1
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Qian G, Qin H, Deng D, Feng Y, Zhang C, Qu X, Zhang Z. Prognostic value of angiographic microvascular resistance in patients with ST-segment elevation myocardial infarction. Clinics (Sao Paulo) 2024; 79:100429. [PMID: 39053030 DOI: 10.1016/j.clinsp.2024.100429] [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] [Received: 03/26/2024] [Revised: 05/24/2024] [Accepted: 06/10/2024] [Indexed: 07/27/2024] Open
Abstract
BACKGROUND The Angiographic Microvascular Resistance (AMR), derived from a solitary angiographic view, has emerged as a viable substitute for the Index of Microcirculatory Resistance (IMR). However, the prognostic significance in ST-Segment Elevation Myocardial Infarction (STEMI) patients is yet to be established. This research endeavors to explore the prognostic capabilities of AMR in patients diagnosed with STEMI. METHODS In this single-center, retrospective study, 232 patients diagnosed with STEMI who received primary Percutaneous Coronary Intervention (PCI) were recruited from January 1, 2018, to June 30, 2022. Utilizing the maximally selected log-rank statistics analysis, participants were divided into two cohorts according to an AMR threshold of 2.55 mmHg*s/cm. The endpoint evaluated was a composite of all-cause mortality or hospital readmission due to heart failure. RESULTS At a median follow-up of 1.74 (1.07, 3.65) years, the composite endpoint event was observed in 28 patients within the higher AMR group and 8 patients within the lower AMR group. The higher AMR group showed a significantly higher risk for composite outcome compared to those within the low-AMR group (HRadj: 3.33; 95% CI 1.30‒8.52; p = 0.03). AMR ≥ 2.55 mmHg*s/cm was an independent predictor of the composite endpoint (HR = 2.33; 95% CI 1.04‒5.21; p = 0.04). Furthermore, a nomogram containing age, sex, left ventricle ejection fraction, post-PCI Quantitative Flow Ratio (QFR), and AMR was developed and indicated a poorer prognosis in the high-risk group for STEMI patients at 3 years. (HR=4.60; 95% CI 1.91‒11.07; p < 0.01). CONCLUSIONS AMR measured after PCI can predict the risk of all-cause death or readmission for heart failure in patients with STEMI. AMR-involved nomograms improved predictive performance over variables alone.
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Affiliation(s)
- Gangzhen Qian
- Department of Cardiovascular Medicine, Center for Circadian Metabolism and Cardiovascular Disease, Southwest Hospital, Army Medical University, Chongqing, China
| | - Haoran Qin
- Department of Cardiovascular Medicine, Center for Circadian Metabolism and Cardiovascular Disease, Southwest Hospital, Army Medical University, Chongqing, China
| | - Dan Deng
- Department of Cardiovascular Medicine, Center for Circadian Metabolism and Cardiovascular Disease, Southwest Hospital, Army Medical University, Chongqing, China
| | - Yue Feng
- Department of Cardiovascular Medicine, Center for Circadian Metabolism and Cardiovascular Disease, Southwest Hospital, Army Medical University, Chongqing, China
| | - Chao Zhang
- Department of Cardiovascular Medicine, Center for Circadian Metabolism and Cardiovascular Disease, Southwest Hospital, Army Medical University, Chongqing, China
| | - Xiaolong Qu
- Department of Cardiovascular Medicine, Center for Circadian Metabolism and Cardiovascular Disease, Southwest Hospital, Army Medical University, Chongqing, China
| | - Zhihui Zhang
- Department of Cardiovascular Medicine, Center for Circadian Metabolism and Cardiovascular Disease, Southwest Hospital, Army Medical University, Chongqing, China.
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2
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Zuccarelli V, Andreaggi S, Walsh JL, Kotronias RA, Chu M, Vibhishanan J, Banning AP, De Maria GL. Treatment and Care of Patients with ST-Segment Elevation Myocardial Infarction-What Challenges Remain after Three Decades of Primary Percutaneous Coronary Intervention? J Clin Med 2024; 13:2923. [PMID: 38792463 PMCID: PMC11122374 DOI: 10.3390/jcm13102923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Revised: 05/11/2024] [Accepted: 05/13/2024] [Indexed: 05/26/2024] Open
Abstract
Primary percutaneous coronary intervention (pPCI) has revolutionized the prognosis of ST-segment elevation myocardial infarction (STEMI) and is the gold standard treatment. As a result of its success, the number of pPCI centres has expanded worldwide. Despite decades of advancements, clinical outcomes in STEMI patients have plateaued. Out-of-hospital cardiac arrest and cardiogenic shock remain a major cause of high in-hospital mortality, whilst the growing burden of heart failure in long-term STEMI survivors presents a growing problem. Many elements aiming to optimize STEMI treatment are still subject to debate or lack sufficient evidence. This review provides an overview of the most contentious current issues in pPCI in STEMI patients, with an emphasis on unresolved questions and persistent challenges.
