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Peters B, Paul JF, Symons R, Franssen WMA, Nchimi A, Ghekiere O. Invasive fractional-flow-reserve prediction by coronary CT angiography using artificial intelligence vs. computational fluid dynamics software in intermediate-grade stenosis. THE INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING 2024; 40:1875-1880. [PMID: 38963591 DOI: 10.1007/s10554-024-03173-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 06/22/2024] [Indexed: 07/05/2024]
Abstract
Coronary computed angiography (CCTA) with non-invasive fractional flow reserve (FFR) calculates lesion-specific ischemia when compared with invasive FFR and can be considered for patients with stable chest pain and intermediate-grade stenoses according to recent guidelines. The objective of this study was to compare a new CCTA-based artificial-intelligence deep-learning model for FFR prediction (FFRAI) to computational fluid dynamics CT-derived FFR (FFRCT) in patients with intermediate-grade coronary stenoses with FFR as reference standard. The FFRAI model was trained with curved multiplanar-reconstruction CCTA images of 500 stenotic vessels in 413 patients, using FFR measurements as the ground truth. We included 37 patients with 39 intermediate-grade stenoses on CCTA and invasive coronary angiography, and with FFRCT and FFR measurements in this retrospective proof of concept study. FFRAI was compared with FFRCT regarding the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy for predicting FFR ≤ 0.80. Sensitivity, specificity, PPV, NPV, and diagnostic accuracy of FFRAI in predicting FFR ≤ 0.80 were 91% (10/11), 82% (23/28), 67% (10/15), 96% (23/24), and 85% (33/39), respectively. Corresponding values for FFRCT were 82% (9/11), 75% (21/28), 56% (9/16), 91% (21/23), and 77% (30/39), respectively. Diagnostic accuracy did not differ significantly between FFRAI and FFRCT (p = 0.12). FFRAI performed similarly to FFRCT for predicting intermediate-grade coronary stenoses with FFR ≤ 0.80. These findings suggest FFRAI as a potential non-invasive imaging tool for guiding therapeutic management in these stenoses.
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Affiliation(s)
- Benjamin Peters
- Faculty of Medicine and Life Sciences, Hasselt University, LCRC, Agoralaan, Diepenbeek, 3590, Belgium.
- Department of Radiology, Jessa Hospital, LCRC, Stadsomvaart 11, Hasselt, 3500, Belgium.
| | - Jean-François Paul
- Department of Radiology, Institut Mutualiste Montsouris, 42 Boulevard Jourdan, Paris, France
| | - Rolf Symons
- Department of Radiology, Imelda Hospital, Bonheiden, Belgium
| | - Wouter M A Franssen
- SMRC Sports Medical Research Center, BIOMED Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | - Alain Nchimi
- GIGA Cardiovascular Sciences, Liège University (ULg), Domaine Universitaire du Sart Tilman, rue de l'Hôpital, Liège, Belgium
- Department of Radiology, Centre Hospitalier Universitaire, Luxembourg, Luxembourg, Luxembourg
| | - Olivier Ghekiere
- Faculty of Medicine and Life Sciences, Hasselt University, LCRC, Agoralaan, Diepenbeek, 3590, Belgium
- Department of Radiology, Jessa Hospital, LCRC, Stadsomvaart 11, Hasselt, 3500, Belgium
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Mehta CR, Naeem A, Patel Y. Cardiac Computed Tomography Angiography in CAD Risk Stratification and Revascularization Planning. Diagnostics (Basel) 2023; 13:2902. [PMID: 37761268 PMCID: PMC10530183 DOI: 10.3390/diagnostics13182902] [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: 07/26/2023] [Revised: 08/25/2023] [Accepted: 09/05/2023] [Indexed: 09/29/2023] Open
Abstract
PURPOSE OF REVIEW Functional stress testing is frequently used to assess for coronary artery disease (CAD) in symptomatic, stable patients with low to intermediate pretest probability. However, patients with highly vulnerable plaque may have preserved luminal patency and, consequently, a falsely negative stress test. Cardiac computed tomography angiography (CCTA) has emerged at the forefront of primary prevention screening and has excellent agency in ruling out obstructive CAD with high negative predictive value while simultaneously characterizing nonobstructive plaque for high-risk features, which invariably alters risk-stratification and pre-procedural decision making. RECENT FINDINGS We review the literature detailing the utility of CCTA in its ability to risk-stratify patients with CAD based on calcium scoring as well as high-risk phenotypic features and to qualify the functional significance of stenotic lesions. SUMMARY Calcium scores ≥ 100 should prompt consideration of statin and aspirin therapy. Spotty calcifications < 3 mm, increased non-calcified plaque > 4 mm3 per mm of the vessel wall, low attenuation < 30 HU soft plaque and necrotic core with a rim of higher attenuation < 130 HU, and a positive remodeling index ratio > 1.1 all confer additive risk for acute plaque rupture when present. Elevations in the perivascular fat attenuation index > -70.1 HU are a strong predictor of all-cause mortality and can further the risk stratification of patients in the setting of a non-to-minimal plaque burden. Lastly, a CT-derived fractional flow reserve (FFRCT) < 0.75 or values from 0.76 to 0.80 in conjunction with additional risk factors is suggestive of flow-limiting disease that would benefit from invasive testing. The wealth of information available through CCTA can allow clinicians to risk-stratify patients at elevated risk for an acute ischemic event and engage in advanced revascularization planning.
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Affiliation(s)
- Chirag R. Mehta
- Department of Cardiology, The Warren Alpert Medical School of Brown University, Providence, RI 02903, USA (Y.P.)
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Ordiene R, Unikas R, Aldujeli A, Benetis R, Jakuska P, Ceponiene I, Jankauskas A, Plisiene J, Lenkutis T, Rudokaite G, Braukyliene R, Stonis M, Davies J, Punjabi PP. Instantaneous wave free ratio value impact on left internal mammary artery graft patency. Perfusion 2023; 38:1230-1239. [PMID: 35521921 PMCID: PMC10466988 DOI: 10.1177/02676591221099808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVES To assess whether instantaneous wave - free ratio (iFR) value is associated with left internal mammary artery (LIMA) graft failure at 12 months follow-up post coronary artery bypass graft (CABG). BACKGROUND Data suggests bypass to a non-significant left anterior descending artery (LAD) lesion due to visual over-estimation may lead to LIMA graft failure. Implementing iFR may result in better arterial graft patency. METHODS In iCABG (iFR guided CABG) study patients planned to undergo an isolated CABG procedure was prospectively enrolled and iFR was performed for LAD. Coronary computed tomography angiography was performed at 2 and 12 months follow-up. The primary endpoint of this study was to determine the rate of LIMA graft occlusion or hypoperfusion at 2 and 12-months follow-up. We considered a composite secondary endpoint of Major adverse cardiovascular and cerebrovascular event (MACCE) as a secondary outcome. RESULTS In total 69 patients were included with no differences regarding age, sex and risk factors. At 2 months, 50 of LIMAs with pre-CABG iFR median 0.855 (0.785 - 0.892) were patent. Hypoperfusion was found in 8 LIMAs (median iFR 0.88 (0.842 - 0.90)). While, 7 LIMAs (median iFR 0.91 (0.88 - 0.96)) were occluded (p = 0.04). At 12 months, when iFR of LAD was >0.85: just 12 (31.6% out of all patent LIMAS) grafts were patent and 24 (100.0% out of all hypoperfused/occluded) grafts were hypoperfused or occluded (p < 0.001). In terms of MACCE, no difference (p = 1.0) was found between all 3 groups divided according to iFR value. CONCLUSIONS Instantaneous wave - free ratio value above 0.85 in LAD is a powerful tool predicting LIMA graft failure at 1-year follow up period.
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Affiliation(s)
- Rasa Ordiene
- Department of Cardiology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Ramunas Unikas
- Department of Cardiology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Ali Aldujeli
- Department of Cardiology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Rimantas Benetis
- Department of Cardiac, Thoracic and Vascular Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Povilas Jakuska
- Department of Cardiac, Thoracic and Vascular Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Indre Ceponiene
- Department of Radiology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Antanas Jankauskas
- Department of Radiology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Jurgita Plisiene
- Department of Cardiology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Tadas Lenkutis
- Department of Cardiac, Thoracic and Vascular Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Gabriele Rudokaite
- Department of Cardiology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Rima Braukyliene
- Department of Cardiology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Mindaugas Stonis
- Department of Anaesthesiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Justin Davies
- Department of Cardiology, Imperial College London, Hammersmith Hospital, London, UK
| | - Prakash P Punjabi
- Division of Cardiothoracic Surgery, Imperial College London, Hammersmith Hospital, London, UK
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Yang G, Li L, Peng X, Tang G, Zheng N, Zhao Y, Li H, Zhang H, Sun F, Ai H. Accuracy and Reproducibility of Coronary Angiography-Derived Fractional Flow Reserve in the Assessment of Coronary Lesion Severity. Int J Gen Med 2023; 16:3805-3814. [PMID: 37662502 PMCID: PMC10473419 DOI: 10.2147/ijgm.s413991] [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: 03/30/2023] [Accepted: 08/01/2023] [Indexed: 09/05/2023] Open
Abstract
Purpose Coronary angiography-derived fractional flow reserve (caFFR) is a novel computational flow dynamics (CFD)-derived assessment of coronary vessel flow with good diagnostic performance. Herein, we performed a retrospective study to evaluate the reproducibility of caFFR findings between observers and investigate the diagnostic performance of caFFR for coronary stenosis defined as FFR ≤0.80, especially in the grey zone (0.75≤caFFR ≤0.80). Patients and Methods A total of 150 patients (167 coronary vessels) underwent caFFR (with FlashAngio used for calculation of flow variables) and subsequent invasive fractional flow reserve (FFR) measurements. Outcomes, including reproducibility, were compared for vessels in and outside the grey zone. Results The correlation of caFFR findings was good between the two laboratories (r = 0.723, p<0.001). The AUC of ROC were both high for caFFR-CoreLab1 and caFFR-CoreLab2 (0.975 and 0.883). The diagnostic accuracy, sensitivity, specificity, and negative and positive predictive values were not significantly different between the two laboratories (p>0.05). caFFR had a strong correlation with measures to FFR (r=0.911, p<0.001). There was no systematic difference between caFFR and FFR on Bland-Altman analysis in and outside the grey zone. There was no difference in diagnostic accuracy between the grey and non-grey zones in the prediction of FFR ≤0.80 (p=0.09). Conclusion The inter-observer reproducibility for caFFR was high, and the diagnostic accuracy of caFFR was good compared to that of FFR.
