1
|
Lee JH, Ahn SG, Jeon HS, Lee JW, Youn YJ, Zhang J, Hu X, Wang J, Lee JM, Hahn JY, Nam CW, Doh JH, Lee BK, Kim W, Huang J, Jiang F, Zhou H, Chen P, Tang L, Jiang W, Chen X, He W, Yoon MH, Tahk SJ, Kim U, Ki YJ, Shin ES, Hwang D, Kang J, Kim HS, Koo BK. Discordance Between Angiographic Assessment and Fractional Flow Reserve or Intravascular Ultrasound in Intermediate Coronary Lesions: A Post-hoc Analysis of the FLAVOUR Trial. Korean Circ J 2024; 54:54.e69. [PMID: 38956940 DOI: 10.4070/kcj.2024.0046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 04/09/2024] [Accepted: 05/20/2024] [Indexed: 07/04/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Angiographic assessment of coronary stenosis severity using quantitative coronary angiography (QCA) is often inconsistent with that based on fractional flow reserve (FFR) or intravascular ultrasound (IVUS). We investigated the incidence of discrepancies between QCA and FFR or IVUS, and the outcomes of FFR- and IVUS-guided strategies in discordant coronary lesions. METHODS This study was a post-hoc analysis of the FLAVOUR study. We used a QCA-derived diameter stenosis (DS) of 60% or greater, the highest tertile, to classify coronary lesions as concordant or discordant with FFR or IVUS criteria for percutaneous coronary intervention (PCI). The patient-oriented composite outcome (POCO) was defined as a composite of death, myocardial infarction, or revascularization at 24 months. RESULTS The discordance rate between QCA and FFR or IVUS was 30.2% (n=551). The QCA-FFR discordance rate was numerically lower than the QCA-IVUS discordance rate (28.2% vs. 32.4%, p=0.050). In 200 patients with ≥60% DS, PCI was deferred according to negative FFR (n=141) and negative IVUS (n=59) (15.3% vs. 6.5%, p<0.001). The POCO incidence was comparable between the FFR- and IVUS-guided deferral strategies (5.9% vs. 3.4%, p=0.479). Conversely, 351 patients with DS <60% underwent PCI according to positive FFR (n=118) and positive IVUS (n=233) (12.8% vs. 25.9%, p<0.001). FFR- and IVUS-guided PCI did not differ in the incidence of POCO (9.5% vs. 6.5%, p=0.294). CONCLUSIONS The proportion of QCA-FFR or IVUS discordance was approximately one third for intermediate coronary lesions. FFR- or IVUS-guided strategies for these lesions were comparable with respect to POCO at 24 months. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02673424.
Collapse
Affiliation(s)
- Jung-Hee Lee
- Division of Cardiology, Department of Internal Medicine, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Sung Gyun Ahn
- Division of Cardiology, Department of Internal Medicine, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea.
| | - Ho Sung Jeon
- Division of Cardiology, Department of Internal Medicine, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jun-Won Lee
- Division of Cardiology, Department of Internal Medicine, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Young Jin Youn
- Division of Cardiology, Department of Internal Medicine, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jinlong Zhang
- Division of Cardiology, Department of Internal Medicine, The Second Affiliated Hospital Zhejiang University School of Medicine, Hangzhou, China
| | - Xinyang Hu
- Division of Cardiology, Department of Internal Medicine, The Second Affiliated Hospital Zhejiang University School of Medicine, Hangzhou, China
| | - Jian'an Wang
- Division of Cardiology, Department of Internal Medicine, The Second Affiliated Hospital Zhejiang University School of Medicine, Hangzhou, China
| | - Joo Myung Lee
- Division of Cardiology, Department of Internal Medicine, Samsung Medical Center, Seoul, Korea
| | - Joo-Yong Hahn
- Division of Cardiology, Department of Internal Medicine, Samsung Medical Center, Seoul, Korea
| | - Chang-Wook Nam
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Joon-Hyung Doh
- Division of Cardiology, Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Bong-Ki Lee
- Division of Cardiology, Department of Internal Medicine, Kangwon National University Hospital, Chuncheon, Korea
| | - Weon Kim
- Division of Cardiology, Department of Internal Medicine, Kyung Hee University Hospital, Seoul, Korea
| | - Jinyu Huang
- Division of Cardiology, Department of Internal Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Fan Jiang
- Division of Cardiology, Department of Internal Medicine, Hangzhou Normal University Affiliated Hospital, Hangzhou, China
| | - Hao Zhou
- Division of Cardiology, Department of Internal Medicine, The 1st Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Peng Chen
- Division of Cardiology, Department of Internal Medicine, The 2nd Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Lijiang Tang
- Division of Cardiology, Department of Internal Medicine, Zhejiang Hospital, Hangzhou, China
| | - Wenbing Jiang
- Division of Cardiology, Department of Internal Medicine, The Third Clinical Institute Affiliated To Wenzhou Medical University, Wenzhou, China
| | - Xiaomin Chen
- Division of Cardiology, Department of Internal Medicine, Ningbo First Hospital, Ningbo, China
| | - Wenming He
- Division of Cardiology, Department of Internal Medicine, The Affiliated Hospital of Medical School of Ningbo University, Ningbo, China
| | - Myeong-Ho Yoon
- Division of Cardiology, Department of Internal Medicine, Ajou University Hospital, Suwon, Korea
| | - Seung-Jea Tahk
- Division of Cardiology, Department of Internal Medicine, Ajou University Hospital, Suwon, Korea
| | - Ung Kim
- Division of Cardiology, Department of Internal Medicine, Yeungnam University Medical Center, Daegu, Korea
| | - You-Jeong Ki
- Division of Cardiology, Department of Internal Medicine, Uijeongbu Eulji Medical Center, Uijeongbu, Korea
| | - Eun-Seok Shin
- Division of Cardiology, Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Doyeon Hwang
- Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Jeehoon Kang
- Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Hyo-Soo Kim
- Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Bon-Kwon Koo
- Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.
| |
Collapse
|
2
|
Ueno H, Hoshino M, Usui E, Sugiyama T, Kanaji Y, Hada M, Misawa T, Nagamine T, Hanyu Y, Nogami K, Sayama K, Matsuda K, Sakamoto T, Yonetsu T, Sasano T, Kakuta T. Prognostic Implications of Fractional Flow Reserve and Coronary Flow Reserve After Drug-Eluting Stent Implantation. Circ J 2024; 88:853-859. [PMID: 37853607 DOI: 10.1253/circj.cj-23-0293] [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: 10/20/2023]
Abstract
BACKGROUND Fractional flow reserve (FFR) after percutaneous coronary intervention (PCI) provides prognostic information, but limited data are available regarding prognostication using post-PCI coronary flow reserve (CFR). In this study we aimed to assess the prognostic value of post-procedural FFR and CFR for target vessel failure (TVF) after PCI.Methods and Results: This lesion-based post-hoc pooled analysis of previously published registry data involved 466 patients with chronic coronary syndrome with single-vessel disease who underwent pre- and post-PCI FFR and CFR measurements, and were followed-up to determine the predictors of TVF. The prognostic value of post-PCI CFR and FFR was compared with that of FFR or CFR alone. Post-PCI FFR/CFR discordant results were observed in 42.5%, and 10.3% of patients had documented TVF. Receiver-operating characteristic curve analysis revealed that the optimal cutoff values of post-PCI FFR and CFR to predict the occurrence of TVF were 0.85 and 2.26, respectively. Significant differences in TVF were detected according to post-PCI FFR (≤0.85 vs. >0.85, P=0.007) and post-PCI CFR (<2.26 vs. ≥2.26, P<0.001). Post-PCI FFR ≤0.85 and post-PCI CFR <2.26 were independent prognostic predictors. CONCLUSIONS After PCI completion, discordant results between FFR and CFR were not uncommon. Post-PCI CFR categorization showed incremental prognostic value for predicting TVF independent of post-PCI FFR risk stratification.
Collapse
Affiliation(s)
- Hiroki Ueno
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital
| | - Masahiro Hoshino
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital
| | - Eisuke Usui
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital
| | - Tomoyo Sugiyama
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital
| | - Yoshihisa Kanaji
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital
| | - Masahiro Hada
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital
| | - Toru Misawa
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital
| | | | - Yoshihiro Hanyu
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital
| | - Kai Nogami
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital
| | - Kodai Sayama
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital
| | - Kazuki Matsuda
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital
| | - Tatsuya Sakamoto
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital
| | - Taishi Yonetsu
- Department of Interventional Cardiology, Tokyo Medical and Dental University
| | - Tetsuo Sasano
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University
| | - Tsunekazu Kakuta
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital
| |
Collapse
|
3
|
Hanyu Y, Hoshino M, Usui E, Sugiyama T, Kanaji Y, Hada M, Nagamine T, Nogami K, Ueno H, Sakamoto T, Yonetsu T, Sasano T, Kakuta T. Combined Assessment of Fractional Flow Reserve and Coronary Flow Velocity Reserve after Drug-Eluting Stent Implantation. J Am Soc Echocardiogr 2024; 37:428-438. [PMID: 38122836 DOI: 10.1016/j.echo.2023.12.006] [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: 11/25/2023] [Revised: 12/08/2023] [Accepted: 12/10/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Coronary flow velocity reserve (CFVR) can be measured noninvasively using stress transthoracic Doppler echocardiography (S-TDE). The prognostic significance of S-TDE-derived CFVR after percutaneous coronary intervention (PCI) remains unknown. The aim of this study was to investigate the prognostic value of post-PCI CFVR and its additional efficacy to fractional flow reserve (FFR) in patients undergoing elective PCI. METHODS A retrospective study was conducted involving 187 consecutive patients with chronic coronary syndrome who underwent elective PCI guided by FFR for the left anterior descending coronary artery. Pre- and post-PCI wire-based FFR and CFVR assessments of the left anterior descending coronary artery using S-TDE were performed in all patients. The association between post-PCI clinical and physiologic parameters and major adverse cardiac events (MACE), defined as a composite of cardiac death, myocardial infarction, heart failure, and unplanned remote target vessel revascularization, was evaluated. RESULTS Three-quarters of patients exhibited CFVR increase after PCI, while all patients showed FFR improvement. During a median follow-up period of 1.5 years, MACE occurred in 21 patients (11.2%). Among clinical demographics, patients with MACE had higher levels of N-terminal pro-brain natriuretic peptide compared with those without MACE (median, 615 pg/mL [interquartile range, 245-1,500 pg/mL] vs 180 pg/mL [interquartile range, 70-559 pg/mL]; P = .010). Post-PCI S-TDE-derived CFVR was lower in patients with MACE, while post-PCI FFR showed a nonsignificant tendency to be lower in patients with MACE. In a multivariable analysis, higher NT-proBNP (adjusted hazard ratio, 1.33; 95% CI, 1.02-1.74; P = .038), post-PCI CFVR ≤ 2.0 (adjusted hazard ratio, 2.93; 95% CI, 1.16-7.40; P = .023), and post-PCI FFR ≤ 0.82 (adjusted hazard ratio, 3.93; 95% CI, 1.52-10.18; P = .005) were independently associated with MACE. CONCLUSIONS In patients with chronic coronary syndrome who underwent successful elective PCI for left anterior descending coronary artery, the combined assessment of S-TDE-derived post-PCI CFVR and post-PCI FFR provided a significant association with the occurrence of MACE.