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Affiliation(s)
- Vittorio Zuccarelli
- Oxford Heart Centre, Oxford University Hospitals NHS Trust, Oxford OX3 9DU, UK; (V.Z.); (S.A.); (J.L.W.); (R.A.K.); (M.C.); (J.V.); (A.P.B.)
| | - Stefano Andreaggi
- Oxford Heart Centre, Oxford University Hospitals NHS Trust, Oxford OX3 9DU, UK; (V.Z.); (S.A.); (J.L.W.); (R.A.K.); (M.C.); (J.V.); (A.P.B.)
- Division of Cardiology, Department of Medicine, University of Verona, 37129 Verona, Italy
| | - Jason L. Walsh
- Oxford Heart Centre, Oxford University Hospitals NHS Trust, Oxford OX3 9DU, UK; (V.Z.); (S.A.); (J.L.W.); (R.A.K.); (M.C.); (J.V.); (A.P.B.)
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford OX1 2JD, UK
| | - Rafail A. Kotronias
- Oxford Heart Centre, Oxford University Hospitals NHS Trust, Oxford OX3 9DU, UK; (V.Z.); (S.A.); (J.L.W.); (R.A.K.); (M.C.); (J.V.); (A.P.B.)
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford OX1 2JD, UK
| | - Miao Chu
- Oxford Heart Centre, Oxford University Hospitals NHS Trust, Oxford OX3 9DU, UK; (V.Z.); (S.A.); (J.L.W.); (R.A.K.); (M.C.); (J.V.); (A.P.B.)
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford OX1 2JD, UK
| | - Jonathan Vibhishanan
- Oxford Heart Centre, Oxford University Hospitals NHS Trust, Oxford OX3 9DU, UK; (V.Z.); (S.A.); (J.L.W.); (R.A.K.); (M.C.); (J.V.); (A.P.B.)
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford OX1 2JD, UK
| | - Adrian P. Banning
- Oxford Heart Centre, Oxford University Hospitals NHS Trust, Oxford OX3 9DU, UK; (V.Z.); (S.A.); (J.L.W.); (R.A.K.); (M.C.); (J.V.); (A.P.B.)
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford OX1 2JD, UK
- National Institute for Health Research (NIHR), Oxford Biomedical Research Centre, Oxford OX3 9DU, UK
| | - Giovanni Luigi De Maria
- Oxford Heart Centre, Oxford University Hospitals NHS Trust, Oxford OX3 9DU, UK; (V.Z.); (S.A.); (J.L.W.); (R.A.K.); (M.C.); (J.V.); (A.P.B.)
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford OX1 2JD, UK
- National Institute for Health Research (NIHR), Oxford Biomedical Research Centre, Oxford OX3 9DU, UK
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3
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Galli M, Niccoli G, De Maria G, Brugaletta S, Montone RA, Vergallo R, Benenati S, Magnani G, D'Amario D, Porto I, Burzotta F, Abbate A, Angiolillo DJ, Crea F. Coronary microvascular obstruction and dysfunction in patients with acute myocardial infarction. Nat Rev Cardiol 2024; 21:283-298. [PMID: 38001231 DOI: 10.1038/s41569-023-00953-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/23/2023] [Indexed: 11/26/2023]
Abstract
Despite prompt epicardial recanalization in patients presenting with ST-segment elevation myocardial infarction (STEMI), coronary microvascular obstruction and dysfunction (CMVO) is still fairly common and is associated with poor prognosis. Various pharmacological and mechanical strategies to treat CMVO have been proposed, but the positive results reported in preclinical and small proof-of-concept studies have not translated into benefits in large clinical trials conducted in the modern treatment setting of patients with STEMI. Therefore, the optimal management of these patients remains a topic of debate. In this Review, we appraise the pathophysiological mechanisms of CMVO, explore the evidence and provide future perspectives on strategies to be implemented to reduce the incidence of CMVO and improve prognosis in patients with STEMI.
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Affiliation(s)
- Mattia Galli
- Department of Cardiology, Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
| | | | - Gianluigi De Maria
- Oxford Heart Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Salvatore Brugaletta
- Institut Clinic Cardiovascular, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Rocco A Montone
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Rocco Vergallo
- Department of Internal Medicine, University of Genoa, Genoa, Italy
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, IRCCS Italian Cardiology Network, Genova, Italy
| | - Stefano Benenati
- Oxford Heart Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, IRCCS Italian Cardiology Network, Genova, Italy
| | - Giulia Magnani
- Department of Cardiology, University of Parma, Parma, Italy
| | - Domenico D'Amario
- Department of Translational Medicine, University of Eastern Piedmont, Novara, Italy
- Division of Cardiology, Azienda Ospedaliero Universitaria 'Maggiore Della Carita', Novara, Italy
| | - Italo Porto
- Department of Internal Medicine, University of Genoa, Genoa, Italy
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, IRCCS Italian Cardiology Network, Genova, Italy
| | - Francesco Burzotta
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Cardiovascular Sciencies, Catholic University of the Sacred Heart, Rome, Italy
| | - Antonio Abbate
- Robert M. Berne Cardiovascular Research Center, Division of Cardiology - Heart and Vascular Center, University of Virginia, Charlottesville, VA, USA
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, FL, USA.