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Affiliation(s)
- Guojian Yang
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, 100730, People’s Republic of China
| | - Le Li
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, 100730, People’s Republic of China
| | - Xi Peng
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, 100730, People’s Republic of China
| | - Guodong Tang
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, 100730, People’s Republic of China
| | - Naixin Zheng
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, 100730, People’s Republic of China
| | - Ying Zhao
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, 100730, People’s Republic of China
| | - Hui Li
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, 100730, People’s Republic of China
| | - Huiping Zhang
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, 100730, People’s Republic of China
| | - Fucheng Sun
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, 100730, People’s Republic of China
| | - Hu Ai
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, 100730, People’s Republic of China
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Tanade C, Chen SJ, Leopold JA, Randles A. Analysis identifying minimal governing parameters for clinically accurate in silico fractional flow reserve. FRONTIERS IN MEDICAL TECHNOLOGY 2022; 4:1034801. [PMID: 36561284 PMCID: PMC9764219 DOI: 10.3389/fmedt.2022.1034801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 11/10/2022] [Indexed: 12/12/2022] Open
Abstract
Background Personalized hemodynamic models can accurately compute fractional flow reserve (FFR) from coronary angiograms and clinical measurements (FFR baseline ), but obtaining patient-specific data could be challenging and sometimes not feasible. Understanding which measurements need to be patient-tuned vs. patient-generalized would inform models with minimal inputs that could expedite data collection and simulation pipelines. Aims To determine the minimum set of patient-specific inputs to compute FFR using invasive measurement of FFR (FFR invasive ) as gold standard. Materials and Methods Personalized coronary geometries ( N = 50 ) were derived from patient coronary angiograms. A computational fluid dynamics framework, FFR baseline , was parameterized with patient-specific inputs: coronary geometry, stenosis geometry, mean arterial pressure, cardiac output, heart rate, hematocrit, and distal pressure location. FFR baseline was validated against FFR invasive and used as the baseline to elucidate the impact of uncertainty on personalized inputs through global uncertainty analysis. FFR streamlined was created by only incorporating the most sensitive inputs and FFR semi-streamlined additionally included patient-specific distal location. Results FFR baseline was validated against FFR invasive via correlation ( r = 0.714 , p < 0.001 ), agreement (mean difference: 0.01 ± 0.09 ), and diagnostic performance (sensitivity: 89.5%, specificity: 93.6%, PPV: 89.5%, NPV: 93.6%, AUC: 0.95). FFR semi-streamlined provided identical diagnostic performance with FFR baseline . Compared to FFR baseline vs. FFR invasive , FFR streamlined vs. FFR invasive had decreased correlation ( r = 0.64 , p < 0.001 ), improved agreement (mean difference: 0.01 ± 0.08 ), and comparable diagnostic performance (sensitivity: 79.0%, specificity: 90.3%, PPV: 83.3%, NPV: 87.5%, AUC: 0.90). Conclusion Streamlined models could match the diagnostic performance of the baseline with a full gamut of patient-specific measurements. Capturing coronary hemodynamics depended most on accurate geometry reconstruction and cardiac output measurement.
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Affiliation(s)
- Cyrus Tanade
- Department of Biomedical Engineering, Duke University, Durham, NC, United States
| | - S. James Chen
- Department of Medicine, University of Colorado, Aurora, CO, United States
| | - Jane A. Leopold
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA, United States
| | - Amanda Randles
- Department of Biomedical Engineering, Duke University, Durham, NC, United States,Correspondence: Amanda Randles
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Lee CH, Hwang J, Kim IC, Cho YK, Park HS, Yoon HJ, Kim H, Han S, Hur SH, Kim KB, Kim JY, Chung JW, Lee JM, Doh JH, Shin ES, Koo BK, Nam CW. Effect of Atorvastatin on Serial Changes in Coronary Physiology and Plaque Parameters. JACC. ASIA 2022; 2:691-703. [PMID: 36444331 PMCID: PMC9700034 DOI: 10.1016/j.jacasi.2022.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 07/13/2022] [Accepted: 07/16/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND The effects of statin on coronary physiology have not been well evaluated. OBJECTIVES The authors performed this prospective study to investigate changes in coronary flow indexes and plaque parameters, and their associations with atorvastatin therapy in patients with coronary artery disease (CAD). METHODS Ninety-five patients with intermediate CAD who received atorvastatin therapy underwent comprehensive physiological assessments with fractional flow reserve (FFR), coronary flow reserve, index of microcirculatory resistance, and intravascular ultrasound at the index procedure, and underwent the same evaluations at 12-month follow-up. Optimal low-density lipoprotein cholesterol (LDL-C) was defined as LDL-C <70 mg/dL or ≥50% reduction from the baseline. The primary endpoint was a change in the FFR. RESULTS Baseline FFR, minimal lumen area, and percent atheroma volume (PAV) were 0.88 ± 0.05, 3.87 ± 1.28, 55.92 ± 7.30, respectively. During 12 months, the percent change in LDL-C was -33.2%, whereas FFR was unchanged (0.87 ± 0.06 at 12 months; P = 0.694). Vessel area, lumen area, and PAV were significantly decreased (all P values <0.05). The achieved LDL-C level and the change of PAV showed significant inverse correlations with the change in FFR. In patients with optimally modified LDL-C, the FFR had increased (0.87 ± 0.06 vs 0.89 ± 0.07; P = 0.014) and the PAV decreased (56.81 ± 6.44% vs 55.18 ± 8.19%; P = 0.031), whereas in all other patients, the FFR had decreased (0.88 ± 0.05 vs 0.86 ± 0.06; P = 0.025) and the PAV remained unchanged. CONCLUSIONS In patients with CAD, atorvastatin did not change FFR despite a decrease in the PAV. However, in patients who achieved the optimal LDL-C target level with atorvastatin, the FFR had significantly increased with decrease of the PAV. (Effect of Atorvastatin on Fractional Flow Reserve in Coronary Artery Disease [FORTE]; NCT01946815).
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Key Words
- CAD, coronary artery disease
- CFR, coronary flow reserve
- FFR, fractional flow reserve
- IMR, index of microcirculatory resistance
- IVUS, intravascular ultrasound
- LDL-C, low-density lipoprotein cholesterol
- LLT, lipid-lowering therapy
- MLA, minimal lumen area
- OR, odds ratio
- PAV, percent atheroma volume
- Pa, proximal aortic pressure
- Pd, distal coronary pressure
- TAV, total atheroma volume
- Tmn, mean transit time
- VH, virtual histology
- fractional flow reserve
- intermediate coronary artery disease
- statin therapy
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Affiliation(s)
- Cheol Hyun Lee
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Daegu, Republic of Korea
| | - Jongmin Hwang
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Daegu, Republic of Korea
| | - In-Cheol Kim
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Daegu, Republic of Korea
| | - Yun-Kyeong Cho
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Daegu, Republic of Korea
| | - Hyoung-Seob Park
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Daegu, Republic of Korea
| | - Hyuck-Jun Yoon
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Daegu, Republic of Korea
| | - Hyungseop Kim
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Daegu, Republic of Korea
| | - Seongwook Han
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Daegu, Republic of Korea
| | - Seung-Ho Hur
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Daegu, Republic of Korea
| | - Kwon-Bae Kim
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Daegu, Republic of Korea
| | - Jin Young Kim
- Department of Radiology, Keimyung University Dongsan Hospital, Daegu, Republic of Korea
| | - Jin-Wook Chung
- Division of Cardiology, Department of Internal Medicine, Keimyung University Daegu Dongsan Hospital, Daegu, Republic of Korea
| | - Joo Myung Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Joon-Hyung Doh
- Department of Medicine, Inje University Ilsan Paik Hospital, Goyang, Republic of Korea
| | - Eun-Seok Shin
- Department of Internal Medicine, Ulsan University Hospital, Ulsan, Republic of Korea
| | - Bon-Kwon Koo
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Chang-Wook Nam
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Daegu, Republic of Korea
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Mortensen MB, Sand NP, Busk M, Jensen JM, Grove EL, Dey D, Iraqi N, Updegrove A, Fonte T, Mathiassen ON, Hosbond S, Bøtker HE, Leipsic J, Narula J, Nørgaard BL. Influence of intensive lipid-lowering on CT derived fractional flow reserve in patients with stable chest pain: Rationale and design of the FLOWPROMOTE study. Clin Cardiol 2022; 45:986-994. [PMID: 36056636 PMCID: PMC9574753 DOI: 10.1002/clc.23895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 07/20/2022] [Accepted: 08/01/2022] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Coronary CT angiography (CTA) derived fractional flow reserve (FFRCT ) shows high diagnostic performance when compared to invasively measured FFR. Presence and extent of low attenuation plaque density have been shown to be associated with abnormal physiology by measured FFR. Moreover, it is well established that statin therapy reduces the rate of plaque progression and results in morphology alterations underlying atherosclerosis. However, the interplay between lipid lowering treatment, plaque regression, and the coronary physiology has not previously been investigated. AIM To test whether lipid lowering therapy is associated with significant improvement in FFRCT , and whether there is a dose-response relationship between lipid lowering intensity, plaque regression, and coronary flow recovery. METHODS Investigator driven, prospective, multicenter, randomized study of patients with stable angina, coronary stenosis ≥50% determined by clinically indicated first-line CTA, and FFRCT ≤ 0.80 in whom coronary revascularization was deferred. Patients are randomized to standard (atorvastatin 40 mg daily) or intensive (rosuvastatin 40 mg + ezetimibe 10 mg daily) lipid lowering therapy for 18 months. Coronary CTA scans with blinded coronary plaque and FFRCT analyses will be repeated after 9 and 18 months. The primary endpoint is the 18-month difference in FFRCT using (1) the FFRCT value 2 cm distal to stenosis and (2) the lowest distal value in the vessel of interest. A total of 104 patients will be included in the study. CONCLUSION The results of this study will provide novel insights into the interplay between lipid lowering, and the pathophysiology in coronary artery disease.