Collapse
Affiliation(s)
- Yoshihiro Hanyu
- Division of Cardiovascular Medicine, Hiratsuka Kyosai Hospital, Hiratsuka, Japan
| | - Masahiro Hoshino
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Japan
| | - Eisuke Usui
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Japan
| | - Tomoyo Sugiyama
- Department of Cardiology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yoshihisa Kanaji
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Japan
| | - Masahiro Hada
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Japan
| | - Tatsuhiro Nagamine
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Japan
| | - Kai Nogami
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Japan
| | - Hiroki Ueno
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Japan
| | - Tatsuya Sakamoto
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Japan
| | - Taishi Yonetsu
- Department of Cardiology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tetsuo Sasano
- Department of Cardiology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tsunekazu Kakuta
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Japan.
| |
Collapse
|
4
|
Liu J, Jin J, Yu B, Zhang S, Lu X, Chen G, Yang Y, Dong H. Determinants and Prognoses of Visual-Functional Mismatches After Mechanical Reperfusion in ST-Elevation Myocardial Infarction. Int J Gen Med 2024; 17:693-704. [PMID: 38435112 PMCID: PMC10908277 DOI: 10.2147/ijgm.s444933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 02/09/2024] [Indexed: 03/05/2024] Open
Abstract
Background Discordance between the anatomy and physiology of the coronary has important implications for managing patients with stable coronary disease, but its significance in ST-elevation myocardial infarction has not been fully elucidated. Methods The retrospective study involved patients diagnosed with ST-elevation myocardial infarction (STEMI) who underwent percutaneous coronary intervention (PCI), along with quantitative coronary angiography (QCA) and quantitative flow ratio (QFR) assessments. Patients were stratified into four groups regarding the severity of the culprit vessel, both visually and functionally: concordantly negative (QCA-diameter stenosis [DS] ≤ 50% and QFR > 0.80), mismatch (QCA-DS > 50% and QFR > 0.80), reverse mismatch (QCA-DS ≤ 50% and QFR ≤ 0.80), and concordantly positive (QCA-DS > 50% and QFR ≤ 0.80). Multivariable logistic regression analyses were conducted to identify the clinical factors linked to visual-functional mismatches. Kaplan‒Meier analysis was conducted to estimate the 18-month adverse cardiovascular events (MACE)-free survival between the four groups. Results The study involved 310 patients, with 68 presenting visual-functional mismatch, and 51 exhibiting reverse mismatch. The mismatch was associated with higher angiography-derived microcirculatory resistance (AMR) (adjusted odds ratio [aOR]=1.016, 95% CI: 1.010-1.022, P<0.001). Reverse mismatch was associated with larger area stenosis (aOR=1.044, 95% CI: 1.004-1.086, P=0.032), lower coronary flow velocity (aOR=0.690, 95% CI: 0.567-0.970, P<0.001) and lower AMR (aOR=0.947, 95% CI: 0.924-0.970, P<0.001). Additionally, the mismatch group showed the worst 18-month MACE-free survival among the four groups (Log rank test p = 0.013). Conclusion AMR plays a significant role in the occurrence of visual-functional mismatches between QCA-DS and QFR, and the mismatch group showed the worst prognosis.
Collapse
Affiliation(s)
- Jieliang Liu
- Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, 510080, People’s Republic of China
| | - Junguo Jin
- Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, 510080, People’s Republic of China
| | - Bingyan Yu
- Department of Cardiology, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong, 510080, People’s Republic of China
| | - Shanghong Zhang
- Department of Cardiology, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong, 510080, People’s Republic of China
| | - Xiaoqi Lu
- Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, 510080, People’s Republic of China
| | - Guoqiang Chen
- Department of Cardiology, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong, 510080, People’s Republic of China
| | - Yi Yang
- Department of Cardiology, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong, 510080, People’s Republic of China
| | - Haojian Dong
- Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, 510080, People’s Republic of China
- Nyingchi People’s Hospital, Nyingchi, Tibet, 860000, People’s Republic of China
| |
Collapse
|
5
|
van Diemen PA, de Winter RW, Schumacher SP, Everaars H, Bom MJ, Jukema RA, Somsen YB, Raijmakers PG, Kooistra RA, Timmer J, Maaniitty T, Robbers LF, von Bartheld MB, Demirkiran A, van Rossum AC, Reiber JH, Knuuti J, Underwood SR, Nagel E, Knaapen P, Driessen RS, Danad I. The diagnostic performance of quantitative flow ratio and perfusion imaging in patients with prior coronary artery disease. Eur Heart J Cardiovasc Imaging 2023; 25:116-126. [PMID: 37578007 PMCID: PMC10735295 DOI: 10.1093/ehjci/jead197] [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: 05/18/2023] [Revised: 07/07/2023] [Accepted: 07/20/2023] [Indexed: 08/15/2023] Open
Abstract
AIMS In chronic coronary syndrome (CCS) patients with documented coronary artery disease (CAD), ischaemia detection by myocardial perfusion imaging (MPI) and an invasive approach are viable diagnostic strategies. We compared the diagnostic performance of quantitative flow ratio (QFR) with single-photon emission computed tomography (SPECT), positron emission tomography (PET), and cardiac magnetic resonance imaging (CMR) in patients with prior CAD [previous percutaneous coronary intervention (PCI) and/or myocardial infarction (MI)]. METHODS AND RESULTS This PACIFIC-2 sub-study evaluated 189 CCS patients with prior CAD for inclusion. Patients underwent SPECT, PET, and CMR followed by invasive coronary angiography with fractional flow reserve (FFR) measurements of all major coronary arteries (N = 567), except for vessels with a sub-total or chronic total occlusion. Quantitative flow ratio computation was attempted in 488 (86%) vessels with measured FFR available (FFR ≤0.80 defined haemodynamically significant CAD). Quantitative flow ratio analysis was successful in 334 (68%) vessels among 166 patients and demonstrated a higher accuracy (84%) and sensitivity (72%) compared with SPECT (66%, P < 0.001 and 46%, P = 0.001), PET (65%, P < 0.001 and 58%, P = 0.032), and CMR (72%, P < 0.001 and 33%, P < 0.001). The specificity of QFR (87%) was similar to that of CMR (83%, P = 0.123) but higher than that of SPECT (71%, P < 0.001) and PET (67%, P < 0.001). Lastly, QFR exhibited a higher area under the receiver operating characteristic curve (0.89) than SPECT (0.57, P < 0.001), PET (0.66, P < 0.001), and CMR (0.60, P < 0.001). CONCLUSION QFR correlated better with FFR in patients with prior CAD than MPI, as reflected in the higher diagnostic performance measures for detecting FFR-defined, vessel-specific, significant CAD.
Collapse
Affiliation(s)
- Pepijn A van Diemen
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam 1081 HV, The Netherlands
| | - Ruben W de Winter
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam 1081 HV, The Netherlands
| | - Stefan P Schumacher
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam 1081 HV, The Netherlands
| | - Henk Everaars
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam 1081 HV, The Netherlands
| | - Michiel J Bom
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam 1081 HV, The Netherlands
| | - Ruurt A Jukema
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam 1081 HV, The Netherlands
| | - Yvemarie B Somsen
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam 1081 HV, The Netherlands
| | - Pieter G Raijmakers
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | | | | | - Teemu Maaniitty
- Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland
| | - Lourens F Robbers
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam 1081 HV, The Netherlands
| | - Martin B von Bartheld
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam 1081 HV, The Netherlands
| | - Ahmet Demirkiran
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam 1081 HV, The Netherlands
| | - Albert C van Rossum
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam 1081 HV, The Netherlands
| | | | - Juhani Knuuti
- Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland
| | | | - Eike Nagel
- Institute of Experimental and Translational Cardiovascular Imaging, DZHK Centre for Cardiovascular Imaging, University Hospital Frankfurt am Main, Frankfurt am Main, Germany
| | - Paul Knaapen
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam 1081 HV, The Netherlands
| | - Roel S Driessen
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam 1081 HV, The Netherlands
| | - Ibrahim Danad
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam 1081 HV, The Netherlands
| |
Collapse
|
6
|
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.
Collapse
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
| |
Collapse
|
7
|
Lu W, Zhang X, Yan G, Ma G. The Differences of Quantitative Flow Ratio in Coronary Artery Stenosis with or without Atrial Fibrillation. J Interv Cardiol 2023; 2023:7278343. [PMID: 37868769 PMCID: PMC10589068 DOI: 10.1155/2023/7278343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 09/21/2023] [Accepted: 10/04/2023] [Indexed: 10/24/2023] Open
Abstract
Quantitative flow ratio (QFR) is a new method for the assessment of the extent of coronary artery stenosis. But it may be obscured by the cardiac remodeling and abnormal blood flow of the coronary artery when encountering atrial fibrillation (AF). The present study aimed to examine the impact of these changed structures and blood flow of coronary arteries on QFR results in AF patients. Methods and Results. We evaluated QFR in 223 patients (112 patients with AF; 111 non-AF patients served as controls) who had undergone percutaneous coronary intervention (PCI) due to severe stenoses in coronary arteries. QFR of the target coronary was determined according to the flow rate of the contrast agent. Results showed that AF patients had significantly higher QFR values than control (0.792 ± 0.118 vs. 0.685 ± 0.167, p < 0.001). We further analyzed local QFR around the stenoses (0.858 ± 0.304 vs. 0.756 ± 0.146, p=0.002), residual QFR (0.958 ± 0.055 vs. 0.929 ± 0.093, p=0.005), and index QFR (0.807 ± 0.108 vs. 0.713 ± 0.152, p < 0.001) in these two groups of patients with and without AF. Further analysis revealed that QFR in AF patients was negatively correlated with coronary flow velocity (R = -0.22, p=0.02) and area of stenosis (R = -0.70, p < 0.001) but positively correlated with the minimum lumen area (MLA) (R = 0.47, p < 0.001). Conclusion. AF patients with coronary artery stenosis have higher QFR values, which are associated with decreased blood flow velocity, smaller stenosis, and larger MLA in AF patients upon cardiac remodeling.
Collapse
Affiliation(s)
- Wenbin Lu
- Department of Cardiology, ZhongDa Hospital Affiliated with Southeast University, China
| | - Xiaoguo Zhang
- Department of Cardiology, ZhongDa Hospital Affiliated with Southeast University, China
| | - Gaoliang Yan
- Department of Cardiology, ZhongDa Hospital Affiliated with Southeast University, China
| | - Genshan Ma
- Department of Cardiology, ZhongDa Hospital Affiliated with Southeast University, China
| |
Collapse
|
8
|
Pintea Bentea G, Berdaoui B, Samyn S, Morissens M, van de Borne P, Castro Rodriguez J. Particularities of coronary physiology in patients with atrial fibrillation: insights from combined pressure and flow indices measurements. Front Cardiovasc Med 2023; 10:1206743. [PMID: 37645524 PMCID: PMC10461314 DOI: 10.3389/fcvm.2023.1206743] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 07/31/2023] [Indexed: 08/31/2023] Open
Abstract
Background Symptoms suggestive of myocardial ischemia are frequently encountered in patients with atrial fibrillation (AF) even in the absence of obstructive coronary artery disease. Nevertheless, an in-depth characterisation of coronary physiology in patients with AF is currently lacking. Objectives We aim to provide an insight into the characteristics of coronary physiology in AF, by performing simultaneous invasive measurements of coronary flow- and pressure- indices in a real-life population of patients with AF and indication of coronary angiography. Methods This is a prospective open label study including patients with permanent or persistent AF and indication of coronary angiography showing intermediate coronary stenosis requiring routine physiological assessment (n = 18 vessels from 14 patients). We measured FFR (fractional flow reserve), and Doppler-derived coronary flow indices, including CFR (coronary flow reserve) and HMR (hyperaemic microvascular resistance). Results From the analysed vessels, 18/18 vessels (100%) presented a pathological CFR (<2.5), indicative of coronary microvascular dysfunction (CMD), and 3/18 (17%) demonstrated obstructive epicardial coronary disease (FFR ≤ 0.8). A large proportion of vessels (15/18; 83%) showed discordant FFR/CFR with preserved FFR and low CFR. 47% of the coronary arteries in patients with AF and non-obstructive epicardial coronary disease presented structural CMD (HMR ≥ 2.5 mmHg/cm/s), and were associated with high BMR and an impaired response to adenosine. Conversely, vessels from patients with AF and non-obstructive epicardial coronary disease with functional CMD (HMR < 2.5 mmHg/cm/s) showed higher bAPV. The permanent AF subpopulation presented increased values of HMR and BMR compared to persistent AF, while structural CMD was more often associated with persistent symptoms at 3 months, taking into account the limited sample size of our study. Conclusion Our findings highlight a systematically impaired CFR in patients with AF even in the absence of obstructive epicardial coronary disease, indicative of CMD. In addition, patients with AF presented more prevalent structural CMD (HMR ≥ 2.5 mmHg/cm/s), characterized by reduced hyperaemic responses to adenosine, possibly interfering with the FFR assessment.