| | - Filippo Crea
- Department of Cardiovascular Sciencies, Catholic University of the Sacred Heart, Rome, Italy
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4
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Della Mora F, Portolan L, Terentes-Printzios D, Vicerè A, Andreaggi S, Biasin M, Pesarini G, Tavella D, Maffeis C, Tafciu E, Benfari G, Oikonomou D, Gkini KP, Galante D, Tsioufis K, Vlachopoulos C, Leone AM, Ribichini F, Scarsini R. Comprehensive Angiography-Derived Functional Assessment of Epicardial and Microvascular Coronary Disease. Correlation With Non-invasive Myocardial Stress Imaging. Am J Cardiol 2024; 217:144-152. [PMID: 38431052 DOI: 10.1016/j.amjcard.2024.01.037] [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: 10/01/2023] [Revised: 12/30/2023] [Accepted: 01/29/2024] [Indexed: 03/05/2024]
Abstract
Coronary angiography (CA) is poorly correlated with non-invasive myocardial stress imaging (NSI) and myocardial ischemia is often observed in patients with unobstructed coronary arteries. Moreover, the diagnostic performance of combined epicardial and microcirculatory angiography-derived physiological assessment and its correlation with NSI remains unknown. A total of 917 coronary vessels in 319 patients who underwent both CA and NSI were included in this multicenter observational retrospective analysis. Quantitative flow ratio (QFR) and angiography-derived index of microcirculatory resistance (IMRangio) analyses were performed to estimate coronary epicardial and microcirculatory function respectively. NSI demonstrated evidence of myocardial ischemia in 76% of the cases. IMRangio (36 [22 to 50] vs 29 [21 to 41], p <0.001) was significantly higher and QFR (0.92 [0.78 to 0.99] vs 0.97 [0.91 to 0.99], p <0.001) was significantly lower in vessels subtending ischemic territories. Overall, the diagnostic accuracy of QFR was moderate (area under the curve of receiver operating characteristic [AUCROC] 0.632 [95% confidence interval [CI] 0.589 to 0.674], p <0.0001) but it was higher in patients with normal microcirculatory function (AUCROC = 0.726 [95% CI 0.669 to 0.784], p <0.0001, p Value for AUCROC comparison = 0.009). Combined QFR/IMRangio assessment provided incremental diagnostic performance compared with the evaluation of epicardial or microcirculatory districts in isolation (p Value for AUC comparison <0.0001) and it was able to identify the predominant mechanism of myocardial ischemia in 77% of the patients with positive NSI. Our study suggests the value of a combined angiography-derived assessment of epicardial and microvascular function for the definition of the predominant mechanism of myocardial ischemia in patients with suspected coronary artery disease.
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Affiliation(s)
- Francesco Della Mora
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Leonardo Portolan
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Dimitrios Terentes-Printzios
- First Department of Cardiology, National and Kapodistrian University of Athens, Medical School, Hippokration Hospital, Athens, Greece
| | - Andrea Vicerè
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Stefano Andreaggi
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Marco Biasin
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Gabriele Pesarini
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Domenico Tavella
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Caterina Maffeis
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Elvin Tafciu
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Giovanni Benfari
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Dimitrios Oikonomou
- First Department of Cardiology, National and Kapodistrian University of Athens, Medical School, Hippokration Hospital, Athens, Greece
| | - Konstantia-Paraskevi Gkini
- First Department of Cardiology, National and Kapodistrian University of Athens, Medical School, Hippokration Hospital, Athens, Greece
| | - Domenico Galante
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Konstantinos Tsioufis
- First Department of Cardiology, National and Kapodistrian University of Athens, Medical School, Hippokration Hospital, Athens, Greece
| | - Charalambos Vlachopoulos
- First Department of Cardiology, National and Kapodistrian University of Athens, Medical School, Hippokration Hospital, Athens, Greece
| | | | - Flavio Ribichini
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Roberto Scarsini
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy.