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Affiliation(s)
| | - Niels-Peter Sand
- Department of Cardiology, Southwestern Hospital, Esbjerg, Denmark
| | - Martin Busk
- Department of Cardiology, Lillebaelt Hospital, Vejle-Kolding, Denmark
| | - Jesper M Jensen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Erik L Grove
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark.,Department Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Damini Dey
- Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Nadia Iraqi
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Tim Fonte
- HeartFlow, Redwood City, California, USA
| | - Ole N Mathiassen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Susanne Hosbond
- Department of Cardiology, Lillebaelt Hospital, Vejle-Kolding, Denmark
| | - Hans E Bøtker
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark.,Department Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Jonathon Leipsic
- Division of Cardiology and Radiology, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - Jagat Narula
- Icahn School of Medicine, Mount Sinai, New York, USA
| | - Bjarne L Nørgaard
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark.,Department Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
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Altstidl JM, Achenbach S, Marwan M, Tröbs M, Schacher N, Ferstl P, Gerlach A, Schlundt C, Gaede L. Comparison of adenosine-independent pressure indices to fractional flow reserve in stent-jailed bifurcation side branches. Catheter Cardiovasc Interv 2022; 100:369-377. [PMID: 35723275 DOI: 10.1002/ccd.30298] [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: 06/21/2021] [Revised: 05/14/2022] [Accepted: 05/29/2022] [Indexed: 01/10/2023]
Abstract
OBJECTIVES AND BACKGROUND This study aims to evaluate whether the high correlation and classification agreement of the instantaneous wave-free ratio (iFR) and the resting distal coronary to aortic pressure ratio (Pd /Pa ) with the fractional flow reserve (FFR) can be confirmed in stent-jailed side branches (J-SB). METHODS Consecutive patients (n = 49) undergoing provisional stenting were prospectively enrolled and a physiological assessment of the J-SB (n = 51) was performed. FFR, iFR, and Pd /Pa were measured and the hemodynamic relevance was determined using cutoff values of ≤0.80, ≤0.89, and ≤0.92, respectively. RESULTS Both iFR (r = 0.75) and Pd /Pa (r = 0.77) correlated closely with FFR. Classification agreement with FFR was 78% for iFR (81% sensitivity, 77% specificity) and 75% for Pd /Pa (63% sensitivity and 80% specificity). However, angiographic diameter stenosis and pressure indices correlated poorly. For a threshold of ≥70% stenosis, agreement concerning hemodynamic relevance was found in 59% for FFR, 69% for iFR, and 61% for Pd /Pa . CONCLUSION As reported for other lesion types, FFR and the adenosine-independent pressure indices iFR and Pd /Pa show close correlation and a high classification agreement of approximately 75%-80% in J-SB. Therefore, iFR can be regarded as a recommendable alternative to FFR for the guidance of provisional stenting in bifurcation lesions.
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Affiliation(s)
- Johannes Michael Altstidl
- Department of Medicine 2 - Cardiology and Angiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Stephan Achenbach
- Department of Medicine 2 - Cardiology and Angiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Mohamed Marwan
- Department of Medicine 2 - Cardiology and Angiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Monique Tröbs
- Department of Medicine 2 - Cardiology and Angiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Nora Schacher
- Department of Medicine 2 - Cardiology and Angiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Paul Ferstl
- Department of Medicine 2 - Cardiology and Angiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Andreas Gerlach
- Department of Medicine 2 - Cardiology and Angiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Christian Schlundt
- Department of Medicine 2 - Cardiology and Angiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Luise Gaede
- Department of Medicine 2 - Cardiology and Angiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
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Kim J, Shin D, Lee JM, Lee SH, Hong D, Choi KH, Hwang D, Boerhout CKM, de Waard GA, Jung JH, Mejia-Renteria H, Hoshino M, Echavarria-Pinto M, Meuwissen M, Matsuo H, Madera-Cambero M, Eftekhari A, Effat MA, Murai T, Marques K, Doh JH, Christiansen EH, Banerjee R, Kim HK, Nam CW, Niccoli G, Nakayama M, Tanaka N, Shin ES, Chamuleau SAJ, van Royen N, Knaapen P, Koo BK, Kakuta T, Escaned J, Piek JJ, van de Hoef TP. Differential Prognostic Value of Revascularization for Coronary Stenosis With Intermediate FFR by Coronary Flow Reserve. JACC Cardiovasc Interv 2022; 15:1033-1043. [PMID: 35490124 DOI: 10.1016/j.jcin.2022.01.297] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 01/21/2022] [Accepted: 01/25/2022] [Indexed: 12/27/2022]
Abstract
OBJECTIVES The authors sought to evaluate comparative prognosis between deferred versus performed percutaneous coronary intervention (PCI) according to coronary flow reserve (CFR) values of patients with intermediate fractional flow reserve (FFR). BACKGROUND For coronary stenosis with intermediate FFR, the prognostic value of PCI remains controversial. The prognostic impact of PCI may be different according to CFR in patients with intermediate FFR. METHODS From the ILIAS Registry (Inclusive Invasive Physiological Assessment in Angina Syndromes Registry, N = 2,322), 400 patients (412 vessels) with intermediate FFR (0.75-0.80) were selected. Patients were stratified into preserved CFR (>2.0, n = 253) and depressed CFR (≤2.0, n = 147) cohorts. Per-vessel clinical outcomes during 5 years of follow-up were compared between deferred versus performed PCI groups in both cohorts. The primary outcome was target vessel failure (TVF), a composite of cardiac death, target vessel myocardial infarction, or target vessel revascularization. RESULTS Among the study population, PCI was deferred for 210 patients (219 vessels, 53.2%) (deferred group) and performed for 190 patients (193 vessels, 46.8%) (performed group). The risk of TVF was comparable between the deferred and performed groups (12.8% vs 14.2%; adjusted HR: 1.403; 95% CI: 0.584-3.369; P = 0.448). When stratified by CFR, PCI was performed in 39.1% (100/261 vessels) of the preserved CFR cohort and 61.9% (93/151 vessels) of the depressed CFR cohort. Within the preserved CFR cohort, the risk of TVF did not differ significantly between the deferred and performed groups (11.0% vs 13.9%; adjusted HR: 0.770; 95% CI: 0.262-2.266; P = 0.635). However, in the depressed CFR cohort, the deferred group had a significantly higher risk of TVF than the performed group (17.2% vs 14.2%; adjusted HR: 4.932; 95% CI: 1.312-18.53; P = 0.018). A significant interaction was observed between CFR and the treatment decision (interaction P = 0.049). Results were consistent after inverse probability weighting adjustment. CONCLUSIONS In patients with intermediate FFR of 0.75 to 0.80, the prognostic value of PCI differed according to CFR, with a significant interaction. PCI was associated with a lower risk of TVF compared with the deferral strategy when CFR was depressed (≤2.0), but there was no difference when CFR was preserved (>2.0). CFR could be used as an additional risk stratification tool to determine treatment strategies in patients with intermediate FFR. (Inclusive Invasive Physiological Assessment in Angina Syndromes Registry [ILIAS Registry]; NCT04485234).
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Affiliation(s)
- Juwon Kim
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Doosup Shin
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Joo Myung Lee
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
| | - Seung Hun Lee
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - David Hong
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ki Hong Choi
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Doyeon Hwang
- Seoul National University Hospital, Department of Internal Medicine, Cardiovascular Center, Seoul, Korea
| | - Coen K M Boerhout
- Department of Cardiology, Amsterdam University Medical Center, Academic Medical Center, Amsterdam, the Netherlands
| | - Guus A de Waard
- Department of Cardiology, Amsterdam University Medical Center, VU University Medical Center, Amsterdam, the Netherlands
| | - Ji-Hyun Jung
- Sejong General Hospital, Sejong Heart Institute, Bucheon, Korea
| | - Hernan Mejia-Renteria
- Hospital Clínico San Carlos, Instituto de Investigación Sanitaria Hospital Clínico San Carlos, Universidad Complutense de Madrid, Madrid, Spain
| | - Masahiro Hoshino
- Department of Cardiology, Tsuchiura Kyodo General Hospital, Tsuchiura City, Japan
| | - Mauro Echavarria-Pinto
- Hospital General Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estad Querétaro, Facultad de Medicina, Universidad Autónoma de Querétaro, Querétaro, Mexico
| | | | - Hitoshi Matsuo
- Department of Cardiovascular Medicine, Gifu Heart Center, Gifu, Japan
| | | | - Ashkan Eftekhari
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Mohamed A Effat
- Division of Cardiovascular Health and Disease, University of Cincinnati, Cincinnati, Ohio, USA
| | - Tadashi Murai
- Department of Cardiology, Tsuchiura Kyodo General Hospital, Tsuchiura City, Japan
| | - Koen Marques
- Department of Cardiology, Amsterdam University Medical Center, VU University Medical Center, Amsterdam, the Netherlands
| | - Joon-Hyung Doh
- Department of Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | | | - Rupak Banerjee
- Department of Mechanical and Materials Engineering, University of Cincinnati, Veterans Affairs Medical Center, Cincinnati, Ohio, USA
| | - Hyun Kuk Kim
- Department of Internal Medicine and Cardiovascular Center, Chosun University Hospital, University of Chosun College of Medicine, Gwangju, Korea
| | - Chang-Wook Nam
- Department of Medicine, Keimyung University Dongsan Medical Center, Daegu, Korea
| | | | - Masafumi Nakayama
- Department of Cardiovascular Medicine, Gifu Heart Center, Gifu, Japan; Toda Central General Hospital, Cardiovascular Center, Toda, Japan
| | - Nobuhiro Tanaka
- Department of Cardiology, Tokyo Medical University Hachioji Medical Center, Tokyo, Japan
| | - Eun-Seok Shin
- Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Steven A J Chamuleau
- Department of Cardiology, Amsterdam University Medical Center, Academic Medical Center, Amsterdam, the Netherlands; Department of Cardiology, Amsterdam University Medical Center, VU University Medical Center, Amsterdam, the Netherlands
| | - Niels van Royen
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Paul Knaapen
- Department of Cardiology, Amsterdam University Medical Center, VU University Medical Center, Amsterdam, the Netherlands
| | - Bon Kwon Koo
- Seoul National University Hospital, Department of Internal Medicine, Cardiovascular Center, Seoul, Korea
| | - Tsunekazu Kakuta
- Department of Cardiology, Tsuchiura Kyodo General Hospital, Tsuchiura City, Japan
| | - Javier Escaned
- Hospital Clínico San Carlos, Instituto de Investigación Sanitaria Hospital Clínico San Carlos, Universidad Complutense de Madrid, Madrid, Spain
| | - Jan J Piek
- Department of Cardiology, Amsterdam University Medical Center, Academic Medical Center, Amsterdam, the Netherlands
| | - Tim P van de Hoef
- Department of Cardiology, Amsterdam University Medical Center, Academic Medical Center, Amsterdam, the Netherlands; Department of Cardiology, Amsterdam University Medical Center, VU University Medical Center, Amsterdam, the Netherlands; Department of Cardiology, NoordWest Ziekenhuisgroep, the Netherlands
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10
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Rajiah P, Cummings KW, Williamson E, Young PM. CT Fractional Flow Reserve: A Practical Guide to Application, Interpretation, and Problem Solving. Radiographics 2022; 42:340-358. [PMID: 35119968 DOI: 10.1148/rg.210097] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
CT fractional flow reserve (FFRCT) is a physiologic simulation technique that models coronary flow from routine coronary CT angiography (CTA). To evaluate lesion-specific ischemia, FFRCT is measured 2 cm distal to a stenotic lesion. FFRCT greater than 0.8 is normal, 0.76-0.8 is borderline, and 0.75 or less is abnormal. FFRCT should always be interpreted in correlation with clinical and anatomic coronary CTA findings. FFRCT increases the specificity of coronary CTA in the evaluation of coronary artery disease, decreases the prevalence of nonobstructive disease in invasive coronary angiography (ICA), and helps with revascularization decisions and planning. Patients with intermediate-risk coronary anatomy at CTA and abnormal FFRCT can undergo ICA and revascularization, whereas those with normal FFRCT can be safely deferred from ICA. In borderline FFRCT values, management is decided in the context of the clinical scenario, but many cases could be safely managed with medical treatment. There are some limitations and pitfalls of FFRCT. Abnormal FFRCT values can be seen in mild stenosis, and normal FFRCTvalues can be seen in severe stenosis. Gradually decreasing or abnormal low FFRCT values at the distal vessel without a proximal focal lesion could be due to diffuse atherosclerosis. Coronary stents, bypass grafts, coronary anomalies, coronary dissection, transcatheter aortic valve replacement, unstable angina, and acute or recent myocardial infarction are situations in which FFRCT has not been validated and should not be used at this time. The authors provide a practical guide to the applications and interpretation of FFRCT, focusing on common pitfalls and challenges. Online supplemental material is available for this article. ©RSNA, 2022.