Collapse
Affiliation(s)
| | | | - Sophie Samyn
- Department of Cardiology, CHU Brugmann, Brussels, Belgium
| | | | | | | |
Collapse
|
9
|
Scoccia A, Neleman T, Ziedses des Plantes AC, Groenland FT, M R Ligthart J, den Dekker WK, Diletti R, Wilschut J, Jan Nuis R, Zijlstra F, Boersma E, Van Mieghem NM, Daemen J. Predictors of discordance between fractional flow reserve (FFR) and diastolic pressure ratio (dPR) in intermediate coronary lesions. IJC HEART & VASCULATURE 2023; 47:101217. [PMID: 37576077 PMCID: PMC10422661 DOI: 10.1016/j.ijcha.2023.101217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 04/24/2023] [Accepted: 04/30/2023] [Indexed: 08/15/2023]
Abstract
Background Recently, non-hyperemic pressure ratios (NHPRs) have been validated as a reliable alternative to fractional flow reserve (FFR). However, a discordance between FFR and NHPRs is observed in 20-25% of cases. The aim of this study is to evaluate predictors of discordance between FFR and diastolic Pressure ratio (dPR). Methods PREDICT is a retrospective, single center, investigator-initiated study including 813 patients (1092vessels) who underwent FFR assessment of intermediate coronary lesions (angiographic 30%-80% stenosis). dPR was calculated using individual pressure waveforms and dedicated software. Clinical, angiographic and hemodynamic variables were compared between patients with concordant and discordant FFR and dPR values. Results Median age was 65 (IQR:59-73) years and 70% were male. Hemodynamically significant lesions, as defined by FFR ≤ 0.80, and dPR ≤ 0.89, were identified in 29.6% and 30.3% of cases, respectively. Overall, FFR and dPR values were discordant in 22.1% patients (17.4% of the vessels). Discordance was related to FFR+/dPR- and FFR-/dPR + in 11.8% and 10.3% of patients, respectively.In case of FFR-dPR discordance, a higher prevalence of left anterior descending arteries lesions was observed (70.5% vs. 53.1%, p < 0.001) and mean values of both FFR and dPR were significantly lower (FFR 0.81 ± 0.05 vs 0.85 ± 0.08, p < 0.001, and dPR 0.89 ± 0.04 vs 0.92 ± 0.08,p < 0.001) as compared to vessels with FFR and dPR concordance. Following multivariable adjustment, dPR delta (defined as the absolute difference between measured dPR to the cut-off value of 0.89) turned out to be the only independent predictor of discordance (OR = 0.74, 95% CI 0.68-0.79, p < 0.001). Conclusion Our study suggests that FFR-to-dPR discordance occurs in approximately one-fifth of patients. Absolute dPR delta appears to be the only independent predictor of discordance.
Collapse
Affiliation(s)
- Alessandra Scoccia
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Tara Neleman
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | - Frederik T.W. Groenland
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Jurgen M R Ligthart
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Wijnand K. den Dekker
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Roberto Diletti
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Jeroen Wilschut
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Rutger Jan Nuis
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Felix Zijlstra
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Eric Boersma
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Nicolas M Van Mieghem
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Joost Daemen
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| |
Collapse
|
10
|
Hwang D, Park SH, Koo BK. Ischemia With Nonobstructive Coronary Artery Disease: Concept, Assessment, and Management. JACC. ASIA 2023; 3:169-184. [PMID: 37181394 PMCID: PMC10167523 DOI: 10.1016/j.jacasi.2023.01.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 01/03/2023] [Accepted: 01/06/2023] [Indexed: 05/16/2023]
Abstract
In daily clinical practice, physicians often encounter patients with angina or those with evidence of myocardial ischemia from noninvasive tests but not having obstructive coronary artery disease. This type of ischemic heart disease is referred to as ischemia with nonobstructive coronary arteries (INOCA). INOCA patients often suffer from recurrent chest pain without adequate management and are associated with poor clinical outcomes. There are several endotypes of INOCA, and each endotype should be treated based on its specific underlying mechanism. Therefore, identifying INOCA and discriminating its underlying mechanisms are important issues and of clinical interest. Invasive physiologic assessment is the first step in the diagnosis of INOCA and discriminating the underlying mechanism; additional provocation tests help physicians identify the vasospastic component in INOCA patients. Comprehensive information acquired from these invasive tests can provide a template for mechanism-specific management for patients with INOCA.
Collapse
Affiliation(s)
- Doyeon Hwang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Sang-Hyeon Park
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Bon-Kwon Koo
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| |
Collapse
|
11
|
Zhang J, Ma M, Li H, Pu Z, Liu H, Huang T, Cheng H, Gong Y, Chu Y, Wang Z, Jiang J, Xia L. Early diagnosis of coronary microvascular dysfunction by myocardial contrast stress echocardiography. MATHEMATICAL BIOSCIENCES AND ENGINEERING : MBE 2023; 20:7845-7858. [PMID: 37161175 DOI: 10.3934/mbe.2023339] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
Coronary microvascular dysfunction (CMD) is one of the basic mechanisms of myocardial ischemia. Myocardial contrast echocardiography (MCE) is a bedside technique that utilises microbubbles which remain entirely within the intravascular space and denotes the status of microvascular perfusion within that region. Some pilot studies suggested that MCE may be used to diagnose CMD, but without further validation. This study is aimed to investigate the diagnostic performance of MCE for the evaluation of CMD. MCE was performed at rest and during adenosine triphosphate stress. ECG triggered real-time frames were acquired in the apical 4-chamber, 3-chamber, 2-chamber, and long-axis imaging planes. These images were imported into Narnar for further processing. Eighty-two participants with suspicion of coronary disease and absence of significant epicardial lesions were prospectively investigated. Thermodilution was used as the gold standard to diagnose CMD. CMD was present in 23 (28%) patients. Myocardial blood flow reserve (MBF) was assessed using MCE. CMD was defined as MBF reserve < 2. The MCE method had a high sensitivity (88.1%) and specificity (95.7%) in the diagnosis of CMD. There was strong agreement with thermodilution (Kappa coefficient was 0.727; 95% CI: 0.57-0.88, p < 0.001). However, the correlation coefficient (r = 0.376; p < 0.001) was not high.
Collapse
Affiliation(s)
- Jucheng Zhang
- Department of Clinical Engineering, School of Medicine, The Second Affiliated Hospital, Zhejiang University, Hangzhou 310009, China
- Key Laboratory of Medical Molecular Imaging of Zhejiang Province, Hangzhou 310009, China
| | - Minwen Ma
- Department of Clinical Engineering, School of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou 310009, China
| | - Huajun Li
- Department of Cardiology, School of Medicine, The Second Affiliated Hospital, Zhejiang University, Hangzhou 310009, China
| | - Zhaoxia Pu
- Department of Cardiology, School of Medicine, The Second Affiliated Hospital, Zhejiang University, Hangzhou 310009, China
| | - Haipeng Liu
- Research Centre for Intelligent Healthcare, Coventry University, Coventry, United Kingdom
| | - Tianhai Huang
- Department of Clinical Engineering, School of Medicine, The Second Affiliated Hospital, Zhejiang University, Hangzhou 310009, China
| | - Huan Cheng
- Key Laboratory for Biomedical Engineering of Ministry of Education, Institute of Biomedical Engineering, Zhejiang University, Hangzhou 310027, China
| | - Yinglan Gong
- Institute of Wenzhou, Zhejiang University, Wenzhou 325036, China
| | - Yonghua Chu
- Department of Clinical Engineering, School of Medicine, The Second Affiliated Hospital, Zhejiang University, Hangzhou 310009, China
| | - Zhikang Wang
- Department of Clinical Engineering, School of Medicine, The Second Affiliated Hospital, Zhejiang University, Hangzhou 310009, China
| | - Jun Jiang
- Department of Cardiology, School of Medicine, The Second Affiliated Hospital, Zhejiang University, Hangzhou 310009, China
| | - Ling Xia
- Key Laboratory for Biomedical Engineering of Ministry of Education, Institute of Biomedical Engineering, Zhejiang University, Hangzhou 310027, China
| |
Collapse
|
12
|
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] [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.
Collapse
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
| |
Collapse
|
13
|
Functional Patterns of Coronary Disease. JACC Cardiovasc Interv 2022; 15:2174-2191. [DOI: 10.1016/j.jcin.2022.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 07/07/2022] [Accepted: 07/12/2022] [Indexed: 11/09/2022]
|
14
|
Eftekhari A, Westra J, Stegehuis V, Holm NR, van de Hoef TP, Kirkeeide RL, Piek JJ, Lance Gould K, Johnson NP, Christiansen EH. Prognostic value of microvascular resistance and its association to fractional flow reserve: a DEFINE-FLOW substudy. Open Heart 2022; 9:openhrt-2022-001981. [PMID: 35410913 PMCID: PMC9003618 DOI: 10.1136/openhrt-2022-001981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 03/24/2022] [Indexed: 11/29/2022] Open
Abstract
Objective This study aimed to evaluate the prognostic value of hyperemic microvascular resistance (HMR) and its relationship with hyperemic stenosis resistance (HSR) index and fractional flow reserve (FFR) in stable coronary artery disease. Methods This is a substudy of the DEFINE-FLOW cohort (NCT02328820), which evaluated the prognosis of lesions (n=456) after combined FFR and coronary flow reserve (CFR) assessment in a prospective, non-blinded, non-randomised, multicentre study in 12 centres in Europe and Japan. Participants (n=430) were evaluated by wire-based measurement of coronary pressure, flow and vascular resistance (ComboWire XT, Phillips Volcano, San Diego, California, USA). Results Mean FFR and CFR were 0.82±0.10 and 2.2±0.6, respectively. When divided according to FFR and CFR thresholds (above and below 0.80 and 2.0, respectively), HMR was highest in lesions with FFR>0.80 and CFR<2.0 (n=99) compared with lesions with FFR≤0.80 and CFR≥2.0 (n=68) (2.92±1.2 vs 1.91±0.64 mm Hg/cm/s, p<0.001). The FFR value was proportional to the ratio between HMR and the HMR+HSR (total resistance), 95% limits of agreement (−0.032; 0.019), bias (−0.003±0.02) and correlation (r2=0.98, p<0.0001). Cox regression model using HMR as continuous parameter for target vessel failure showed an HR of 1.51, 95% CI (0.9 to 2.4), p=0.10. Conclusions Increased HMR was not associated with a higher rate of adverse clinical events, in this population of mainly stable patients. FFR can be equally well expressed as HMR/HMR+HSR, thereby providing an alternative conceptual formulation linking epicardial severity with microvascular resistance. Trial registration number NCT02328820.