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5
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De Maria GL, Greenwood JP, Zaman AG, Carrié D, Coste P, Valgimigli M, Behan M, Berry C, Erglis A, Panoulas VF, Van Belle E, Juhl Terkelsen C, Hunziker Munsch L, Jain AK, Lassen JF, Palmer N, Stone GW, Banning AP. Pressure-Controlled Intermittent Coronary Sinus Occlusion (PiCSO) in Acute Myocardial Infarction: The PiCSO-AMI-I Trial. Circ Cardiovasc Interv 2024; 17:e013675. [PMID: 38626079 DOI: 10.1161/circinterventions.123.013675] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 01/09/2024] [Indexed: 04/18/2024]
Abstract
BACKGROUND Primary percutaneous coronary intervention (pPCI) has improved clinical outcomes in patients with ST-segment-elevation myocardial infarction. However, as many as 50% of patients still have suboptimal myocardial reperfusion and experience extensive myocardial necrosis. The PiCSO-AMI-I trial (Pressure-Controlled Intermittent Coronary Sinus Occlusion-Acute Myocardial Infarction-I) evaluated whether PiCSO therapy can further reduce myocardial infarct size (IS) in patients undergoing pPCI. METHODS Patients with anterior ST-segment-elevation myocardial infarction and Thrombolysis in Myocardial Infarction flow 0-1 were randomized at 16 European centers to PiCSO-assisted pPCI or conventional pPCI. The PiCSO Impulse Catheter (8Fr balloon-tipped catheter) was inserted via femoral venous access after antegrade flow restoration of the culprit vessel and before proceeding with stenting. The primary end point was the difference in IS (expressed as a percentage of left ventricular mass) at 5 days by cardiac magnetic resonance. Secondary end points were the extent of microvascular obstruction and intramyocardial hemorrhage at 5 days and IS at 6 months. RESULTS Among 145 randomized patients, 72 received PiCSO-assisted pPCI and 73 conventional pPCI. No differences were observed in IS at 5 days (27.2%±12.4% versus 28.3%±11.45%; P=0.59) and 6 months (19.2%±10.1% versus 18.8%±7.7%; P=0.83), nor were differences between PiCSO-treated and control patients noted in terms of the occurrence of microvascular obstruction (67.2% versus 64.6%; P=0.85) or intramyocardial hemorrhage (55.7% versus 60%; P=0.72). The study was prematurely discontinued by the sponsor with no further clinical follow-up beyond 6 months. However, up to 6 months of PiCSO use appeared safe with no device-related adverse events. CONCLUSIONS In this prematurely discontinued randomized trial, PiCSO therapy as an adjunct to pPCI did not reduce IS when compared with conventional pPCI in patients with anterior ST-segment-elevation myocardial infarction. PiCSO use was associated with increased procedural time and contrast but no increase in adverse events up to 6 months. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03625869.
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Affiliation(s)
- Giovanni Luigi De Maria
- Oxford Heart Centre, Oxford University Hospitals NHS Trust, United Kingdom (G.L.D.M., A.P.B.)
- National Institute for Health Research Oxford Biomedical Research Centre, United Kingdom (G.L.D.M., A.P.B.)
| | - John P Greenwood
- Leeds University and Leeds Teaching Hospitals NHS Trust, United Kingdom (J.P.G.)
| | - Azfar G Zaman
- Cardiothoracic Centre, Freeman Hospital and Newcastle University, Newcastle upon Tyne, United Kingdom (A.G.Z.)
| | | | - Pierre Coste
- Hôpital Cardiologique du Haut Lévéque, University of Bordeaux, France (P.C.)
| | - Marco Valgimigli
- Istituto Cardiocentro Ticino-Ente Ospedaliero Cantonale, Lugano, Switzerland (M.V.)
| | - Miles Behan
- Edinburgh Heart Centre, United Kingdom (M.B.)
| | - Colin Berry
- Golden Jubilee National Hospital, Glasgow, United Kingdom (C.B.)
| | - Andrejs Erglis
- Pauls Stradins Clinical University Hospital, University of Latvia, Riga, Latvia (A.E.)
| | - Vasileios F Panoulas
- Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom (V.F.P.)
| | - Eric Van Belle
- Institut Coeur-Poumon, Centre Hospitalier Regional, INSERM U1011, Lille Cedex, France (E.V.B.)
| | | | | | - Ajay K Jain
- Barts Heart Centre, London, United Kingdom (A.K.J.)
| | | | - Nick Palmer
- Liverpool Heart and Chest Hospital, United Kingdom (N.P.)
| | - Gregg W Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (G.W.S.)
| | - Adrian P Banning
- Oxford Heart Centre, Oxford University Hospitals NHS Trust, United Kingdom (G.L.D.M., A.P.B.)
- National Institute for Health Research Oxford Biomedical Research Centre, United Kingdom (G.L.D.M., A.P.B.)