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Affiliation(s)
- Prabhakar Rajiah
- From the Department of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN 55905 (P.R., E.W., P.M.Y.); and Department of Radiology, Mayo Clinic, Phoenix, Ariz (K.W.C.)
| | - Kristopher W Cummings
- From the Department of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN 55905 (P.R., E.W., P.M.Y.); and Department of Radiology, Mayo Clinic, Phoenix, Ariz (K.W.C.)
| | - Eric Williamson
- From the Department of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN 55905 (P.R., E.W., P.M.Y.); and Department of Radiology, Mayo Clinic, Phoenix, Ariz (K.W.C.)
| | - Phillip M Young
- From the Department of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN 55905 (P.R., E.W., P.M.Y.); and Department of Radiology, Mayo Clinic, Phoenix, Ariz (K.W.C.)
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11
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N Dahl J, Nielsen MB, Birn H, Rasmussen LD, Ivarsen P, Svensson M, Bangalore S, Bøttcher M, Winther S. Prognostic value of computed tomography derived fractional flow reserve for predicting cardiac events and mortality in kidney transplant candidates. J Cardiovasc Comput Tomogr 2022; 16:442-451. [DOI: 10.1016/j.jcct.2022.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 02/16/2022] [Accepted: 03/08/2022] [Indexed: 12/15/2022]
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12
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Ghobrial M, Haley HA, Gosling R, Rammohan V, Lawford PV, Hose DR, Gunn JP, Morris PD. The new role of diagnostic angiography in coronary physiological assessment. Heart 2021; 107:783-789. [PMID: 33419878 PMCID: PMC8077221 DOI: 10.1136/heartjnl-2020-318289] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 12/05/2020] [Accepted: 12/08/2020] [Indexed: 11/28/2022] Open
Abstract
The role of 'stand-alone' coronary angiography (CAG) in the management of patients with chronic coronary syndromes is the subject of debate, with arguments for its replacement with CT angiography on the one hand and its confinement to the interventional cardiac catheter laboratory on the other. Nevertheless, it remains the standard of care in most centres. Recently, computational methods have been developed in which the laws of fluid dynamics can be applied to angiographic images to yield 'virtual' (computed) measures of blood flow, such as fractional flow reserve. Together with the CAG itself, this technology can provide an 'all-in-one' anatomical and functional investigation, which is particularly useful in the case of borderline lesions. It can add to the diagnostic value of CAG by providing increased precision and reduce the need for further non-invasive and functional tests of ischaemia, at minimal cost. In this paper, we place this technology in context, with emphasis on its potential to become established in the diagnostic workup of patients with suspected coronary artery disease, particularly in the non-interventional setting. We discuss the derivation and reliability of angiographically derived fractional flow reserve (CAG-FFR) as well as its limitations and how CAG-FFR could be integrated within existing national guidance. The assessment of coronary physiology may no longer be the preserve of the interventional cardiologist.
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Affiliation(s)
- Mina Ghobrial
- Mathematical Modellling in Medicine, Department of Infection Immunity and Cardiovascular Disease, The Medical School, University of Sheffield, Sheffield, UK
| | - Hazel Arfah Haley
- Mathematical Modellling in Medicine, Department of Infection Immunity and Cardiovascular Disease, The Medical School, University of Sheffield, Sheffield, UK
| | - Rebecca Gosling
- Mathematical Modellling in Medicine, Department of Infection Immunity and Cardiovascular Disease, The Medical School, University of Sheffield, Sheffield, UK
- Department of Cardiology, Sheffield Teaching Hospitals, Sheffield, UK
| | - Vignesh Rammohan
- Mathematical Modellling in Medicine, Department of Infection Immunity and Cardiovascular Disease, The Medical School, University of Sheffield, Sheffield, UK
- Insigneo, In Silico Medicine, University of Sheffield, Sheffield, UK
| | - Patricia V Lawford
- Mathematical Modellling in Medicine, Department of Infection Immunity and Cardiovascular Disease, The Medical School, University of Sheffield, Sheffield, UK
- Insigneo, In Silico Medicine, University of Sheffield, Sheffield, UK
| | - D Rod Hose
- Mathematical Modellling in Medicine, Department of Infection Immunity and Cardiovascular Disease, The Medical School, University of Sheffield, Sheffield, UK
- Insigneo, In Silico Medicine, University of Sheffield, Sheffield, UK
| | - Julian P Gunn
- Mathematical Modellling in Medicine, Department of Infection Immunity and Cardiovascular Disease, The Medical School, University of Sheffield, Sheffield, UK
- Department of Cardiology, Sheffield Teaching Hospitals, Sheffield, UK
- Insigneo, In Silico Medicine, University of Sheffield, Sheffield, UK
| | - Paul D Morris
- Mathematical Modellling in Medicine, Department of Infection Immunity and Cardiovascular Disease, The Medical School, University of Sheffield, Sheffield, UK
- Department of Cardiology, Sheffield Teaching Hospitals, Sheffield, UK
- Insigneo, In Silico Medicine, University of Sheffield, Sheffield, UK
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13
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Shin D, Lee JM, Lee SH, Hwang D, Choi KH, Kim HK, Doh JH, Nam CW, Shin ES, Hoshino M, Murai T, Yonetsu T, Mejía-Rentería H, Kakuta T, Escaned J, Koo BK. Non-randomized comparison between revascularization and deferral for intermediate coronary stenosis with abnormal fractional flow reserve and preserved coronary flow reserve. Sci Rep 2021; 11:9126. [PMID: 33911143 PMCID: PMC8080642 DOI: 10.1038/s41598-021-88732-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 04/16/2021] [Indexed: 01/03/2023] Open
Abstract
Limited data are available regarding comparative prognosis after percutaneous coronary intervention (PCI) versus deferral of revascularization in patients with intermediate stenosis with abnormal fractional flow reserve (FFR) but preserved coronary flow reserve (CFR). From the International Collaboration of Comprehensive Physiologic Assessment Registry (NCT03690713), a total of 330 patients (338 vessels) who had coronary stenosis with FFR ≤ 0.80 but CFR > 2.0 were selected for the current analysis. Patient-level clinical outcome was assessed by major adverse cardiac events (MACE) at 5 years, a composite of all-cause death, target-vessel myocardial infarction (MI), or target-vessel revascularization. Among the study population, 231 patients (233 vessels) underwent PCI and 99 patients (105 vessels) were deferred. During 5 years of follow-up, cumulative incidence of MACE was 13.0% (31 patients) without significant difference between PCI and deferred groups (12.7% vs. 14.0%, adjusted HR 1.301, 95% CI 0.611-2.769, P = 0.495). Multiple sensitivity analyses by propensity score matching and inverse probability weighting also showed no significant difference in patient-level MACE and vessel-specific MI or revascularization. In this hypothesis-generating study, there was no significant difference in clinical outcomes between PCI and deferred groups among patients with intermediate stenosis with FFR ≤ 0.80 but CFR > 2.0. Further study is needed to confirm this finding.Clinical Trial Registration: International Collaboration of Comprehensive Physiologic Assessment Registry (NCT03690713; registration date: 10/01/2018).