Collapse
Affiliation(s)
- Ashkan Eftekhari
- Department of Cardiology, Aarhus University Hospital Skejby, Aarhus, Denmark
- Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Jelmer Westra
- Department of Cardiology, Aarhus University Hospital Skejby, Aarhus, Denmark
| | - Valérie Stegehuis
- Amsterdam UMC, University of Amsterdam, Heart Center,Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Niels Ramsing Holm
- Department of Cardiology, Aarhus University Hospital Skejby, Aarhus, Denmark
| | - Tim P van de Hoef
- Amsterdam UMC, University of Amsterdam, Heart Center,Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Richard L Kirkeeide
- Weatherhead PET Center, Division of Cardiology, Department of Medicine, McGovern Medical School at UTHealth and Memorial Hermann Hospital, Houston, Texas, USA
| | - Jan J Piek
- Amsterdam UMC, University of Amsterdam, Heart Center,Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - K Lance Gould
- Weatherhead PET Center, Division of Cardiology, Department of Medicine, McGovern Medical School at UTHealth and Memorial Hermann Hospital, Houston, Texas, USA
| | - Nils P Johnson
- Weatherhead PET Center, Division of Cardiology, Department of Medicine, McGovern Medical School at UTHealth and Memorial Hermann Hospital, Houston, Texas, USA
| | | |
Collapse
|
15
|
Li C, Xu R, Yao K, Zhang J, Chen S, Pang L, Lu H, Dai Y, Qian J, Shi H, Ge J. Functional significance of intermediate coronary stenosis in patients with single-vessel coronary artery disease: A comparison of dynamic SPECT coronary flow reserve with intracoronary pressure-derived fractional flow reserve (FFR). J Nucl Cardiol 2022; 29:622-629. [PMID: 32770319 DOI: 10.1007/s12350-020-02293-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 07/09/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND The aim of this study was to investigate the correlation of coronary flow reserve (CFR) assessed by rest/stress myocardial perfusion imaging with dynamic single-photon emission computed tomography (SPECT) with intracoronary pressure-derived fractional flow reserve (FFR) in patients with single-vessel coronary artery disease (CAD). METHODS Patients with suspected or known stable CAD who were referred for invasive coronary angiography were prospectively enrolled. Both invasive FFR and SPECT were performed in subjects with single-vessel intermediate coronary stenosis. A cutoff value of < 0.8 was used to define abnormal FFR. RESULTS A total of 34 patients were enrolled. The mean age of the subjects was 62.1 ± 6.7 years, and 79.4% were male. SPECT-derived CFR showed a significantly moderate correlation with FFR (r = 0.505, P = .003). The diagnostic performance for the identification of abnormal FFR in terms of sensitivity, specificity, and accuracy was 88.9%, 83.3%, and 87.9%, respectively, for CFR, with an optimized cutoff value of 1.73. CONCLUSION In patients with single-vessel CAD, SPECT CFR was useful for the detection of functionally significant stenosis. Our data support the use of this technique as an optional method for hemodynamic assessment, especially when FFR results are in normal range.
Collapse
Affiliation(s)
- Chenguang Li
- Department of Cardiology, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Rende Xu
- Department of Cardiology, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Kang Yao
- Department of Cardiology, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Jie Zhang
- Department of Nuclear Medicine, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Shuguang Chen
- Department of Nuclear Medicine, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Lifang Pang
- Department of Nuclear Medicine, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Hao Lu
- Department of Cardiology, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Yuxiang Dai
- Department of Cardiology, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Juying Qian
- Department of Cardiology, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Hongcheng Shi
- Department of Nuclear Medicine, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China.
| | - Junbo Ge
- Department of Cardiology, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China.
| |
Collapse
|
16
|
Mangiacapra F, Viscusi MM, Verolino G, Paolucci L, Nusca A, Melfi R, Ussia GP, Grigioni F. Invasive Assessment of Coronary Microvascular Function. J Clin Med 2021; 11:jcm11010228. [PMID: 35011968 PMCID: PMC8745537 DOI: 10.3390/jcm11010228] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 12/21/2021] [Accepted: 12/29/2021] [Indexed: 01/01/2023] Open
Abstract
The critical role of the coronary microvascular compartment and its invasive functional assessment has become apparent in light of the significant proportion of patients presenting signs and symptoms of myocardial ischemia, despite the absence of epicardial disease, or after the adequate treatment of it. However, coronary microvascular dysfunction (CMD) represents a diagnostic challenge because of the small dimensions of the coronary microvasculature, which prevents direct angiographic visualization. Several diagnostic tools are now available for the invasive assessment of the coronary microvascular function, which, in association with the physiological indices used to investigate the epicardial department, may provide a comprehensive evaluation of the coronary circulation as a whole. Recent evidence suggests that the physiology-guided management of CMD, although apparently costly and time-consuming, may offer a net clinical benefit in terms of symptom improvement among patients with angina and ischemic heart disease. However, despite the results of several observational studies, the prognostic effect of the physiology-driven management of CMD within this population is currently a matter of debate, and therefore represents an unmet clinical need that urgently deserves further investigation.
Collapse
|
17
|
Mangiacapra F, Viscusi MM, Paolucci L, Nusca A, Melfi R, Ussia GP, Grigioni F. The Pivotal Role of Invasive Functional Assessment in Patients With Myocardial Infarction With Non-Obstructive Coronary Arteries (MINOCA). Front Cardiovasc Med 2021; 8:781485. [PMID: 34869695 PMCID: PMC8637881 DOI: 10.3389/fcvm.2021.781485] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 10/25/2021] [Indexed: 01/10/2023] Open
Abstract
Myocardial infarction with non-obstructive coronary arteries (MINOCA) encompasses several pathophysiological mechanisms not yet fully understood. Among the latter, vasomotion abnormalities and coronary microvascular dysfunction (CMD) play a major role for both epidemiological and prognostic reasons. Despite current guidelines do not recommend routine physiological assessment of both epicardial and microvascular coronary compartments within the context of an acute myocardial infarction, several recent evidence support the critical role of a comprehensive invasive functional assessment in order to identify the underlying pathophysiological mechanism and consequently to select an appropriate therapeutic strategy. Unfortunately, optimal medical therapy for these patients is not currently established due to the lack of dedicated trials evaluating clinical outcomes of commonly used medications for secondary prevention in MINOCA patients. For this reason, additional research is warranted to provide personalized treatments for patients affected by this puzzling clinical entity.
Collapse
Affiliation(s)
- Fabio Mangiacapra
- Unit of Cardiovascular Science, Department of Medicine, Campus Bio-Medico University, Rome, Italy
| | | | | | | | | | | | | |
Collapse
|
18
|
Ge X, Liu Y, Tu S, Simakov S, Vassilevski Y, Liang F. Model-based analysis of the sensitivities and diagnostic implications of FFR and CFR under various pathological conditions. INTERNATIONAL JOURNAL FOR NUMERICAL METHODS IN BIOMEDICAL ENGINEERING 2021; 37:e3257. [PMID: 31487426 DOI: 10.1002/cnm.3257] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 07/28/2019] [Accepted: 09/01/2019] [Indexed: 06/10/2023]
Abstract
Although fractional flow reserve (FFR) and coronary flow reserve (CFR) are both frequently used to assess the functional severity of coronary artery stenosis, discordant results of diagnosis between FFR and CFR in some patient cohorts have been reported. In the present study, a computational model was employed to quantify the impacts of various pathophysiological factors on FFR and CFR. In addition, a hyperemic myocardial ischemic index (HMIx) was proposed as a reference for comparing the diagnostic performances of FFR and CFR. Obtained results showed that CFR was more susceptible than FFR to the influence of many pathophysiological factors unrelated to coronary artery stenosis. In particular, the numerical study proved that increasing hyperemic coronary microvascular resistance significantly elevated FFR while reducing CFR despite fixed severity of coronary artery stenosis, whereas introducing aortic valve disease only caused a significant decrease in CFR with little influence on FFR. These results provided theoretical evidence for explaining some clinical observations, such as the increased risk of discordant diagnostic results between FFR and CFR in patients with increased hyperemic microvascular resistance, and significant increase in CFR after surgical relief of severe aortic valve disease. When evaluated with respect to the predictive value for hyperemic myocardial ischemia, the performance of FFR was found to be considerably compromised in the presence of severe coronary vasodilation dysfunction or aortic valve disease, whereas the relationship between CFR and HMIx remained relatively stable, suggesting that CFR may be a more reliable indicator of myocardial ischemia under complex pathophysiological conditions.
Collapse
Affiliation(s)
- Xinyang Ge
- School of Naval Architecture, Ocean and Civil Engineering, Shanghai Jiao Tong University, Shanghai, 200240, China
- Collaborative Innovation Center for Advanced Ship and Deep-Sea Exploration (CISSE), Shanghai Jiao Tong University, Shanghai, 200240, China
| | - Youjun Liu
- College of Life Science and Bioengineering, Beijing University of Technology, Beijing, 100124, China
| | - Shengxian Tu
- Med-X Research Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, 200030, China
| | - Sergey Simakov
- Moscow Institute of Physics and Technology, Dolgoprudny, 141700, Russia
- Institute for Personalized Medicine, Sechenov University, Moscow, 119991, Russia
| | - Yuri Vassilevski
- Moscow Institute of Physics and Technology, Dolgoprudny, 141700, Russia
- Institute for Personalized Medicine, Sechenov University, Moscow, 119991, Russia
- Institute of Numerical Mathematics, Russian Academy of Sciences, Moscow, 119333, Russia
| | - Fuyou Liang
- School of Naval Architecture, Ocean and Civil Engineering, Shanghai Jiao Tong University, Shanghai, 200240, China
- Collaborative Innovation Center for Advanced Ship and Deep-Sea Exploration (CISSE), Shanghai Jiao Tong University, Shanghai, 200240, China
- Institute for Personalized Medicine, Sechenov University, Moscow, 119991, Russia
| |
Collapse
|
19
|
Banerjee RK, Ramadurai S, Manegaonkar SM, Rao MB, Rakkimuthu S, Effat MA. Comparison Between 5- and 1-Year Outcomes Using Cutoff Values of Pressure Drop Coefficient and Fractional Flow Reserve for Diagnosing Coronary Artery Diseases. Front Physiol 2021; 12:689517. [PMID: 34335296 PMCID: PMC8317064 DOI: 10.3389/fphys.2021.689517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 05/28/2021] [Indexed: 12/02/2022] Open
Abstract
Background The current pressure-based coronary diagnostic index, fractional flow reserve (FFR), has a limited efficacy in the presence of microvascular disease (MVD). To overcome the limitations of FFR, the objective is to assess the recently introduced pressure drop coefficient (CDP), a fundamental fluid dynamics-based combined pressure–flow index. Methods We hypothesize that CDP will result in improved clinical outcomes in comparison to FFR. To test the hypothesis, chi-square test was performed to compare the percent major adverse cardiac events (%MACE) at 5 years between (a) FFR < 0.75 and CDP > 27.9 and (b) FFR < 0.80 and CDP > 25.4 groups using a prospective cohort study. Furthermore, Kaplan–Meier survival curves were compared between the FFR and CDP groups. The results were considered statistically significant for p < 0.05. The outcomes of the CDP arm were presumptive as clinical decision was solely based on the FFR. Results For the complete patient group, the %MACE in the CDP > 27.9 group (10 out of 35, 29%) was lower in comparison to the FFR < 0.75 group (11 out of 20, 55%), and the difference was near significant (p = 0.05). The survival analysis showed a significantly higher survival rate (p = 0.01) in the CDP > 27.9 group (n = 35) when compared to the FFR < 0.75 group (n = 20). The results remained similar for the FFR = 0.80 cutoff. The comparison of the 5-year MACE outcomes with the 1-year outcomes for the complete patient group showed similar trends, with a higher statistical significance for a longer follow-up period of 5 years. Conclusion Based on the MACE and survival analysis outcomes, CDP could possibly be an alternate diagnostic index for decision-making in the cardiac catheterization laboratory. Clinical Trial Registration www.ClinicalTrials.gov, identifier NCT01719016.