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6
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Fawaz S, Marin F, Khan SA, F G Simpson R, Kotronias RA, Chai J, Acute Myocardial Infarction (OxAMI) Study Investigators O, Al-Janabi F, Jagathesan R, Konstantinou K, Mohdnazri SR, Clesham GJ, Tang KH, Cook CM, Channon KM, Banning AP, Davies JR, V Karamasis G, De Maria GL, Keeble TR. Comparison of bolus versus continuous thermodilution derived indices of microvascular dysfunction in revascularized coronary syndromes. IJC HEART & VASCULATURE 2024; 51:101374. [PMID: 38496256 PMCID: PMC10940925 DOI: 10.1016/j.ijcha.2024.101374] [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: 01/28/2024] [Accepted: 02/22/2024] [Indexed: 03/19/2024]
Abstract
Background The assessment of coronary microvascular dysfunction (CMD) using invasive methods is a field of growing interest, however the preferred method remains debated. Bolus and continuous thermodilution are commonly used methods, but weak agreement has been observed in patients with angina with non-obstructive coronary arteries (ANOCA). This study examined their agreement in revascularized acute coronary syndromes (ACS) and chronic coronary syndromes (CCS) patients. Objective To compare bolus thermodilution and continuous thermodilution indices of CMD in revascularized ACS and CCS patients and assess their diagnostic agreement at pre-defined cut-off points. Methods Patients from two centers underwent paired bolus and continuous thermodilution assessments after revascularization. CMD indices were compared between the two methods and their agreements at binary cut-off points were assessed. Results Ninety-six patients and 116 vessels were included. The mean age was 64 ± 11 years, and 20 (21 %) were female. Overall, weak correlations were observed between the Index of Microcirculatory Resistance (IMR) and continuous thermodilution microvascular resistance (Rµ) (rho = 0.30p = 0.001). The median coronary flow reserve (CFR) from continuous thermodilution (CFRcont) and bolus thermodilution (CFRbolus) were 2.19 (1.76-2.67) and 2.55 (1.50-3.58), respectively (p < 0.001). Weak correlation and agreement were observed between CFRcont and CFRbolus (rho = 0.37, p < 0.001, ICC 0.228 [0.055-0.389]). When assessed at CFR cut-off values of 2.0 and 2.5, the methods disagreed in 41 (35 %) and 45 (39 %) of cases, respectively. Conclusions There is a significant difference and weak agreement between bolus and continuous thermodilution-derived indices, which must be considered when diagnosing CMD in ACS and CCS patients.
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Affiliation(s)
- Samer Fawaz
- Essex Cardiothoracic Centre, Mid and South Essex NHS Hospitals Trust, Basildon, SS16 5NL, United Kingdom
- Department of Circulatory Health Research, Anglia Ruskin University, Chelmsford, CM1 1SQ, United Kingdom
| | - Federico Marin
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, British Heart Foundation Centre of Research Excellence, University of Oxford, Oxford, U.K
- NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, U.K
| | - Sarosh A Khan
- Essex Cardiothoracic Centre, Mid and South Essex NHS Hospitals Trust, Basildon, SS16 5NL, United Kingdom
- Department of Circulatory Health Research, Anglia Ruskin University, Chelmsford, CM1 1SQ, United Kingdom
| | - Rupert F G Simpson
- Essex Cardiothoracic Centre, Mid and South Essex NHS Hospitals Trust, Basildon, SS16 5NL, United Kingdom
- Department of Circulatory Health Research, Anglia Ruskin University, Chelmsford, CM1 1SQ, United Kingdom
| | - Rafail A Kotronias
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, British Heart Foundation Centre of Research Excellence, University of Oxford, Oxford, U.K
- NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, U.K
| | - Jason Chai
- Attikon University Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
- NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, U.K
| | - Oxford Acute Myocardial Infarction (OxAMI) Study Investigators
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, British Heart Foundation Centre of Research Excellence, University of Oxford, Oxford, U.K
- NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, U.K
| | - Firas Al-Janabi
- Essex Cardiothoracic Centre, Mid and South Essex NHS Hospitals Trust, Basildon, SS16 5NL, United Kingdom
| | - Rohan Jagathesan
- Essex Cardiothoracic Centre, Mid and South Essex NHS Hospitals Trust, Basildon, SS16 5NL, United Kingdom