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Affiliation(s)
- Doosup Shin
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Joo Myung Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Korea.
| | - Seung Hun Lee
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Doyeon Hwang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, 101 Daehang-ro, Chongno-gu, Seoul, 110-744, Korea
| | - Ki Hong Choi
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Korea
| | - Hyun Kuk Kim
- Department of Internal Medicine and Cardiovascular Center, Chosun University Hospital, University of Chosun College of Medicine, Gwangju, Korea
| | - Joon-Hyung Doh
- Department of Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Chang-Wook Nam
- Department of Medicine, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Eun-Seok Shin
- Division of Cardiology, Ulsan Medical Center, Ulsan, Korea
| | - Masahiro Hoshino
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Tadashi Murai
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Taishi Yonetsu
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | | | - Tsunekazu Kakuta
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Javier Escaned
- Cardiovascular Institute, Hospital Clinico San Carlos, Madrid, Spain
- Centro Nacional de Investigaciónes Cardiovasculares Carlos III (CNIC), Madrid, Spain
| | - Bon-Kwon Koo
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, 101 Daehang-ro, Chongno-gu, Seoul, 110-744, Korea.
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14
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Westra J, Eftekhari A, Tu S, Campo G, Escaned J, Winther S, Matsuo H, Qu X, Koltowski L, Chang Y, Liu T, Yang J, Andersen BK, Wijns W, Böttcher M, Christiansen EH, Xu B, Holm NR. Resting distal to aortic pressure ratio and fractional flow reserve discordance affects the diagnostic performance of quantitative flow ratio: Results from an individual patient data meta-analysis. Catheter Cardiovasc Interv 2021; 97:825-832. [PMID: 32478462 DOI: 10.1002/ccd.28976] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 04/06/2020] [Accepted: 05/04/2020] [Indexed: 01/10/2023]
Abstract
OBJECTIVE To evaluate the diagnostic performance of quantitative flow ratio (QFR) related to fractional flow reserve (FFR) and resting distal-to-aortic pressure ratio (resting Pd/Pa) concordance. BACKGROUND QFR is a method for computation of FFR based on standard coronary angiography. It is unclear how QFR is performed in patients with discordance between FFR and resting pressure ratios (distal-to-aortic pressure ratio [Pd/Pa]). MATERIALS AND METHODS The main comparison was the diagnostic performance of QFR with FFR as reference stratified by correspondence between FFR and resting Pd/Pa. Secondary outcome measures included distribution of clinical or procedural characteristics stratified by FFR and resting Pd/Pa correspondence. RESULTS Four prospective studies matched the inclusion criteria. Analysis was performed on patient level data reaching a total of 759 patients and 887 vessels with paired FFR, QFR, and resting Pd/Pa. Median FFR was 0.85 (IQR: 0.77-0.90). Diagnostic accuracy of QFR with FFR as reference was higher if FFR corresponded to resting Pd/Pa: accuracy 90% (95% CI: 88-92) versus 72% (95% CI: 64-80), p < .001, and sAUC 0.95 (95% CI: 0.92-0.96) versus 0.73 (95% CI: 0.69-0.77), p < .001. Resting Pd/Pa and FFR discordance were related to age, sex, hypertension, and lesion severity. CONCLUSION Diagnostic performance of QFR with FFR as reference is reduced for lesions with discordant FFR (≤0.80) and resting Pd/Pa (≤0.92) measurements.
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Affiliation(s)
- Jelmer Westra
- Department of Cardiology, Aarhus University Hospital, Skejby, Denmark
| | - Ashkan Eftekhari
- Department of Cardiology, Aarhus University Hospital, Skejby, Denmark
| | - Shengxian Tu
- School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Gianluca Campo
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Cona, Italy.,Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
| | - Javier Escaned
- Department of Cardiology, Hospital Clinico San Carlos, Madrid, Spain
| | - Simon Winther
- Department of Cardiology, Aarhus University Hospital, Skejby, Denmark
| | - Hitoshi Matsuo
- Department of Cardiovascular Medicine, Gifu Heart Center, Gifu City, Japan
| | - Xinkai Qu
- Huadong Hospital, Fudan University, Shanghai, China
| | - Lukasz Koltowski
- 1st Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Yunxiao Chang
- School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Tommy Liu
- Department of Cardiology, Hagaziesskenhuis, The Hague, The Netherlands
| | - Junqing Yang
- Department of Cardiology, Guangdong General Hospital, Guangzhou, China
| | | | - William Wijns
- The Lambe Institute for Translational Medicine and Curam, National University of Ireland Galway, Galway, Ireland
| | - Morten Böttcher
- Department of Cardiology, Hospital Unit West Jutland, Herning, Denmark
| | | | - Bo Xu
- National Clinical Research Center for Cardiovascular Diseases, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing, China
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15
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Scully TG, Toner L, Yeoh J, Farouque O, Yudi MB, Horrigan M, Clark DJ. Safety and Long-Term Clinical Outcomes of Fractional Flow Reserve Guided Coronary Revascularisation. Heart Lung Circ 2021; 30:1343-1347. [PMID: 33781698 DOI: 10.1016/j.hlc.2021.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 12/31/2020] [Accepted: 02/11/2021] [Indexed: 01/09/2023]
Abstract
BACKGROUND Increasingly, fractional flow reserve (FFR) is employed to assess coronary artery stenoses although there is limited real world long-term outcome data with a recent report questioning its safety. This study aimed to assess the in-hospital complications and clinical outcomes up to 10 years after FFR-guided revascularisation at a tertiary Australian hospital. METHODS The cohort comprised 274 consecutive patients undergoing FFR from 2010 to 2015 with follow-up to 2020. In-hospital complications and long-term outcomes were compared between patients with FFR≤0.80 and FFR>0.80. Major adverse cardiac events (MACE) comprised cardiac death, myocardial infarction (MI) and target vessel revascularisation (TVR). RESULTS The FFR was ≤0.80 in 166 and >0.80 in 108 patients. Stable coronary disease was present in 95%. Revascularisation was undertaken in 86.7% of the FFR≤0.80 group and in 2.8% of the group with an FFR>0.80. In-hospital adverse events were 3.3% with no pressure wire-related coronary dissection, stroke or death. At median follow-up of 5 years, patients with FFR≤0.80 and FFR>0.80 had a similar rate of cardiac death (2.6% versus 5.0%, p=0.335) and MI (2.6% versus 6.9%, p=0.154). In the FFR>0.80 group, MACE (17.8% v 7.9%; p=0.018) and TVR (12.9% v 5.3%; p=0.033) were significantly higher. CONCLUSION This observational study highlights the safety and long-term effectiveness of FFR-guided coronary revascularisation in patients with predominantly stable disease.
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Affiliation(s)
- Timothy G Scully
- Department of Cardiology, Austin Health, Melbourne, Vic, Australia
| | - Liam Toner
- Department of Cardiology, Austin Health, Melbourne, Vic, Australia
| | - Julian Yeoh
- Department of Cardiology, Austin Health, Melbourne, Vic, Australia; University of Melbourne, Melbourne, Vic, Australia
| | - Omar Farouque
- Department of Cardiology, Austin Health, Melbourne, Vic, Australia; University of Melbourne, Melbourne, Vic, Australia
| | - Matias B Yudi
- Department of Cardiology, Austin Health, Melbourne, Vic, Australia
| | - Mark Horrigan
- Department of Cardiology, Austin Health, Melbourne, Vic, Australia
| | - David J Clark
- Department of Cardiology, Austin Health, Melbourne, Vic, Australia; University of Melbourne, Melbourne, Vic, Australia.
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16
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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
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17
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Kayaert P, Coeman M, Gevaert S, De Pauw M, Haine S. Physiology-Based Revascularization of Left Main Coronary Artery Disease. J Interv Cardiol 2021; 2021:4218769. [PMID: 33628144 PMCID: PMC7892248 DOI: 10.1155/2021/4218769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 01/12/2021] [Accepted: 01/22/2021] [Indexed: 01/10/2023] Open
Abstract
It is of critical importance to correctly assess the significance of a left main lesion. Underestimation of significance beholds the risk of inappropriate deferral of revascularization, whereas overestimation may trigger major but unnecessary interventions. This article addresses the invasive physiological assessment of left main disease and its role in deciding upon revascularization. It mainly focuses on the available evidence for fractional flow reserve and instantaneous wave-free ratio, their interpretation, and limitations. We also discuss alternative invasive physiological indices and imaging, as well as the link between physiology, ischemia, and prognosis.
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Affiliation(s)
- Peter Kayaert
- Department of Cardiology, Ghent University Hospital, Ghent, Belgium
| | - Mathieu Coeman
- Department of Cardiology, Jan Yperman Ziekenhuis, Ypres, Belgium
| | - Sofie Gevaert
- Department of Cardiology, Ghent University Hospital, Ghent, Belgium
| | - Michel De Pauw
- Department of Cardiology, Ghent University Hospital, Ghent, Belgium
| | - Steven Haine
- Department of Cardiology, Antwerp University Hospital, Antwerp, Belgium
- Department of Cardiovascular Diseases, University of Antwerp, Antwerp, Belgium
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18
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Nicol ED, Weir-McCall JR. Using FFR CT to Guide Management Strategy in Women: Two Steps Forward and One Step Back. JACC Cardiovasc Imaging 2020; 13:2588-2590. [PMID: 32861657 DOI: 10.1016/j.jcmg.2020.07.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 07/24/2020] [Indexed: 11/25/2022]
Affiliation(s)
- Edward D Nicol
- Division of Cardiology, Royal Brompton Hospital, London, United Kingdom.