Collapse
Affiliation(s)
- Rupak K Banerjee
- Department of Mechanical and Materials Engineering, University of Cincinnati, Cincinnati, OH, United States.,Research Services, Veteran Affairs Medical Services, Cincinnati, OH, United States
| | - Sruthi Ramadurai
- Department of Mechanical and Materials Engineering, University of Cincinnati, Cincinnati, OH, United States
| | - Shreyash M Manegaonkar
- Department of Mechanical and Materials Engineering, University of Cincinnati, Cincinnati, OH, United States
| | - Marepalli B Rao
- Department of Environmental and Public Health Sciences, University of Cincinnati, Cincinnati, OH, United States
| | - Sathyaprabha Rakkimuthu
- Department of Mechanical and Materials Engineering, University of Cincinnati, Cincinnati, OH, United States
| | - Mohamed A Effat
- Department of Cardiology, University of Cincinnati Medical Center, Cincinnati, OH, United States
| |
Collapse
|
20
|
Hair J, Timmins L, El Sayed R, Samady H, Oshinski J. Effect of Patient-Specific Coronary Flow Reserve Values on the Accuracy of MRI-Based Virtual Fractional Flow Reserve. Front Cardiovasc Med 2021; 8:663767. [PMID: 34277727 PMCID: PMC8282891 DOI: 10.3389/fcvm.2021.663767] [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: 02/03/2021] [Accepted: 05/28/2021] [Indexed: 01/09/2023] Open
Abstract
The purpose of this study is to investigate the effect of varying coronary flow reserve (CFR) values on the calculation of computationally-derived fractional flow reserve (FFR). CFR reflects both vessel resistance due to an epicardial stenosis, and resistance in the distal microvascular tissue. Patients may have a wide range of CFR related to the tissue substrate that is independent of epicardial stenosis levels. Most computationally based virtual FFR values such as FFRCT do not measure patient specific CFR values but use a population-average value to create hyperemic flow conditions. In this study, a coronary arterial computational geometry was constructed using magnetic resonance angiography (MRA) data acquired in a patient with moderate CAD. Coronary flow waveforms under rest and stress conditions were acquired in 13 patients with phase-contrast magnetic resonance (PCMR) to calculate CFR, and these flow waveforms and CFR values were applied as inlet flow boundary conditions to determine FFR based on computational fluid dynamics (CFD) simulations. The stress flow waveform gave a measure of the functional significance of the vessel when evaluated with the physiologically-accurate behavior with the patient-specific CFR. The resting flow waveform was then scaled by a series of CFR values determined in the 13 patients to simulate how hyperemic flow and CFR affects FFR values. We found that FFR values calculated using non-patient-specific CFR values did not accurately predict those calculated with the true hyperemic flow waveform. This indicates that both patient-specific anatomic and flow information are required to accurately non-invasively assess the functional significance of coronary lesions.
Collapse
Affiliation(s)
- Jackson Hair
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, United States.,Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, United States
| | - Lucas Timmins
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT, United States.,Scientific Computing and Imaging Institute, University of Utah, Salt Lake City, UT, United States
| | - Retta El Sayed
- Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, United States
| | - Habib Samady
- Division of Cardiology, Department of Medicine, Emory School of Medicine, Atlanta, GA, United States
| | - John Oshinski
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, United States.,Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, United States
| |
Collapse
|
21
|
Goto R, Takashima H, Ohashi H, Ando H, Suzuki A, Sakurai S, Nakano Y, Sawada H, Fujimoto M, Suzuki Y, Waseda K, Ohashi W, Amano T. Independent predictors of discordance between the resting full-cycle ratio and fractional flow reserve. Heart Vessels 2021; 36:790-798. [PMID: 33398440 DOI: 10.1007/s00380-020-01763-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 12/18/2020] [Indexed: 01/19/2023]
Abstract
The resting full-cycle ratio (RFR), a novel resting index, is well correlated with and shows good diagnostic accuracy to the fractional flow reserve (FFR). However, discordance results between the RFR and FFR have been observed to occur in about 20% of cases. This study aimed to clarify the prevalence and factors of discordant results between the RFR and FFR through a direct comparison of these values in daily clinical practice. A total of 220 intermediate coronary lesions of 156 consecutive patients with RFR and FFR measurements were allocated to four groups according to RFR and FFR cutoff values. We compared the angiographic, clinical, and hemodynamic variables among the groups. Discordant results between the RFR and FFR were observed in 19.6% of vessels, and the proportion of discordant results was significantly higher in the left main trunk and left anterior descending artery (LM + LAD) than in non-LAD vessels (25.2% vs. 12.3%, p = 0.006). In the multivariable regression analysis, LM + LAD location, hemodialysis, and peripheral artery disease were associated with a low RFR among patients with a high FFR. Conversely, the absence of diabetes mellitus and the presence of higher hemoglobin levels were associated with a higher RFR among patients with a low FFR. Specific angiographic and clinical characteristics such as LM + LAD location, hemodialysis, peripheral artery disease, and absence of diabetes mellitus and anemia can be independent predictors of physiologic discordance between the RFR and FFR.
Collapse
Affiliation(s)
- Reiji Goto
- Department of Cardiology, Aichi Medical University, 1-1 Yazakokarimata, Nagakute, Aichi, 480-1195, Japan
| | - Hiroaki Takashima
- Department of Cardiology, Aichi Medical University, 1-1 Yazakokarimata, Nagakute, Aichi, 480-1195, Japan.
| | - Hirofumi Ohashi
- Department of Cardiology, Aichi Medical University, 1-1 Yazakokarimata, Nagakute, Aichi, 480-1195, Japan
| | - Hirohiko Ando
- Department of Cardiology, Aichi Medical University, 1-1 Yazakokarimata, Nagakute, Aichi, 480-1195, Japan
| | - Akihiro Suzuki
- Department of Cardiology, Aichi Medical University, 1-1 Yazakokarimata, Nagakute, Aichi, 480-1195, Japan
| | - Shinichiro Sakurai
- Department of Cardiology, Aichi Medical University, 1-1 Yazakokarimata, Nagakute, Aichi, 480-1195, Japan
| | - Yusuke Nakano
- Department of Cardiology, Aichi Medical University, 1-1 Yazakokarimata, Nagakute, Aichi, 480-1195, Japan
| | - Hiroaki Sawada
- Department of Cardiology, Aichi Medical University, 1-1 Yazakokarimata, Nagakute, Aichi, 480-1195, Japan
| | - Masanobu Fujimoto
- Department of Cardiology, Aichi Medical University, 1-1 Yazakokarimata, Nagakute, Aichi, 480-1195, Japan
| | - Yasushi Suzuki
- Department of Cardiology, Aichi Medical University, 1-1 Yazakokarimata, Nagakute, Aichi, 480-1195, Japan
| | - Katsuhisa Waseda
- Department of Cardiology, Aichi Medical University, 1-1 Yazakokarimata, Nagakute, Aichi, 480-1195, Japan
- Medical Education Center, Aichi Medical University, 1-1 Yazakokarimata, Nagakute, Aichi, Japan
| | - Wataru Ohashi
- Division of Biostatistics, Clinical Research Center, Aichi Medical University, 1-1 Yazakokarimata, Nagakute, Aichi, Japan
| | - Tetsuya Amano
- Department of Cardiology, Aichi Medical University, 1-1 Yazakokarimata, Nagakute, Aichi, 480-1195, Japan
| |
Collapse
|
22
|
Geng L, Yuan Y, Du P, Gao L, Wang Y, Li J, Guo W, Huang Y, Zhang Q. Association of quantitative flow ratio-derived microcirculatory indices with anatomical-functional discordance in intermediate coronary lesions. Int J Cardiovasc Imaging 2021; 37:2803-2813. [PMID: 34059977 DOI: 10.1007/s10554-021-02292-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 05/16/2021] [Indexed: 12/18/2022]
Abstract
Discrepancy between coronary lesion severity and functional significance has always been a relevant issue in the management of patients undergoing coronary angiography and/or revascularization. We sought to investigate the relationship between quantitative flow ratio (QFR)-derived microcirculatory indices and anatomical-functional mismatch/reverse mismatch in intermediate coronary lesions. Intravascular ultrasound (IVUS) imaging and QFR were analyzed in 117 de novo intermediate coronary lesions. Lesions with QFR ≤ 0.8 were considered hemodynamically significant. Anatomical significance of the lesions was defined according to the best cutoff value of combined IVUS parameters for predicting QFR ≤ 0.8. QFR-derived microcirculatory indices including contrast-flow QFR minus fixed-flow QFR (cQFR-fQFR), hyperemic flow velocity and angiography-derived index of microcirculatory resistance (IMRangio) were calculated. The best cutoff values of IVUS parameters for predicting QFR ≤ 0.8 were minimum lumen area (MLA) 3.1mm2 and plaque burden (PB) 70%, with area under the curve of 0.635 and 0.703, respectively. The total discordance rate of lesion functional significance between IVUS and QFR assessments was 26.5%, with 21 lesions (17.9%) being classified as mismatch (MLA ≤ 3.1mm2 and PB ≥ 70% and QFR > 0.8) and 10 lesions (8.5%) as reverse-mismatch (MLA > 3.1 mm2 or PB < 70% and QFR ≤ 0.8). At multivariate analysis, IMRangio was identified as an independent predictor of mismatch (OR1.675, 95%CI:1.176-2.386, P = 0.004), whereas hyperemic flow velocity was identified as an independent predictor of reverse-mismatch (OR 1.233, 95%CI:1.073-1.416, P = 0.003). In intermediate coronary lesions, although MLA 3.1mm2 and PB 70% determined by IVUS are predictive of QFR-defined functional significance, the discordance rate remains substantial. QFR-derived microcirculatory indices are independently associated with anatomical-functional discordance between IVUS and QFR assessments.
Collapse
Affiliation(s)
- Liang Geng
- Department of Cardiology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, 200092, China.,Department of Cardiology, JI'AN Hospital, Shanghai East Hospital, Ji An, 343006, China
| | - Yuan Yuan
- Department of Cardiology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, 200092, China
| | - Peizhao Du
- Department of Cardiology, Baoshan Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai, 201900, China
| | - Liming Gao
- Department of Cardiology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, 200092, China
| | - Yunkai Wang
- Department of Cardiology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, 200092, China
| | - Jiming Li
- Department of Cardiology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, 200092, China
| | - Wei Guo
- Department of Cardiology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, 200092, China
| | - Ying Huang
- Department of Cardiology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, 200092, China
| | - Qi Zhang
- Department of Cardiology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, 200092, China.
| |
Collapse
|
23
|
Patel KK, Spertus JA, Chan PS, Sperry BW, Al Badarin F, Kennedy KF, Thompson RC, Case JA, McGhie AI, Bateman TM. Myocardial blood flow reserve assessed by positron emission tomography myocardial perfusion imaging identifies patients with a survival benefit from early revascularization. Eur Heart J 2021; 41:759-768. [PMID: 31228200 DOI: 10.1093/eurheartj/ehz389] [Citation(s) in RCA: 106] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Revised: 04/13/2019] [Accepted: 05/20/2019] [Indexed: 01/08/2023] Open
Abstract
AIMS Positron emission tomography (PET) myocardial perfusion imaging (MPI) can non-invasively measure myocardial blood flow reserve (MBFR). We aimed to examine whether MBFR identifies patients with a survival benefit after revascularization, helping to guide post-test management. METHODS AND RESULTS We examined all-cause mortality in 12 594 consecutive patients undergoing Rb82 rest/stress PET MPI from January 2010 to December 2016, after excluding those with cardiomyopathy, prior coronary artery bypass surgery (CABG), and missing MBFR. Myocardial blood flow reserve was calculated as the ratio of stress to rest absolute myocardial blood flow. A Cox model adjusted for patient and test characteristics, early revascularization (percutaneous coronary intervention or CABG ≤90 days of MPI), and the interaction between MBFR and early revascularization was developed to identify predictors of all-cause mortality. After a median follow-up of 3.2 years, 897 patients (7.1%) underwent early revascularization and 1699 patients (13.5%) died. Ischaemia was present in 4051 (32.3%) patients, with 1413 (11.2%) having ≥10% ischaemia. Mean MBFR was 2.0 ± 1.3, with MBFR <1.8 in 4836 (38.5%). After multivariable adjustment, every 0.1 unit decrease in MBFR was associated with 9% greater hazard of all-cause death (hazard ratio 1.09, 95% confidence interval 1.08-1.10; P < 0.001). There was a significant interaction between MBFR and early revascularization (P < 0.001); such that patients with MBFR ≤1.8 had a survival benefit with early revascularization, regardless of type of revascularization or level of ischaemia. CONCLUSION Myocardial blood flow reserve on PET MPI is associated with all-cause mortality and can identify patients who receive a survival benefit with early revascularization compared to medical therapy. This may be used to guide revascularization, and prospective validation is needed.