| | - Klio Konstantinou
- Essex Cardiothoracic Centre, Mid and South Essex NHS Hospitals Trust, Basildon, SS16 5NL, United Kingdom
| | - Shah R Mohdnazri
- Essex Cardiothoracic Centre, Mid and South Essex NHS Hospitals Trust, Basildon, SS16 5NL, United Kingdom
| | - Gerald J Clesham
- Essex Cardiothoracic Centre, Mid and South Essex NHS Hospitals Trust, Basildon, SS16 5NL, United Kingdom
- Department of Circulatory Health Research, Anglia Ruskin University, Chelmsford, CM1 1SQ, United Kingdom
| | - Kare H Tang
- Essex Cardiothoracic Centre, Mid and South Essex NHS Hospitals Trust, Basildon, SS16 5NL, United Kingdom
| | - Christopher M Cook
- Essex Cardiothoracic Centre, Mid and South Essex NHS Hospitals Trust, Basildon, SS16 5NL, United Kingdom
- Department of Circulatory Health Research, Anglia Ruskin University, Chelmsford, CM1 1SQ, United Kingdom
| | - Keith M Channon
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, British Heart Foundation Centre of Research Excellence, University of Oxford, Oxford, U.K
- NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, U.K
| | - Adrian P Banning
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, British Heart Foundation Centre of Research Excellence, University of Oxford, Oxford, U.K
- NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, U.K
| | - John R Davies
- Essex Cardiothoracic Centre, Mid and South Essex NHS Hospitals Trust, Basildon, SS16 5NL, United Kingdom
- Department of Circulatory Health Research, Anglia Ruskin University, Chelmsford, CM1 1SQ, United Kingdom
| | - Grigoris V Karamasis
- Attikon University Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Giovanni L De Maria
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, British Heart Foundation Centre of Research Excellence, University of Oxford, Oxford, U.K
- NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, U.K
| | - Thomas R Keeble
- Essex Cardiothoracic Centre, Mid and South Essex NHS Hospitals Trust, Basildon, SS16 5NL, United Kingdom
- Department of Circulatory Health Research, Anglia Ruskin University, Chelmsford, CM1 1SQ, United Kingdom
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7
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Scarsini R, Portolan L, Della Mora F, Fabroni M, Andreaggi S, Mainardi A, Springhetti P, Dotto A, Del Sole PA, Fezzi S, Pazzi S, Tavella D, Mammone C, Lunardi M, Pesarini G, Benfari G, Ribichini FL. Coronary microvascular dysfunction in patients undergoing transcatheter aortic valve implantation. Heart 2024; 110:603-612. [PMID: 38040448 DOI: 10.1136/heartjnl-2023-323461] [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: 09/12/2023] [Accepted: 11/09/2023] [Indexed: 12/03/2023] Open
Abstract
OBJECTIVES This study aimed to evaluate the prognostic value of coronary microvascular dysfunction (CMD) at long term after transcatheter aortic valve implantation (TAVI) and to explore its relationship with extravalvular cardiac damage (EVCD). Moreover, we sought to test the correlation between angiography-derived index of microcirculatory resistance (IMRangio) and invasive IMR in patients with aortic stenosis (AS). METHODS This was a retrospective analysis of the Verona Valvular Heart Disease Registry (Italy) including 250 patients (83 (80-86) years, 53% female) with severe AS who underwent TAVI between 2019 and 2021. IMRangio was calculated offline using a computational flow model applied to coronary angiography obtained during the TAVI workup. CMD was defined as IMRangio ≥30 units.The primary endpoint was the composite of cardiovascular death and rehospitalisation for heart failure (HF). Advanced EVCD was defined as pulmonary circulation impairment, severe tricuspid regurgitation or right ventricular dysfunction.The correlation between IMR and IMRangio was prospectively assessed in 31 patients undergoing TAVI. RESULTS The primary endpoint occurred in 28 (11.2%) patients at a median follow-up of 22 (IQR 12-30) months. Patients with CMD met the primary endpoint more frequently than those without CMD (22.9% vs 2.8%, p<0.0001). Patients with CMD were more frequently characterised by advanced EVCD (33 (31.4%) vs 27 (18.6%), p=0.024). CMD was an independent predictor of adverse outcomes (adjusted HR 6.672 (2.251 to 19.778), p=0.001) and provided incremental prognostic value compared with conventional clinical and imaging variables. IMRangio demonstrated fair correlation with IMR. CONCLUSIONS CMD is an independent predictor of cardiovascular mortality and HF after TAVI.