| | - Jonathan R Weir-McCall
- University of Cambridge School of Clinical Medicine, Cambridge, United Kingdom; Royal Papworth Hospital, Cambridge, United Kingdom
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19
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Hamaya R, Mittleman MA, Hoshino M, Kanaji Y, Murai T, Lee JM, Choi KH, Zhang JJ, Ye F, Li X, Ge Z, Chen SL, Kakuta T. Prognostic Value of Prerevascularization Fractional Flow Reserve Mediated by the Postrevascularization Level. JAMA Netw Open 2020; 3:e2018162. [PMID: 32997128 PMCID: PMC7527875 DOI: 10.1001/jamanetworkopen.2020.18162] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
IMPORTANCE The prognostic value of pre-percutaneous coronary intervention (PCI) fractional flow reserve (FFR) may be associated with the post-PCI FFR and their interaction. To correctly interpret the prognostic value of pre-PCI FFR, it is essential to understand to what extent the association of pre-PCI FFR with clinical outcomes is explained by post-PCI FFR. OBJECTIVE To investigate the extent to which post-PCI FFR mediates the association of pre-PCI FFR with vessel-related outcomes using an international, multicenter collaboration registry. DESIGN, SETTING, AND PARTICIPANTS This cohort study used pooled patient data from 4 international FFR registries. A total of 1488 patients with pre-PCI FFR of 0.80 or less who underwent elective PCI were included. Data collection was conducted from November 2011 to August 2019, and analysis was conducted from September 2019 to July 2020. MAIN OUTCOMES AND MEASURES The primary outcome was target vessel failure (TVF) during 2 years of follow-up. The extent to which post-PCI FFR of less than 0.90 mediated the association of pre-PCI FFR less than 0.75 (vs pre-PCI FFR of 0.75 or greater) with TVF was evaluated using a mediation analysis in a counterfactual framework. RESULTS Among 1488 patients, the mean (SD) age was 63.5 (9.9) years and 1161 patients (78.0%) were men. The median (interquartile range) pre-PCI and post-PCI FFR were 0.71 (0.62-0.76) and 0.88 (0.83-0.92), respectively. The direct association of low pre-PCI FFR (ie, <0.75) with TVF was significant (odds ratio, 1.81; 95% CI, 1.03-3.17; P = .04), while the mediation by post-PCI FFR level of less than 0.90 was not (indirect association: odds ratio, 1.03; 95% CI, 0.98-1.09; P = .24). In sensitivity analyses using several pre-PCI cutoffs, the mediations by post-PCI FFR were consistently weak. CONCLUSIONS AND RELEVANCE In this study, the association of pre-PCI FFR with TVF was not significantly mediated by post-PCI FFR. Poor prognosis due to progressed atherosclerosis, represented as low FFR, may not be reversed by successful PCI that increases FFR. Therefore, the prognostic value of pre-PCI FFR may mainly reflect the global atherosclerotic burden, not the extent of the modifiable epicardial stenosis.
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Affiliation(s)
- Rikuta Hamaya
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Murray A. Mittleman
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Cardiovascular Epidemiology Research Unit, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Masahiro Hoshino
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Yoshihisa Kanaji
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Tadashi Murai
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Joo Myung Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ki Hong Choi
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jun-Jie Zhang
- Division of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Fei Ye
- Division of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Xiaobo Li
- Division of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Zhen Ge
- Division of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Shao-Liang Chen
- Division of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Tsunekazu Kakuta
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
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20
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Fairbairn TA, Dobson R, Hurwitz-Koweek L, Matsuo H, Norgaard BL, Rønnow Sand NP, Nieman K, Bax JJ, Pontone G, Raff G, Chinnaiyan KM, Rabbat M, Amano T, Kawasaki T, Akasaka T, Kitabata H, Binukrishnan S, Rogers C, Berman D, Patel MR, Douglas PS, Leipsic J. Sex Differences in Coronary Computed Tomography Angiography-Derived Fractional Flow Reserve: Lessons From ADVANCE. JACC Cardiovasc Imaging 2020; 13:2576-2587. [PMID: 32861656 DOI: 10.1016/j.jcmg.2020.07.008] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 06/29/2020] [Accepted: 07/01/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVES This study is to determine the management and clinical outcomes of patients investigated with coronary computed tomography angiography (CCTA)-derived fractional flow reserve (FFRCT) according to sex. BACKGROUND Women are underdiagnosed with conventional ischemia testing, have lower rates of obstructive coronary artery disease (CAD) at invasive coronary angiography (ICA), yet higher mortality compared to men. Whether FFRCT improves sex-based patient management decisions compared to CCTA alone is unknown. METHODS Subjects with symptoms and CAD on CCTA were enrolled (2015 to 2017). Demographics, symptom status, CCTA anatomy, coronary volume to myocardial mass ratio (V/M), lowest FFRCT values, and management plans were captured. Endpoints included reclassification rate between CCTA and FFRCT management plans, incidence of ICA demonstrating obstructive CAD (≥50% stenosis) and revascularization rates. RESULTS A total of 4,737 patients (n = 1,603 females, 33.8%) underwent CCTA and FFRCT. Women were older (age 68 ± 10 years vs. 65 ± 10 years; p < 0.0001) with more atypical symptoms (41.5% vs. 33.9%; p < 0.0001). Women had less obstructive CAD (65.4% vs. 74.7%; p < 0.0001) at CCTA, higher FFRCT (0.76 ± 0.10 vs. 0.73 ± 0.10; p < 0.0001), and lower likelihood of positive FFRCT ≤ 0.80 for the same degree stenosis (p < 0.0001). A positive FFRCT ≤0.80 resulted in equal referral to ICA (n = 510 [54.5%] vs. n = 1,249 [56.5%]; p = 0.31), but more nonobstructive CAD (n = 208 [32.1%] vs. n = 354 [24.5%]; p = 0.0003) and less revascularization (n = 294 [31.4%] vs. n = 800 [36.2%]; p < 0.0001) in women, unless the FFRCT was ≤0.75 where revascularization rates were similar (n = 253 [41.9%] vs. n = 715 [46.4%]; p = 0.06). Women have a higher V/M ratio (26.17 ± 7.58 mm3/g vs. 24.76 ± 7.22 mm3/g; p < 0.0001) that is associated with higher FFRCT independent of degree stenosis (p < 0.001). Predictors of revascularization included stenosis severity, FFRCT, symptoms, and V/M ratio (p < 0.001) but not female sex (p = 0.284). CONCLUSIONS FFRCT differs between the sexes, as women have a higher FFRCT for the same degree of stenosis. In FFRCT-positive CAD, women have less obstructive CAD at ICA and less revascularization, which is associated with higher V/M ratio. The findings suggest that CAD and FFRCT variations by sex need specific interpretation as these differences may affect therapeutic decision making and clinical outcomes. (Assessing Diagnostic Value of Non-invasive FFRCT in Coronary Care [ADVANCE]; NCT02499679).
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Affiliation(s)
| | - Rebecca Dobson
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | | | - Hitoshi Matsuo
- Wakayama Medical University, Wakayama, Japan; Gifu Heart Center, Gifu, Japan
| | | | | | - Koen Nieman
- Stanford University Medical Center, Palo Alto, California, USA
| | - Jeroen J Bax
- Leiden University Medical Center, Leiden, the Netherlands
| | - Gianluca Pontone
- Centro Cardiologico Monzino, IRCCS, University of Milan, Milan, Italy
| | - Gilbert Raff
- William Beaumont Hospital, Royal Oaks, Michigan, USA
| | | | - Mark Rabbat
- Loyola University Medical Center, Maywood, Illinois, USA
| | | | | | | | | | | | | | - Daniel Berman
- Cedars Sinai Medical Centre, Beverly Hills, California, USA
| | - Manesh R Patel
- Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Jonathon Leipsic
- Department of Radiology, University of British Columbia, Vancouver, British Columbia, Canada
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21
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Influence of Anatomical and Clinical Characteristics on Long-Term Prognosis of FFR-Guided Deferred Coronary Lesions. JACC Cardiovasc Interv 2020; 13:1907-1916. [DOI: 10.1016/j.jcin.2020.05.040] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 05/12/2020] [Accepted: 05/18/2020] [Indexed: 12/13/2022]
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22
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Determinants of insufficient improvement in fractional flow reserve following percutaneous coronary intervention. Heart Vessels 2020; 35:1650-1656. [DOI: 10.1007/s00380-020-01645-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 06/05/2020] [Indexed: 12/29/2022]
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23
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Warisawa T, Cook CM, Howard JP, Ahmad Y, Doi S, Nakayama M, Goto S, Yakuta Y, Karube K, Shun-Shin MJ, Petraco R, Sen S, Nijjer S, Al Lamee R, Ishibashi Y, Matsuda H, Escaned J, di Mario C, Francis DP, Akashi YJ, Davies JE. Physiological Pattern of Disease Assessed by Pressure-Wire Pullback Has an Influence on Fractional Flow Reserve/Instantaneous Wave-Free Ratio Discordance. Circ Cardiovasc Interv 2020; 12:e007494. [PMID: 31084237 PMCID: PMC6553990 DOI: 10.1161/circinterventions.118.007494] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) disagree on the hemodynamic significance of a coronary lesion in ≈20% of cases. It is unknown whether the physiological pattern of disease is an influencing factor for this. This study assessed whether the physiological pattern of coronary artery disease influences discordance between FFR and iFR measurement. METHODS AND RESULTS Three-hundred and sixty intermediate coronary lesions (345 patients; mean age, 64.4±10.3 years; 76% men) with combined FFR, iFR, and iFR pressure-wire pullback were included for analysis from an international multicenter registry. Cut points for hemodynamic significance were FFR ≤0.80 and iFR ≤0.89, respectively. Lesions were classified into FFR+/iFR+ (n=154; 42.7%), FFR-/iFR+ (n=38; 10.6%), FFR+/iFR- (n=41; 11.4%), and FFR-/iFR- (n=127; 35.3%) groups. The physiological pattern of disease was classified according to the iFR pullback recordings as predominantly physiologically focal (n=171; 47.5%) or predominantly physiologically diffuse (n=189; 52.5%). Median FFR and iFR were 0.80 (interquartile range, 0.75-0.85) and 0.89 (interquartile range, 0.86-0.92), respectively. FFR disagreed with iFR in 22% (79 of 360). The physiological pattern of disease was the only influencing factor relating to FFR/iFR discordance: predominantly physiologically focal was significantly associated with FFR+/iFR- (58.5% [24 of 41]), and predominantly physiologically diffuse was significantly associated with FFR-/iFR+ (81.6% [31 of 38]; P<0.001 for pattern of disease between FFR+/iFR- and FFR-/iFR+ groups). CONCLUSIONS The physiological pattern of coronary artery disease was an important influencing factor for FFR/iFR discordance.