Collapse
Affiliation(s)
- Krishna K Patel
- Department of Cardiology, University of Missouri - Kansas City, Kansas City, MO 64111, USA.,Saint Luke's Mid America Heart Institute, 4401 Wornall Rd, 9th floor CV Research, Kansas City, MO 64111, USA
| | - John A Spertus
- Department of Cardiology, University of Missouri - Kansas City, Kansas City, MO 64111, USA.,Saint Luke's Mid America Heart Institute, 4401 Wornall Rd, 9th floor CV Research, Kansas City, MO 64111, USA
| | - Paul S Chan
- Department of Cardiology, University of Missouri - Kansas City, Kansas City, MO 64111, USA.,Saint Luke's Mid America Heart Institute, 4401 Wornall Rd, 9th floor CV Research, Kansas City, MO 64111, USA
| | - Brett W Sperry
- Department of Cardiology, University of Missouri - Kansas City, Kansas City, MO 64111, USA.,Saint Luke's Mid America Heart Institute, 4401 Wornall Rd, 9th floor CV Research, Kansas City, MO 64111, USA
| | - Firas Al Badarin
- Department of Cardiology, University of Missouri - Kansas City, Kansas City, MO 64111, USA.,Saint Luke's Mid America Heart Institute, 4401 Wornall Rd, 9th floor CV Research, Kansas City, MO 64111, USA
| | - Kevin F Kennedy
- Saint Luke's Mid America Heart Institute, 4401 Wornall Rd, 9th floor CV Research, Kansas City, MO 64111, USA
| | - Randall C Thompson
- Department of Cardiology, University of Missouri - Kansas City, Kansas City, MO 64111, USA.,Saint Luke's Mid America Heart Institute, 4401 Wornall Rd, 9th floor CV Research, Kansas City, MO 64111, USA
| | - James A Case
- Cardiovascular Imaging Technologies, Kansas City, MO, USA
| | - A Iain McGhie
- Department of Cardiology, University of Missouri - Kansas City, Kansas City, MO 64111, USA.,Saint Luke's Mid America Heart Institute, 4401 Wornall Rd, 9th floor CV Research, Kansas City, MO 64111, USA
| | - Timothy M Bateman
- Department of Cardiology, University of Missouri - Kansas City, Kansas City, MO 64111, USA.,Saint Luke's Mid America Heart Institute, 4401 Wornall Rd, 9th floor CV Research, Kansas City, MO 64111, USA
| |
Collapse
|
24
|
Ghorbanniahassankiadeh A, Marks DS, LaDisa JF. Correlation of Computational Instantaneous Wave-Free Ratio With Fractional Flow Reserve for Intermediate Multivessel Coronary Disease. J Biomech Eng 2021; 143:1096333. [PMID: 33454732 DOI: 10.1115/1.4049746] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Indexed: 01/14/2023]
Abstract
This study computationally assesses the accuracy of an instantaneous wave-free ratio (iFR) threshold range compared to standard modalities such as fractional flow reserve (FFR) and coronary flow reserve (CFR) for multiple intermediate lesions near the left main (LM) coronary bifurcation. iFR is an adenosine-independent index encouraged for assessment of coronary artery disease (CAD), but different thresholds are debated. This becomes particularly challenging in cases of multivessel disease when sensitivity to downstream lesions is unclear. Idealized LM coronary arteries with 34 different intermediate stenoses were created and categorized (Medina) as single and multiple lesion groups. Computational fluid dynamics modeling was performed with physiologic boundary conditions using an open-source software (simvascular1) to solve the time-dependent Navier-Stokes equations. A strong linear relationship between iFR and FFR was observed among studied models, indicating computational iFR values of 0.92 and 0.93 are statistically equivalent to an FFR of 0.80 in single and multiple lesion groups, respectively. At the clinical FFR value (i.e., 0.8), a triple-lesion group had smaller CFR compared to the single and double lesion groups (e.g., triple = 3.077 versus single = 3.133 and double = 3.132). In general, the effect of additional intermediate downstream lesions (minimum lumen area > 3 mm2) was not statistically significant for iFR and CFR. A computational iFR of 0.92 best predicts an FFR of 0.80 and may be recommended as threshold criteria for computational assessment of LM stenosis following additional validation using patient-specific models.
Collapse
Affiliation(s)
- Arash Ghorbanniahassankiadeh
- Department of Biomedical Engineering, Medical College of Wisconsin and Marquette University, 8701 W Watertown Plank Road, Milwaukee, WI 53226
| | - David S Marks
- Division of Cardiovascular Medicine, Department of Medicine, Medical College of Wisconsin, 8701 W Watertown Plank Road, Milwaukee, WI 53226
| | - John F LaDisa
- Department of Biomedical Engineering, Medical College of Wisconsin and Marquette University, 8701 W Watertown Plank Road, Milwaukee, WI 53226; Department of Physiology, Medical College of Wisconsin, 8701 W Watertown Plank Road, Milwaukee, WI 53226; Department of Medicine, Medical College of Wisconsin, 8701 W Watertown Plank Road, Milwaukee, WI 53226
| |
Collapse
|
25
|
Yamagishi M, Tamaki N, Akasaka T, Ikeda T, Ueshima K, Uemura S, Otsuji Y, Kihara Y, Kimura K, Kimura T, Kusama Y, Kumita S, Sakuma H, Jinzaki M, Daida H, Takeishi Y, Tada H, Chikamori T, Tsujita K, Teraoka K, Nakajima K, Nakata T, Nakatani S, Nogami A, Node K, Nohara A, Hirayama A, Funabashi N, Miura M, Mochizuki T, Yokoi H, Yoshioka K, Watanabe M, Asanuma T, Ishikawa Y, Ohara T, Kaikita K, Kasai T, Kato E, Kamiyama H, Kawashiri M, Kiso K, Kitagawa K, Kido T, Kinoshita T, Kiriyama T, Kume T, Kurata A, Kurisu S, Kosuge M, Kodani E, Sato A, Shiono Y, Shiomi H, Taki J, Takeuchi M, Tanaka A, Tanaka N, Tanaka R, Nakahashi T, Nakahara T, Nomura A, Hashimoto A, Hayashi K, Higashi M, Hiro T, Fukamachi D, Matsuo H, Matsumoto N, Miyauchi K, Miyagawa M, Yamada Y, Yoshinaga K, Wada H, Watanabe T, Ozaki Y, Kohsaka S, Shimizu W, Yasuda S, Yoshino H. JCS 2018 Guideline on Diagnosis of Chronic Coronary Heart Diseases. Circ J 2021; 85:402-572. [PMID: 33597320 DOI: 10.1253/circj.cj-19-1131] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
| | - Nagara Tamaki
- Department of Radiology, Kyoto Prefectural University of Medicine Graduate School
| | - Takashi Akasaka
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Graduate School
| | - Kenji Ueshima
- Center for Accessing Early Promising Treatment, Kyoto University Hospital
| | - Shiro Uemura
- Department of Cardiology, Kawasaki Medical School
| | - Yutaka Otsuji
- Second Department of Internal Medicine, University of Occupational and Environmental Health, Japan
| | - Yasuki Kihara
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences
| | - Kazuo Kimura
- Division of Cardiology, Yokohama City University Medical Center
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School
| | | | | | - Hajime Sakuma
- Department of Radiology, Mie University Graduate School
| | | | - Hiroyuki Daida
- Department of Cardiovascular Medicine, Juntendo University Graduate School
| | | | - Hiroshi Tada
- Department of Cardiovascular Medicine, University of Fukui
| | | | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University
| | | | - Kenichi Nakajima
- Department of Functional Imaging and Artificial Intelligence, Kanazawa Universtiy
| | | | - Satoshi Nakatani
- Division of Functional Diagnostics, Department of Health Sciences, Osaka University Graduate School of Medicine
| | | | - Koichi Node
- Department of Cardiovascular Medicine, Saga University
| | - Atsushi Nohara
- Division of Clinical Genetics, Ishikawa Prefectural Central Hospital
| | | | | | - Masaru Miura
- Department of Cardiology, Tokyo Metropolitan Children's Medical Center
| | | | | | | | - Masafumi Watanabe
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University
| | - Toshihiko Asanuma
- Division of Functional Diagnostics, Department of Health Sciences, Osaka University Graduate School
| | - Yuichi Ishikawa
- Department of Pediatric Cardiology, Fukuoka Children's Hospital
| | - Takahiro Ohara
- Division of Community Medicine, Tohoku Medical and Pharmaceutical University
| | - Koichi Kaikita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University
| | - Tokuo Kasai
- Department of Cardiology, Uonuma Kinen Hospital
| | - Eri Kato
- Department of Cardiovascular Medicine, Department of Clinical Laboratory, Kyoto University Hospital
| | | | - Masaaki Kawashiri
- Department of Cardiovascular and Internal Medicine, Kanazawa University
| | - Keisuke Kiso
- Department of Diagnostic Radiology, Tohoku University Hospital
| | - Kakuya Kitagawa
- Department of Advanced Diagnostic Imaging, Mie University Graduate School
| | - Teruhito Kido
- Department of Radiology, Ehime University Graduate School
| | | | | | | | - Akira Kurata
- Department of Radiology, Ehime University Graduate School
| | - Satoshi Kurisu
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences
| | - Masami Kosuge
- Division of Cardiology, Yokohama City University Medical Center
| | - Eitaro Kodani
- Department of Internal Medicine and Cardiology, Nippon Medical School Tama Nagayama Hospital
| | - Akira Sato
- Department of Cardiology, University of Tsukuba
| | - Yasutsugu Shiono
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Hiroki Shiomi
- Department of Cardiovascular Medicine, Kyoto University Graduate School
| | - Junichi Taki
- Department of Nuclear Medicine, Kanazawa University
| | - Masaaki Takeuchi
- Department of Laboratory and Transfusion Medicine, Hospital of the University of Occupational and Environmental Health, Japan
| | | | - Nobuhiro Tanaka
- Department of Cardiology, Tokyo Medical University Hachioji Medical Center
| | - Ryoichi Tanaka
- Department of Reconstructive Oral and Maxillofacial Surgery, Iwate Medical University
| | | | | | - Akihiro Nomura
- Innovative Clinical Research Center, Kanazawa University Hospital
| | - Akiyoshi Hashimoto
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University
| | - Kenshi Hayashi
- Department of Cardiovascular Medicine, Kanazawa University Hospital
| | - Masahiro Higashi
- Department of Radiology, National Hospital Organization Osaka National Hospital
| | - Takafumi Hiro
- Division of Cardiology, Department of Medicine, Nihon University
| | | | - Hitoshi Matsuo
- Department of Cardiovascular Medicine, Gifu Heart Center
| | - Naoya Matsumoto
- Division of Cardiology, Department of Medicine, Nihon University
| | | | | | | | - Keiichiro Yoshinaga
- Department of Diagnostic and Therapeutic Nuclear Medicine, Molecular Imaging at the National Institute of Radiological Sciences
| | - Hideki Wada
- Department of Cardiology, Juntendo University Shizuoka Hospital
| | - Tetsu Watanabe
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University
| | - Yukio Ozaki
- Department of Cardiology, Fujita Medical University
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
| | | | | |
Collapse
|
26
|
Kumar S, Mehta PK, Eshtehardi P, Hung OY, Koh J, Kumar A, Al‐Badri A, Rabah R, D'Souza M, Gupta S, McDaniel M, Vaccarino V, Douglas J, Mavromatis K, Lee JM, Quyyumi A, Samady H. Functional coronary angiography in symptomatic patients with no obstructive coronary artery disease. Catheter Cardiovasc Interv 2020; 98:827-835. [DOI: 10.1002/ccd.29237] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 08/12/2020] [Accepted: 08/15/2020] [Indexed: 12/13/2022]