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Affiliation(s)
- Roberto Scarsini
- Department of Medicine, Division of Cardiology, University of Verona, Verona, Italy
- Interventional Cardiology Unit, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Leonardo Portolan
- Department of Medicine, Division of Cardiology, University of Verona, Verona, Italy
| | - Francesco Della Mora
- Department of Medicine, Division of Cardiology, University of Verona, Verona, Italy
| | - Margherita Fabroni
- Department of Medicine, Division of Cardiology, University of Verona, Verona, Italy
| | - Stefano Andreaggi
- Department of Medicine, Division of Cardiology, University of Verona, Verona, Italy
| | - Andrea Mainardi
- Department of Medicine, Division of Cardiology, University of Verona, Verona, Italy
| | - Paolo Springhetti
- Department of Medicine, Division of Cardiology, University of Verona, Verona, Italy
| | - Alberto Dotto
- Department of Medicine, Division of Cardiology, University of Verona, Verona, Italy
| | | | - Simone Fezzi
- Department of Medicine, Division of Cardiology, University of Verona, Verona, Italy
| | - Sara Pazzi
- Department of Medicine, Division of Cardiology, University of Verona, Verona, Italy
| | - Domenico Tavella
- Department of Medicine, Division of Cardiology, University of Verona, Verona, Italy
- Interventional Cardiology Unit, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Concetta Mammone
- Department of Medicine, Division of Cardiology, University of Verona, Verona, Italy
- Interventional Cardiology Unit, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Mattia Lunardi
- Department of Medicine, Division of Cardiology, University of Verona, Verona, Italy
- Interventional Cardiology Unit, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Gabriele Pesarini
- Department of Medicine, Division of Cardiology, University of Verona, Verona, Italy
- Interventional Cardiology Unit, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Giovanni Benfari
- Department of Medicine, Division of Cardiology, University of Verona, Verona, Italy
| | - Flavio Luciano Ribichini
- Department of Medicine, Division of Cardiology, University of Verona, Verona, Italy
- Interventional Cardiology Unit, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
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Scarsini R, Kotronias RA, Della Mora F, Portolan L, Andreaggi S, Benenati S, Marin F, Sgreva S, Comuzzi A, Butturini C, Pesarini G, Tavella D, Channon KM, Garcia Garcia HM, Ribichini F, Banning AP, De Maria GL. Angiography-Derived Index of Microcirculatory Resistance to Define the Risk of Early Discharge in STEMI. Circ Cardiovasc Interv 2024; 17:e013556. [PMID: 38375667 DOI: 10.1161/circinterventions.123.013556] [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: 08/25/2023] [Accepted: 11/28/2023] [Indexed: 02/21/2024]
Abstract
BACKGROUND Patients with ST-segment-elevation myocardial infarction but no coronary microvascular injury are at low risk of early cardiovascular complications (ECC). We aim to assess whether nonhyperemic angiography-derived index of microcirculatory resistance (NH-IMRangio) could be a user-friendly tool to identify patients at low risk of ECC, potentially candidates for expedited care pathway and early hospital discharge. METHODS Retrospective analysis of 2 independent, international, prospective, observational cohorts included 568 patients with ST-segment-elevation myocardial infarction. NH-IMRangio was calculated based on standard coronary angiographic views with 3-dimensional-modeling and computational analysis of the coronary flow. RESULTS Overall, ECC (a composite of cardiovascular death, cardiogenic shock, acute heart failure, life-threatening arrhythmias, resuscitated cardiac arrest, left ventricular thrombus, post-ST-segment-elevation myocardial infarction mechanical complications, and rehospitalization for acute heart failure or acute myocardial infarction at 30 days follow-up), occurred in 54 (9.3%) patients. NH-IMRangio was significantly correlated with pressure/thermodilution-based index of microcirculatory resistance (r=0.607; P<0.0001) and demonstrated good accuracy in predicting ECC (area under the curve, 0.766 [95% CI, 0.706-0.827]; P<0.0001). Importantly, ECC occurred more frequently in patients with NH-IMRangio ≥40 units (18.1% versus 1.4%; P<0.0001). At multivariable analysis, NH-IMRangio provided incremental prognostic value to conventional clinical, angiographic, and echocardiographic features (adjusted-odds ratio, 14.861 [95% CI, 5.177-42.661]; P<0.0001). NH-IMRangio<40 units showed an excellent negative predictive value (98.6%) in ruling out ECC. Discharging patients with NH-IMRangio<40 units at 48 hours after admission would reduce the total in-hospital stay by 943 days (median 2 [1-4] days per patient). CONCLUSIONS NH-IMRangio is a valuable risk-stratification tool in patients with ST-segment-elevation myocardial infarction. NH-IMRangio guided strategies to early discharge may contribute to safely shorten hospital stay, optimizing resources utilization.
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Affiliation(s)
- Roberto Scarsini
- Division of Cardiology, Department of Medicine, University of Verona, Italy (R.S., F.D.M., L.P., S.A., S.S., A.C., C.B., G.P., D.T., F.R.)
| | - Rafail A Kotronias
- Oxford Heart Centre, Oxford University Hospitals NHS Trust, United Kingdom (R.A.K., S.B., F.M., K.M.C., A.P.B., G.L.D.M.)
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, United Kingdom (R.A.K., S.B., F.M., K.M.C., A.P.B., G.L.D.M.)
