR>0.80 and iFR≥0.90); high FFR and low iFR (Group 2 [n=33]: FFR>0.80 and iFR<0.90); low FFR and high iFR (Group 3 [n=82]: FFR≤0.80 and iFR≥0.90); and concordant abnormal (Group 4 [n=136]: FFR≤0.80 and iFR<0.90). RESULTS Angiographic stenosis severity assessed by percent diameter stenosis, minimum lumen diameter and lesion length was increased from Group 1 to Group 4 (all p<0.001). SYNTAX score increased and FFR decreased proportionally from Group 1 to Group 4 (all p<0.001). In multivariable GEE model, female, diabetes mellitus, smaller reference vessel diameter, and higher %DS were significantly associated with low iFR among high FFR groups (Group 2 discordance). Conversely, males, absence of diabetes mellitus and lower %DS were significantly associated with high iFR among low FFR groups (Group 3 discordance). CONCLUSIONS Four groups classified according to FFR and iFR were different in clinical and angiographic characteristics, SYNTAX score, and predictors of discordance. The lesions with discordant FFR and iFR may need to be interpreted as a different clinical entity.
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Affiliation(s)
- Joo Myung Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Eun-Seok Shin
- Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, South Korea; Division of Cardiology, Dietrich Bonhoeffer Hospital, Academic Teaching Hospital of University of Greifswald, Greifswald, Germany
| | - Chang-Wook Nam
- Department of Medicine, Keimyung University Dongsan Medical Center, Daegu, South Korea
| | - Joon-Hyung Doh
- Department of Medicine, Inje University Ilsan Paik Hospital, Goyang, South Korea
| | - Doyeon Hwang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, South Korea
| | - Jonghanne Park
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, South Korea
| | - Kyung-Jin Kim
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, South Korea
| | - Jinlong Zhang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, South Korea
| | - Bon-Kwon Koo
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, South Korea; Institute on Aging, Seoul National University, Seoul, South Korea.
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