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Affiliation(s)
- Takayuki Warisawa
- International Center for Circulatory Health, National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, United Kingdom (T.W., C.M.C., J.P.H., Y.A., M.J.S.-S., R.P., S.S., S.N., R.A.L., D.P.F., J.E.D.).,Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan (T.W., Y.I., Y.J.A.)
| | - Christopher M Cook
- International Center for Circulatory Health, National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, United Kingdom (T.W., C.M.C., J.P.H., Y.A., M.J.S.-S., R.P., S.S., S.N., R.A.L., D.P.F., J.E.D.)
| | - James P Howard
- International Center for Circulatory Health, National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, United Kingdom (T.W., C.M.C., J.P.H., Y.A., M.J.S.-S., R.P., S.S., S.N., R.A.L., D.P.F., J.E.D.)
| | - Yousif Ahmad
- International Center for Circulatory Health, National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, United Kingdom (T.W., C.M.C., J.P.H., Y.A., M.J.S.-S., R.P., S.S., S.N., R.A.L., D.P.F., J.E.D.)
| | - Shunichi Doi
- Department of Cardiovascular Medicine, St. Marianna University School of Medicine, Yokohama City Seibu Hospital, Japan (S.D., H.M.)
| | - Masafumi Nakayama
- Cardiovascular Center, Toda Central General Hospital, Japan (M.N., S.G.).,Tokyo Women's Medical University-Waseda University Joint Institution for Advanced Biomedical Sciences, Japan (M.N.)
| | - Sonoka Goto
- Cardiovascular Center, Toda Central General Hospital, Japan (M.N., S.G.).,Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain (S.G., J.E.)
| | - Yohei Yakuta
- Department of Cardiology, Kanazawa Cardiovascular Hospital, Japan (Y.Y.)
| | - Kenichi Karube
- Department of Cardiovascular Medicine, Okaya City Hospital, Japan (K.K.)
| | - Matthew J Shun-Shin
- International Center for Circulatory Health, National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, United Kingdom (T.W., C.M.C., J.P.H., Y.A., M.J.S.-S., R.P., S.S., S.N., R.A.L., D.P.F., J.E.D.)
| | - Ricardo Petraco
- International Center for Circulatory Health, National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, United Kingdom (T.W., C.M.C., J.P.H., Y.A., M.J.S.-S., R.P., S.S., S.N., R.A.L., D.P.F., J.E.D.)
| | - Sayan Sen
- International Center for Circulatory Health, National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, United Kingdom (T.W., C.M.C., J.P.H., Y.A., M.J.S.-S., R.P., S.S., S.N., R.A.L., D.P.F., J.E.D.)
| | - Sukhjinder Nijjer
- International Center for Circulatory Health, National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, United Kingdom (T.W., C.M.C., J.P.H., Y.A., M.J.S.-S., R.P., S.S., S.N., R.A.L., D.P.F., J.E.D.)
| | - Rasha Al Lamee
- International Center for Circulatory Health, National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, United Kingdom (T.W., C.M.C., J.P.H., Y.A., M.J.S.-S., R.P., S.S., S.N., R.A.L., D.P.F., J.E.D.)
| | - Yuki Ishibashi
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan (T.W., Y.I., Y.J.A.)
| | - Hisao Matsuda
- Department of Cardiovascular Medicine, St. Marianna University School of Medicine, Yokohama City Seibu Hospital, Japan (S.D., H.M.)
| | - Javier Escaned
- Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain (S.G., J.E.)
| | - Carlo di Mario
- Structural Interventional Cardiology, Careggi University Hospital, Florence, Italy (C.d.M.)
| | - Darrel P Francis
- International Center for Circulatory Health, National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, United Kingdom (T.W., C.M.C., J.P.H., Y.A., M.J.S.-S., R.P., S.S., S.N., R.A.L., D.P.F., J.E.D.)
| | - Yoshihiro J Akashi
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan (T.W., Y.I., Y.J.A.)
| | - Justin E Davies
- International Center for Circulatory Health, National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, United Kingdom (T.W., C.M.C., J.P.H., Y.A., M.J.S.-S., R.P., S.S., S.N., R.A.L., D.P.F., J.E.D.)
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24
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Ahn JM, Park DW, Kim SO, Kang DY, Lee CH, Lee PH, Lee SW, Park SW, Park SJ. Prognostic Value of Resting Distal-to-Aortic Coronary Pressure in Clinical Practice. Circ Cardiovasc Interv 2020; 13:e007868. [PMID: 32345039 DOI: 10.1161/circinterventions.118.007868] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The resting distal-to-aortic coronary pressure ratio (Pd/Pa) is a universally available, hyperemia-free physiological index of coronary stenosis. We investigated clinical outcomes according to resting Pd/Pa versus hyperemic fractional flow reserve (FFR). METHODS From the IRIS-FFR (Interventional Cardiology Research Incooperation Society Fractional Flow Reserve) registry, 7014 lesions in 4707 patients with valid resting Pd/Pa and FFR were included in this study. The primary outcome was major adverse cardiac events (MACE; a composite of cardiac death, myocardial infarction, and repeat intervention). The MACE rate was compared among resting Pd/Pa ≤0.92 and FFR ≤0.80. A marginal Cox model accounted for correlated data in patients with multiple lesions. RESULTS During a median follow-up of 2.0 years, 223 MACEs occurred. Resting Pd/Pa was an independent predictor for the occurrence of MACE (adjusted hazard ratio [aHR], 1.89 [95% CI, 1.32-2.71]; P=0.001) over clinical and angiographic variables. When resting Pd/Pa and FFR were added into a multivariable model, MACE was no longer significantly associated with resting Pd/Pa (aHR, 1.35 [95% CI, 0.93-1.97]; P=0.12) but remained to be associated with FFR (aHR, 2.34 [95% CI, 1.56-3.54]; P<0.001). Compared with lesions with normal value of resting Pa/Pa and FFR, lesions with abnormal values of either resting Pd/Pa (aHR, 2.12 [95% CI, 1.17-3.84]; P=0.014) or FFR (aHR, 2.32 [95% CI, 1.52-3.55]; P<0.001) or both (aHR, 2.37 [95% CI, 1.57-3.57]; P<0.001) showed a significantly increased risk of the occurrence of MACE. CONCLUSIONS Resting Pd/Pa appeared to be a less-robust prognostic index than FFR. Resting Pd/Pa could be used as a prognostic index when hyperemic agents are contraindicated or not easily available. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01366404.
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Affiliation(s)
- Jung-Min Ahn
- Department of Cardiology, Asan Medical Center (J.-M.A., D.-W.P., D.-Y.K., P.H.L., S.-W.L., S.-W.P., S.-J.P.), University of Ulsan College of Medicine, Seoul, South Korea
| | - Duk-Woo Park
- Department of Cardiology, Asan Medical Center (J.-M.A., D.-W.P., D.-Y.K., P.H.L., S.-W.L., S.-W.P., S.-J.P.), University of Ulsan College of Medicine, Seoul, South Korea
| | - Seon-Ok Kim
- Department of Clinical Epidemiology and Biostatistics (S.-O.K.), University of Ulsan College of Medicine, Seoul, South Korea
| | - Do-Yoon Kang
- Department of Cardiology, Asan Medical Center (J.-M.A., D.-W.P., D.-Y.K., P.H.L., S.-W.L., S.-W.P., S.-J.P.), University of Ulsan College of Medicine, Seoul, South Korea
| | - Cheol-Hyun Lee
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Daegu, South Korea (C.-H.L.)
| | - Pil Hyung Lee
- Department of Cardiology, Asan Medical Center (J.-M.A., D.-W.P., D.-Y.K., P.H.L., S.-W.L., S.-W.P., S.-J.P.), University of Ulsan College of Medicine, Seoul, South Korea
| | - Seung-Whan Lee
- Department of Cardiology, Asan Medical Center (J.-M.A., D.-W.P., D.-Y.K., P.H.L., S.-W.L., S.-W.P., S.-J.P.), University of Ulsan College of Medicine, Seoul, South Korea
| | - Seong-Wook Park
- Department of Cardiology, Asan Medical Center (J.-M.A., D.-W.P., D.-Y.K., P.H.L., S.-W.L., S.-W.P., S.-J.P.), University of Ulsan College of Medicine, Seoul, South Korea
| | - Seung-Jung Park
- Department of Cardiology, Asan Medical Center (J.-M.A., D.-W.P., D.-Y.K., P.H.L., S.-W.L., S.-W.P., S.-J.P.), University of Ulsan College of Medicine, Seoul, South Korea
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25
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Hennigan B, Berry C, Collison D, Corcoran D, Eteiba H, Good R, McEntegart M, Watkins S, McClure JD, Mangion K, Ford TJ, Petrie MC, Hood S, Rocchiccioli P, Shaukat A, Lindsay M, Oldroyd KG. Percutaneous coronary intervention versus medical therapy in patients with angina and grey-zone fractional flow reserve values: a randomised clinical trial. Heart 2020; 106:758-764. [PMID: 32114516 PMCID: PMC7229900 DOI: 10.1136/heartjnl-2019-316075] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 12/27/2019] [Accepted: 01/03/2020] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION There is conflicting evidence regarding the benefits of percutaneous coronary intervention (PCI) in patients with grey zone fractional flow reserve (GZFFR artery) values (0.75-0.80). The prevalence of ischaemia is unknown. We wished to define the prevalence of ischaemia in GZFFR artery and assess whether PCI is superior to optimal medical therapy (OMT) for angina control. METHODS We enrolled 104 patients with angina with 1:1 randomisation to PCI or OMT. The artery was interrogated with a Doppler flow/pressure wire. Patients underwent Magnetic Resonance Imaging (MRI) with follow-up at 3 and 12 months. The primary outcome was angina status at 3 months using the Seattle Angina Questionnaire (SAQ). RESULTS 104 patients (age 60±9 years), 79 (76%) males and 79 (76%) Left Anterior Descending (LAD) stenoses were randomised. Coronary physiology and SAQ were similar. Of 98 patients with stress perfusion MRI data, 17 (17%) had abnormal perfusion (≥2 segments with ≥25% ischaemia or ≥1 segment with ≥50% ischaemia) in the target GZFFR artery. Of 89 patients with invasive physiology data, 26 (28%) had coronary flow velocity reserve <2.0 in the target GZFFR artery. After 3 months of follow-up, compared with patients treated with OMT only, patients treated by PCI and OMT had greater improvements in SAQ angina frequency (21 (28) vs 10 (23); p=0.026) and quality of life (24 (26) vs 11 (24); p=0.008) though these differences were no longer significant at 12 months. CONCLUSIONS Non-invasive evidence of major ischaemia is uncommon in patients with GZFFR artery. Compared with OMT alone, patients randomised to undergo PCI reported improved symptoms after 3 months but these differences were no longer significant after 12 months. TRIAL REGISTRATION NUMBER NCT02425969.