Affiliation(s)
- Sonali Kumar
- Division of Cardiology, Department of Internal Medicine Emory Women's Heart Center Atlanta Georgia USA
- Division of Cardiology, Department of Internal Medicine Andreas Gruentzig Cardiovascular Center Atlanta Georgia USA
| | - Puja K. Mehta
- Division of Cardiology, Department of Internal Medicine Emory Women's Heart Center Atlanta Georgia USA
- Division of Cardiology, Department of Internal Medicine Emory Clinical Cardiovascular Research Institute Atlanta Georgia USA
| | - Parham Eshtehardi
- Division of Cardiology, Department of Internal Medicine Andreas Gruentzig Cardiovascular Center Atlanta Georgia USA
| | - Olivia Y. Hung
- Division of Cardiology, Department of Internal Medicine Andreas Gruentzig Cardiovascular Center Atlanta Georgia USA
| | - Jin‐Sin Koh
- Division of Cardiology, Department of Internal Medicine Andreas Gruentzig Cardiovascular Center Atlanta Georgia USA
| | - Arnav Kumar
- Division of Cardiology, Department of Internal Medicine Emory Clinical Cardiovascular Research Institute Atlanta Georgia USA
- Division of Cardiology, Department of Internal Medicine Andreas Gruentzig Cardiovascular Center Atlanta Georgia USA
| | - Ahmed Al‐Badri
- Division of Cardiology, Department of Internal Medicine Emory Clinical Cardiovascular Research Institute Atlanta Georgia USA
| | - Rani Rabah
- Division of Cardiology, Department of Internal Medicine Andreas Gruentzig Cardiovascular Center Atlanta Georgia USA
| | - Melroy D'Souza
- J. Willis Hurst Internal Medicine Residency Program Emory University School of Medicine Atlanta Georgia USA
| | - Sonu Gupta
- Division of Cardiology, Department of Internal Medicine Andreas Gruentzig Cardiovascular Center Atlanta Georgia USA
| | - Michael McDaniel
- Division of Cardiology, Department of Internal Medicine Andreas Gruentzig Cardiovascular Center Atlanta Georgia USA
| | - Viola Vaccarino
- Department of Epidemiology Rollins School of Public Health, Emory University Atlanta Georgia USA
| | - John Douglas
- Division of Cardiology, Department of Internal Medicine Andreas Gruentzig Cardiovascular Center Atlanta Georgia USA
| | - Kreton Mavromatis
- Division of Cardiology, Department of Internal Medicine Andreas Gruentzig Cardiovascular Center Atlanta Georgia USA
| | - Joo Myung Lee
- Division of Cardiology, Department of Internal Medicine Andreas Gruentzig Cardiovascular Center Atlanta Georgia USA
- Division of Cardiology, Department of Internal Medicine Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine Seoul Republic of Korea
| | - Arshed Quyyumi
- Division of Cardiology, Department of Internal Medicine Emory Clinical Cardiovascular Research Institute Atlanta Georgia USA
| | - Habib Samady
- Division of Cardiology, Department of Internal Medicine Emory Clinical Cardiovascular Research Institute Atlanta Georgia USA
- Division of Cardiology, Department of Internal Medicine Andreas Gruentzig Cardiovascular Center Atlanta Georgia USA
| |
Collapse
|
27
|
Vancheri F, Longo G, Vancheri S, Henein M. Coronary Microvascular Dysfunction. J Clin Med 2020; 9:E2880. [PMID: 32899944 PMCID: PMC7563453 DOI: 10.3390/jcm9092880] [Citation(s) in RCA: 148] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 09/02/2020] [Accepted: 09/02/2020] [Indexed: 01/09/2023] Open
Abstract
Many patients with chest pain undergoing coronary angiography do not show significant obstructive coronary lesions. A substantial proportion of these patients have abnormalities in the function and structure of coronary microcirculation due to endothelial and smooth muscle cell dysfunction. The coronary microcirculation has a fundamental role in the regulation of coronary blood flow in response to cardiac oxygen requirements. Impairment of this mechanism, defined as coronary microvascular dysfunction (CMD), carries an increased risk of adverse cardiovascular clinical outcomes. Coronary endothelial dysfunction accounts for approximately two-thirds of clinical conditions presenting with symptoms and signs of myocardial ischemia without obstructive coronary disease, termed "ischemia with non-obstructive coronary artery disease" (INOCA) and for a small proportion of "myocardial infarction with non-obstructive coronary artery disease" (MINOCA). More frequently, the clinical presentation of INOCA is microvascular angina due to CMD, while some patients present vasospastic angina due to epicardial spasm, and mixed epicardial and microvascular forms. CMD may be associated with focal and diffuse epicardial coronary atherosclerosis, which may reinforce each other. Both INOCA and MINOCA are more common in females. Clinical classification of CMD includes the association with conditions in which atherosclerosis has limited relevance, with non-obstructive atherosclerosis, and with obstructive atherosclerosis. Several studies already exist which support the evidence that CMD is part of systemic microvascular disease involving multiple organs, such as brain and kidney. Moreover, CMD is strongly associated with the development of heart failure with preserved ejection fraction (HFpEF), diabetes, hypertensive heart disease, and also chronic inflammatory and autoimmune diseases. Since coronary microcirculation is not visible on invasive angiography or computed tomographic coronary angiography (CTCA), the diagnosis of CMD is usually based on functional assessment of microcirculation, which can be performed by both invasive and non-invasive methods, including the assessment of delayed flow of contrast during angiography, measurement of coronary flow reserve (CFR) and index of microvascular resistance (IMR), evaluation of angina induced by intracoronary acetylcholine infusion, and assessment of myocardial perfusion by positron emission tomography (PET) and magnetic resonance (CMR).
Collapse
Affiliation(s)
- Federico Vancheri
- Department of Internal Medicine, S.Elia Hospital, 93100 Caltanissetta, Italy
| | - Giovanni Longo
- Cardiovascular and Interventional Department, S.Elia Hospital, 93100 Caltanissetta, Italy;
| | - Sergio Vancheri
- Radiology Department, I.R.C.C.S. Policlinico San Matteo, 27100 Pavia, Italy;
| | - Michael Henein
- Institute of Public Health and Clinical Medicine, Umea University, SE-90187 Umea, Sweden;
- Department of Fluid Mechanics, Brunel University, Middlesex, London UB8 3PH, UK
- Molecular and Nuclear Research Institute, St George’s University, London SW17 0RE, UK
| |
Collapse
|
28
|
Knott KD, Seraphim A, Augusto JB, Xue H, Chacko L, Aung N, Petersen SE, Cooper JA, Manisty C, Bhuva AN, Kotecha T, Bourantas CV, Davies RH, Brown LA, Plein S, Fontana M, Kellman P, Moon JC. The Prognostic Significance of Quantitative Myocardial Perfusion: An Artificial Intelligence-Based Approach Using Perfusion Mapping. Circulation 2020; 141:1282-1291. [PMID: 32078380 PMCID: PMC7176346 DOI: 10.1161/circulationaha.119.044666] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 01/23/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Myocardial perfusion reflects the macro- and microvascular coronary circulation. Recent quantitation developments using cardiovascular magnetic resonance perfusion permit automated measurement clinically. We explored the prognostic significance of stress myocardial blood flow (MBF) and myocardial perfusion reserve (MPR, the ratio of stress to rest MBF). METHODS A 2-center study of patients with both suspected and known coronary artery disease referred clinically for perfusion assessment. Image analysis was performed automatically using a novel artificial intelligence approach deriving global and regional stress and rest MBF and MPR. Cox proportional hazard models adjusting for comorbidities and cardiovascular magnetic resonance parameters sought associations of stress MBF and MPR with death and major adverse cardiovascular events (MACE), including myocardial infarction, stroke, heart failure hospitalization, late (>90 day) revascularization, and death. RESULTS A total of 1049 patients were included with a median follow-up of 605 (interquartile range, 464-814) days. There were 42 (4.0%) deaths and 188 MACE in 174 (16.6%) patients. Stress MBF and MPR were independently associated with both death and MACE. For each 1 mL·g-1·min-1 decrease in stress MBF, the adjusted hazard ratios for death and MACE were 1.93 (95% CI, 1.08-3.48, P=0.028) and 2.14 (95% CI, 1.58-2.90, P<0.0001), respectively, even after adjusting for age and comorbidity. For each 1 U decrease in MPR, the adjusted hazard ratios for death and MACE were 2.45 (95% CI, 1.42-4.24, P=0.001) and 1.74 (95% CI, 1.36-2.22, P<0.0001), respectively. In patients without regional perfusion defects on clinical read and no known macrovascular coronary artery disease (n=783), MPR remained independently associated with death and MACE, with stress MBF remaining associated with MACE only. CONCLUSIONS In patients with known or suspected coronary artery disease, reduced MBF and MPR measured automatically inline using artificial intelligence quantification of cardiovascular magnetic resonance perfusion mapping provides a strong, independent predictor of adverse cardiovascular outcomes.
Collapse
Affiliation(s)
- Kristopher D. Knott
- Institute of Cardiovascular Science, University College London, United Kingdom (K.D.K., A.S., J.B.A., L.C., C.M., A.N.B., T.K., C.V.B., R.H.D., M.F., J.C.M.)
- Barts Heart Centre, St Bartholomew’s Hospital, London, United Kingdom (K.D.K., A.S., J.B.A., N.A., S.E.P., C.M., A.N.B., C.V.B., R.H.D., J.C.M.)
| | - Andreas Seraphim
- Institute of Cardiovascular Science, University College London, United Kingdom (K.D.K., A.S., J.B.A., L.C., C.M., A.N.B., T.K., C.V.B., R.H.D., M.F., J.C.M.)
- Barts Heart Centre, St Bartholomew’s Hospital, London, United Kingdom (K.D.K., A.S., J.B.A., N.A., S.E.P., C.M., A.N.B., C.V.B., R.H.D., J.C.M.)
| | - Joao B. Augusto
- Institute of Cardiovascular Science, University College London, United Kingdom (K.D.K., A.S., J.B.A., L.C., C.M., A.N.B., T.K., C.V.B., R.H.D., M.F., J.C.M.)
- Barts Heart Centre, St Bartholomew’s Hospital, London, United Kingdom (K.D.K., A.S., J.B.A., N.A., S.E.P., C.M., A.N.B., C.V.B., R.H.D., J.C.M.)
| | - Hui Xue
- National Heart, Lung, and Blood Institute, National Institutes of Health, Department of Health and Human Services, Bethesda, MD (H.X., P.K.)
| | - Liza Chacko
- Institute of Cardiovascular Science, University College London, United Kingdom (K.D.K., A.S., J.B.A., L.C., C.M., A.N.B., T.K., C.V.B., R.H.D., M.F., J.C.M.)
- Royal Free Hospital, London, United Kingdom (L.C., T.K., M.F.)
| | - Nay Aung
- Barts Heart Centre, St Bartholomew’s Hospital, London, United Kingdom (K.D.K., A.S., J.B.A., N.A., S.E.P., C.M., A.N.B., C.V.B., R.H.D., J.C.M.)
- William Harvey Research Institute, Queen Mary University of London, United Kingdom (N.A., S.E.P., J.A.C.)
| | - Steffen E. Petersen
- Barts Heart Centre, St Bartholomew’s Hospital, London, United Kingdom (K.D.K., A.S., J.B.A., N.A., S.E.P., C.M., A.N.B., C.V.B., R.H.D., J.C.M.)