- National Institute for Health Research, Oxford Biomedical Research Centre, United Kingdom (R.A.K., S.B., F.M., K.M.C., A.P.B., G.L.D.M.)
| | - Francesco Della Mora
- Division of Cardiology, Department of Medicine, University of Verona, Italy (R.S., F.D.M., L.P., S.A., S.S., A.C., C.B., G.P., D.T., F.R.)
| | - Leonardo Portolan
- Division of Cardiology, Department of Medicine, University of Verona, Italy (R.S., F.D.M., L.P., S.A., S.S., A.C., C.B., G.P., D.T., F.R.)
| | - Stefano Andreaggi
- Division of Cardiology, Department of Medicine, University of Verona, Italy (R.S., F.D.M., L.P., S.A., S.S., A.C., C.B., G.P., D.T., F.R.)
| | - Stefano Benenati
- Oxford Heart Centre, Oxford University Hospitals NHS Trust, United Kingdom (R.A.K., S.B., F.M., K.M.C., A.P.B., G.L.D.M.)
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, United Kingdom (R.A.K., S.B., F.M., K.M.C., A.P.B., G.L.D.M.)
- National Institute for Health Research, Oxford Biomedical Research Centre, United Kingdom (R.A.K., S.B., F.M., K.M.C., A.P.B., G.L.D.M.)
| | - Federico Marin
- Oxford Heart Centre, Oxford University Hospitals NHS Trust, United Kingdom (R.A.K., S.B., F.M., K.M.C., A.P.B., G.L.D.M.)
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, United Kingdom (R.A.K., S.B., F.M., K.M.C., A.P.B., G.L.D.M.)
- National Institute for Health Research, Oxford Biomedical Research Centre, United Kingdom (R.A.K., S.B., F.M., K.M.C., A.P.B., G.L.D.M.)
| | - Sara Sgreva
- Division of Cardiology, Department of Medicine, University of Verona, Italy (R.S., F.D.M., L.P., S.A., S.S., A.C., C.B., G.P., D.T., F.R.)
| | - Alberto Comuzzi
- Division of Cardiology, Department of Medicine, University of Verona, Italy (R.S., F.D.M., L.P., S.A., S.S., A.C., C.B., G.P., D.T., F.R.)
| | - Caterina Butturini
- Division of Cardiology, Department of Medicine, University of Verona, Italy (R.S., F.D.M., L.P., S.A., S.S., A.C., C.B., G.P., D.T., F.R.)
| | - Gabriele Pesarini
- Division of Cardiology, Department of Medicine, University of Verona, Italy (R.S., F.D.M., L.P., S.A., S.S., A.C., C.B., G.P., D.T., F.R.)
| | - Domenico Tavella
- Division of Cardiology, Department of Medicine, University of Verona, Italy (R.S., F.D.M., L.P., S.A., S.S., A.C., C.B., G.P., D.T., F.R.)
| | - Keith M Channon
- Oxford Heart Centre, Oxford University Hospitals NHS Trust, United Kingdom (R.A.K., S.B., F.M., K.M.C., A.P.B., G.L.D.M.)
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, United Kingdom (R.A.K., S.B., F.M., K.M.C., A.P.B., G.L.D.M.)
- National Institute for Health Research, Oxford Biomedical Research Centre, United Kingdom (R.A.K., S.B., F.M., K.M.C., A.P.B., G.L.D.M.)
| | | | - Flavio Ribichini
- Division of Cardiology, Department of Medicine, University of Verona, Italy (R.S., F.D.M., L.P., S.A., S.S., A.C., C.B., G.P., D.T., F.R.)
| | - Adrian P Banning
- Oxford Heart Centre, Oxford University Hospitals NHS Trust, United Kingdom (R.A.K., S.B., F.M., K.M.C., A.P.B., G.L.D.M.)
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, United Kingdom (R.A.K., S.B., F.M., K.M.C., A.P.B., G.L.D.M.)
- National Institute for Health Research, Oxford Biomedical Research Centre, United Kingdom (R.A.K., S.B., F.M., K.M.C., A.P.B., G.L.D.M.)
| | - Giovanni Luigi De Maria
- Oxford Heart Centre, Oxford University Hospitals NHS Trust, United Kingdom (R.A.K., S.B., F.M., K.M.C., A.P.B., G.L.D.M.)
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, United Kingdom (R.A.K., S.B., F.M., K.M.C., A.P.B., G.L.D.M.)
- National Institute for Health Research, Oxford Biomedical Research Centre, United Kingdom (R.A.K., S.B., F.M., K.M.C., A.P.B., G.L.D.M.)
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9
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Saada M, Lavi S. Angiography-Derived Index of Microvascular Resistance: A New Frontier in the Management of Patients With Coronary Artery Disease. Can J Cardiol 2024; 40:444-446. [PMID: 38097172 DOI: 10.1016/j.cjca.2023.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Revised: 12/02/2023] [Accepted: 12/08/2023] [Indexed: 02/12/2024] Open
Affiliation(s)
- Majdi Saada
- London Health Sciences Centre, London, Ontario, Canada; Department of Medicine, Western University, London, Ontario, Canada
| | - Shahar Lavi
- London Health Sciences Centre, London, Ontario, Canada; Department of Medicine, Western University, London, Ontario, Canada.
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