- William Harvey Research Institute, Queen Mary University of London, United Kingdom (N.A., S.E.P., J.A.C.)
| | - Jackie A. Cooper
- William Harvey Research Institute, Queen Mary University of London, United Kingdom (N.A., S.E.P., J.A.C.)
| | - Charlotte Manisty
- Institute of Cardiovascular Science, University College London, United Kingdom (K.D.K., A.S., J.B.A., L.C., C.M., A.N.B., T.K., C.V.B., R.H.D., M.F., J.C.M.)
- Barts Heart Centre, St Bartholomew’s Hospital, London, United Kingdom (K.D.K., A.S., J.B.A., N.A., S.E.P., C.M., A.N.B., C.V.B., R.H.D., J.C.M.)
| | - Anish N. Bhuva
- Institute of Cardiovascular Science, University College London, United Kingdom (K.D.K., A.S., J.B.A., L.C., C.M., A.N.B., T.K., C.V.B., R.H.D., M.F., J.C.M.)
- Barts Heart Centre, St Bartholomew’s Hospital, London, United Kingdom (K.D.K., A.S., J.B.A., N.A., S.E.P., C.M., A.N.B., C.V.B., R.H.D., J.C.M.)
| | - Tushar Kotecha
- Institute of Cardiovascular Science, University College London, United Kingdom (K.D.K., A.S., J.B.A., L.C., C.M., A.N.B., T.K., C.V.B., R.H.D., M.F., J.C.M.)
- Royal Free Hospital, London, United Kingdom (L.C., T.K., M.F.)
| | - Christos V. Bourantas
- Institute of Cardiovascular Science, University College London, United Kingdom (K.D.K., A.S., J.B.A., L.C., C.M., A.N.B., T.K., C.V.B., R.H.D., M.F., J.C.M.)
- Barts Heart Centre, St Bartholomew’s Hospital, London, United Kingdom (K.D.K., A.S., J.B.A., N.A., S.E.P., C.M., A.N.B., C.V.B., R.H.D., J.C.M.)
| | - Rhodri H. Davies
- Institute of Cardiovascular Science, University College London, United Kingdom (K.D.K., A.S., J.B.A., L.C., C.M., A.N.B., T.K., C.V.B., R.H.D., M.F., J.C.M.)
- Barts Heart Centre, St Bartholomew’s Hospital, London, United Kingdom (K.D.K., A.S., J.B.A., N.A., S.E.P., C.M., A.N.B., C.V.B., R.H.D., J.C.M.)
| | - Louise A.E. Brown
- Department of Biomedical Imaging Science, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, United Kingdom (L.A.E.B., S.P.)
| | - Sven Plein
- Department of Biomedical Imaging Science, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, United Kingdom (L.A.E.B., S.P.)
| | - Marianna Fontana
- Institute of Cardiovascular Science, University College London, United Kingdom (K.D.K., A.S., J.B.A., L.C., C.M., A.N.B., T.K., C.V.B., R.H.D., M.F., J.C.M.)
- Royal Free Hospital, London, United Kingdom (L.C., T.K., M.F.)
| | - Peter Kellman
- National Heart, Lung, and Blood Institute, National Institutes of Health, Department of Health and Human Services, Bethesda, MD (H.X., P.K.)
| | - James C. Moon
- Institute of Cardiovascular Science, University College London, United Kingdom (K.D.K., A.S., J.B.A., L.C., C.M., A.N.B., T.K., C.V.B., R.H.D., M.F., J.C.M.)
- Barts Heart Centre, St Bartholomew’s Hospital, London, United Kingdom (K.D.K., A.S., J.B.A., N.A., S.E.P., C.M., A.N.B., C.V.B., R.H.D., J.C.M.)
| |
Collapse
|
29
|
D. Clarke JR, Kennedy R, Duarte Lau F, I. Lancaster G, W. Zarich S. Invasive Evaluation of the Microvasculature in Acute Myocardial Infarction: Coronary Flow Reserve versus the Index of Microcirculatory Resistance. J Clin Med 2019; 9:jcm9010086. [PMID: 31905738 PMCID: PMC7019371 DOI: 10.3390/jcm9010086] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 12/24/2019] [Accepted: 12/27/2019] [Indexed: 01/10/2023] Open
Abstract
Acute myocardial infarction (AMI) is one of the most common causes of death in both the developed and developing world. It has high associated morbidity despite prompt institution of recommended therapy. The focus over the last few decades in ST-segment elevation AMI has been on timely reperfusion of the epicardial vessel. However, microvascular consequences after reperfusion, such as microvascular obstruction (MVO), are equally reliable predictors of outcome. The attention on the microcirculation has meant that traditional angiographic/anatomic methods are insufficient. We searched PubMed and the Cochrane database for English-language studies published between January 2000 and November 2019 that investigated the use of invasive physiologic tools in AMI. Based on these results, we provide a comprehensive review regarding the role for the invasive evaluation of the microcirculation in AMI, with specific emphasis on coronary flow reserve (CFR) and the index of microcirculatory resistance (IMR).
Collapse
Affiliation(s)
- John-Ross D. Clarke
- Department of Internal Medicine, Yale-New Haven Health/Bridgeport Hospital, Bridgeport, CT 06610, USA;
- Correspondence: ; Tel.: +1-203-260-4510
| | - Randol Kennedy
- Department of Internal Medicine, St. Vincent Charity Medical Center, Cleveland, OH 44115, USA;
| | - Freddy Duarte Lau
- Department of Internal Medicine, Yale-New Haven Health/Bridgeport Hospital, Bridgeport, CT 06610, USA;
| | - Gilead I. Lancaster
- The Heart and Vascular Institute, Yale-New Haven Health/Bridgeport Hospital, Bridgeport, CT 06610, USA; (G.I.L.); (S.W.Z.)
| | - Stuart W. Zarich
- The Heart and Vascular Institute, Yale-New Haven Health/Bridgeport Hospital, Bridgeport, CT 06610, USA; (G.I.L.); (S.W.Z.)
| |
Collapse
|
30
|
Validation of post-stenting fractional flow reserve with intravascular ultrasound parameters for optimal stent deployment. Int J Cardiovasc Imaging 2019; 36:197-203. [DOI: 10.1007/s10554-019-01712-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 10/03/2019] [Indexed: 11/26/2022]
|
31
|
Ahn SG, Lee SJ. Dose Coronary Angiography Suffice for Assessment of Intermediate Coronary Stenosis? Korean Circ J 2019; 49:1033-1034. [PMID: 31456370 PMCID: PMC6813155 DOI: 10.4070/kcj.2019.0227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Accepted: 07/16/2019] [Indexed: 12/02/2022] Open
Affiliation(s)
- Sung Gyun Ahn
- Department of Internal Medicine, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea.
| | - Sang Jun Lee
- Department of Internal Medicine, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| |
Collapse
|
32
|
Allaqaband H, Gutterman DD, Kadlec AO. Physiological Consequences of Coronary Arteriolar Dysfunction and Its Influence on Cardiovascular Disease. Physiology (Bethesda) 2019; 33:338-347. [PMID: 30109826 DOI: 10.1152/physiol.00019.2018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
To date, the major focus of diagnostic modalities and interventions to treat coronary artery disease has been the large epicardial vessels. Despite substantial data showing that microcirculatory dysfunction is a strong predictor of future adverse cardiovascular events, very little research has gone into developing techniques for in vivo diagnosis and therapeutic interventions to improve microcirculatory function. In this review, we will discuss the pathophysiology of coronary arteriolar dysfunction, define its prognostic implications, evaluate the diagnostic modalities available, and provide speculation on current and potential therapeutic opportunities.
Collapse
Affiliation(s)
- Hassan Allaqaband
- Cardiovascular Center, Medical College of Wisconsin , Milwaukee, Wisconsin
| | - David D Gutterman
- Cardiovascular Center, Medical College of Wisconsin , Milwaukee, Wisconsin.,Department of Physiology, Medical College of Wisconsin , Milwaukee, Wisconsin.,Department of Medicine, Division of Cardiology, Medical College of Wisconsin , Milwaukee, Wisconsin.,Department of Veterans Administration Medical Center, Milwaukee, Wisconsin
| | - Andrew O Kadlec
- Cardiovascular Center, Medical College of Wisconsin , Milwaukee, Wisconsin.,Department of Physiology, Medical College of Wisconsin , Milwaukee, Wisconsin.,Department of Medicine, Division of Cardiology, Medical College of Wisconsin , Milwaukee, Wisconsin
| |
Collapse
|
33
|
Role of local coronary blood flow patterns and shear stress on the development of microvascular and epicardial endothelial dysfunction and coronary plaque. Curr Opin Cardiol 2018; 33:638-644. [DOI: 10.1097/hco.0000000000000571] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
34
|
Stegehuis VE, Wijntjens GW, Piek JJ, van de Hoef TP. Fractional Flow Reserve or Coronary Flow Reserve for the Assessment of Myocardial Perfusion : Implications of FFR as an Imperfect Reference Standard for Myocardial Ischemia. Curr Cardiol Rep 2018; 20:77. [PMID: 30046914 PMCID: PMC6061210 DOI: 10.1007/s11886-018-1017-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Purpose of Review Accumulating evidence exists for the value of coronary physiology for clinical decision-making in ischemic heart disease (IHD). The most frequently used pressure-derived index to assess stenosis severity, the fractional flow reserve (FFR), has long been considered the gold standard for this purpose, despite the fact that the FFR assesses solely epicardial stenosis severity and aims to estimate coronary flow impairment in the coronary circulation. The coronary flow reserve (CFR) directly assesses coronary blood flow in the coronary circulation, including both the epicardial coronary artery and the coronary microvasculature, but is nowadays less established than FFR. It is now recognized that both tools may provide insight into the pathophysiological substrate of ischemic heart disease, and that particularly combined FFR and CFR measurements provide a comprehensive insight into the multilevel involvement of IHD. This review discusses the diagnostic and prognostic characteristics, as well as future implications of combined assessment of FFR and CFR pressure and flow measurements as parameters for inducible ischemia. Recent Findings FFR and CFR disagree in up to 40% of all cases, giving rise to fundamental questions regarding the role of FFR in contemporary ischemic heart disease management, and implying a renewed approach in clinical management of these patients using combined coronary pressure and flow measurement to allow appropriate identification of patients at risk for cardiovascular events. Summary This review emphasizes the value of comprehensive coronary physiology measurements in assessing the pathophysiological substrate of IHD, and the importance of acknowledging the broad spectrum of epicardial and microcirculatory involvement in IHD. Increasing interest and large clinical trials are expected to further strengthen the potential of advanced coronary physiology in interventional cardiology, consequently inducing reconsideration of current clinical guidelines.
Collapse
Affiliation(s)
- Valérie E Stegehuis
- Amsterdam UMC, University of Amsterdam, Department of Cardiology, Heart Centre, Meibergdreef 9, Amsterdam, The Netherlands
| | - Gilbert W Wijntjens
- Amsterdam UMC, University of Amsterdam, Department of Cardiology, Heart Centre, Meibergdreef 9, Amsterdam, The Netherlands
| | - Jan J Piek
- Amsterdam UMC, University of Amsterdam, Department of Cardiology, Heart Centre, Meibergdreef 9, Amsterdam, The Netherlands
| | - Tim P van de Hoef
- Amsterdam UMC, University of Amsterdam, Department of Cardiology, Heart Centre, Meibergdreef 9, Amsterdam, The Netherlands.
| |
Collapse
|
35
|
Koo BK. What Is the Clinical Relevance of the Discordance Between Fractional Flow Reserve and Coronary Flow Reserve? JACC Cardiovasc Interv 2017; 10:1008-1010. [DOI: 10.1016/j.jcin.2017.03.038] [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: 03/28/2017] [Accepted: 03/30/2017] [Indexed: 11/28/2022]
|