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Affiliation(s)
- Barry Hennigan
- Cardiology Department, Golden Jubilee National Hospital, Glasgow, United Kingdom .,BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Science, University of Glasgow, Glasgow, UK.,Cardiology Department, The Mater Private Hospital Cork, Cork, Ireland
| | - Colin Berry
- Cardiology Department, Golden Jubilee National Hospital, Glasgow, United Kingdom.,BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Science, University of Glasgow, Glasgow, UK
| | - Damien Collison
- Cardiology Department, Golden Jubilee National Hospital, Glasgow, United Kingdom.,BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Science, University of Glasgow, Glasgow, UK
| | - David Corcoran
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Science, University of Glasgow, Glasgow, UK
| | - Hany Eteiba
- Cardiology Department, Golden Jubilee National Hospital, Glasgow, United Kingdom.,BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Science, University of Glasgow, Glasgow, UK
| | - Richard Good
- Cardiology Department, Golden Jubilee National Hospital, Glasgow, United Kingdom
| | - Margaret McEntegart
- Cardiology Department, Golden Jubilee National Hospital, Glasgow, United Kingdom.,BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Science, University of Glasgow, Glasgow, UK
| | - Stuart Watkins
- Cardiology Department, Golden Jubilee National Hospital, Glasgow, United Kingdom
| | - John D McClure
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Science, University of Glasgow, Glasgow, UK
| | - Kenneth Mangion
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Science, University of Glasgow, Glasgow, UK
| | - Thomas Joseph Ford
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Science, University of Glasgow, Glasgow, UK
| | - Mark C Petrie
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Science, University of Glasgow, Glasgow, UK
| | - Stuart Hood
- Cardiology Department, Golden Jubilee National Hospital, Glasgow, United Kingdom.,BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Science, University of Glasgow, Glasgow, UK
| | - Paul Rocchiccioli
- Cardiology Department, Golden Jubilee National Hospital, Glasgow, United Kingdom.,BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Science, University of Glasgow, Glasgow, UK
| | - Aadil Shaukat
- Cardiology Department, Golden Jubilee National Hospital, Glasgow, United Kingdom
| | - Mitchell Lindsay
- Cardiology Department, Golden Jubilee National Hospital, Glasgow, United Kingdom
| | - Keith G Oldroyd
- Cardiology Department, Golden Jubilee National Hospital, Glasgow, United Kingdom.,BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Science, University of Glasgow, Glasgow, UK
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26
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Megaly M, Khalil C, Saad M, Xenogiannis I, Omer M, Anantha Narayanan M, Pershad A, Garcia S, Seto AH, Burke MN, Brilakis ES. Outcomes With Deferred Versus Performed Revascularization of Coronary Lesions With Gray-Zone Fractional Flow Reserve Values. Circ Cardiovasc Interv 2019; 12:e008315. [PMID: 31752518 DOI: 10.1161/circinterventions.119.008315] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Management of coronary lesions with fractional flow reserve values in the gray zone (0.75-0.80) remains controversial due to conflicting data on the performance versus deferral of revascularization. METHODS We performed a systematic review and meta-analysis of 7 observational studies including 2683 patients that compared the outcomes of deferred versus performed revascularization of coronary lesions with gray-zone fractional flow reserve values. RESULTS During a mean follow-up of 31±9 months, the incidence of major adverse cardiovascular events (12.54 % versus 11.25%; odds ratio [OR], 1.64 [95% CI, 0.78-3.44]; P=0.19, I2=84%), cardiac mortality (1.25% versus 0.72%; OR, 1.78 [95% CI, 0.58-5.46]; P=0.31, I2=18%), and myocardial infarction (1.28% versus 2.66%; OR, 0.79 [95% CI, 0.22-2.79]; P=0.71, I2=65%) was similar with deferral versus performance of revascularization in coronary lesions with gray-zone fractional flow reserve. Deferral of revascularization was associated with a higher incidence of target vessel revascularization (9.12% versus 5.78%; OR, 1.85 [95% CI, 1.03-3.33]; P=0.04, I2=62%). When the analysis was limited only to studies that used percutaneous coronary intervention for revascularization, deferred revascularization remained associated with a higher risk of target vessel revascularization (18% versus 7.3%; OR, 3.04 [95% CI, 1.53-6.02]; P<0.001) and was associated with a higher risk of major adverse cardiovascular event (23.2% versus 13.4%; OR, 3.38 [95% CI, 1.92-5.95]; P<0.001). CONCLUSIONS In lesions with gray-zone fractional flow reserve, revascularization was associated with a similar incidence of major adverse cardiovascular event but a lower incidence of target vessel revascularization over a mean follow-up of approximately 2.5 years. CLINICAL TRIAL REGISTRATION URL: https://www.crd.york.ac.uk/prospero/. Unique identifier: CRD42019128076.
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Affiliation(s)
- Michael Megaly
- Minneapolis Heart Institute, Abbott Northwestern Hospital, MN (M.M., I.X., M.O., S.G., M.N.B., E.S.B.).,Hennepin Healthcare, Minneapolis, MN (M.M., M.O.)
| | - Charl Khalil
- Department of Medicine, University at Buffalo, NY (C.K.)
| | - Marwan Saad
- Division of Cardiovascular Medicine, The Warren Alpert School of Medicine at Brown University, Providence, RI (M.S.).,Department of Cardiovascular Medicine, Ain Shams University Hospitals, Cairo, Egypt (M.S.)
| | - Iosif Xenogiannis
- Minneapolis Heart Institute, Abbott Northwestern Hospital, MN (M.M., I.X., M.O., S.G., M.N.B., E.S.B.)
| | - Mohamed Omer
- Minneapolis Heart Institute, Abbott Northwestern Hospital, MN (M.M., I.X., M.O., S.G., M.N.B., E.S.B.).,Hennepin Healthcare, Minneapolis, MN (M.M., M.O.)
| | | | - Ashish Pershad
- Division of Cardiology, Banner University Medical Center and University of Arizona, Phoenix, AZ (A.P.)
| | - Santiago Garcia
- Minneapolis Heart Institute, Abbott Northwestern Hospital, MN (M.M., I.X., M.O., S.G., M.N.B., E.S.B.)
| | - Arnold H Seto
- Division of Cardiology, Long Beach VA Medical Center, Orange, CA (A.H.S.)
| | - M Nicholas Burke
- Minneapolis Heart Institute, Abbott Northwestern Hospital, MN (M.M., I.X., M.O., S.G., M.N.B., E.S.B.)
| | - Emmanouil S Brilakis
- Minneapolis Heart Institute, Abbott Northwestern Hospital, MN (M.M., I.X., M.O., S.G., M.N.B., E.S.B.)
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27
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Modi BN, Rahman H, Kaier T, Ryan M, Williams R, Briceno N, Ellis H, Pavlidis A, Redwood S, Clapp B, Perera D. Revisiting the Optimal Fractional Flow Reserve and Instantaneous Wave-Free Ratio Thresholds for Predicting the Physiological Significance of Coronary Artery Disease. Circ Cardiovasc Interv 2019; 11:e007041. [PMID: 30562079 DOI: 10.1161/circinterventions.118.007041] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND There has been a gradual upward creep of revascularization thresholds for both fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR), before the clinical outcome trials for both indices. The increase in revascularization that has potentially resulted is at odds with increasing evidence questioning the benefits of revascularizing stable coronary disease. Using an independent invasive reference standard, this study primarily aimed to define optimal thresholds for FFR and iFR and also aimed to compare the performance of iFR, FFR, and resting distal coronary pressure (Pd)/central aortic pressure (Pa). METHODS AND RESULTS Pd and Pa were measured in 75 patients undergoing coronary angiography±percutaneous coronary intervention with resting Pd/Pa, iFR, and FFR calculated. Doppler average peak flow velocity was simultaneously measured and hyperemic stenosis resistance calculated as hyperemic stenosis resistance=Pa-Pd/average peak flow velocity (using hyperemic stenosis resistance >0.80 mm Hg/cm per second as invasive reference standard). An FFR threshold of 0.75 had an optimum diagnostic accuracy (84%), whereas for iFR this was 0.86 (76%). At these thresholds, the discordance in classification between indices was 11%. The accuracy of contemporary thresholds (FFR, 0.80; iFR, 0.89) was significantly lower (78.7% and 65.3%, respectively) with a 25% rate of discordance. The optimal threshold for Pd/Pa was 0.88 (77.3% accuracy). When comparing indices at optimal thresholds, FFR showed the best diagnostic performance (area under the curve, 0.91 FFR versus 0.79 iFR and 0.77 Pd/Pa, P=0.002). CONCLUSIONS Contemporary thresholds provide suboptimal diagnostic accuracy compared with an FFR threshold of 0.75 and iFR threshold of 0.86 (cutoffs in derivation studies). Whether more rigorous thresholds would result in selecting populations gaining greater symptom and prognostic benefit needs assessing in future trials of physiology-guided revascularization.
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Affiliation(s)
- Bhavik N Modi
- NIHR Biomedical Research Centre and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, St Thomas' Campus, King's College London, United Kingdom
| | - Haseeb Rahman
- NIHR Biomedical Research Centre and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, St Thomas' Campus, King's College London, United Kingdom
| | - Thomas Kaier
- NIHR Biomedical Research Centre and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, St Thomas' Campus, King's College London, United Kingdom
| | - Matthew Ryan
- NIHR Biomedical Research Centre and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, St Thomas' Campus, King's College London, United Kingdom
| | - Rupert Williams
- NIHR Biomedical Research Centre and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, St Thomas' Campus, King's College London, United Kingdom
| | - Natalia Briceno
- NIHR Biomedical Research Centre and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, St Thomas' Campus, King's College London, United Kingdom
| | - Howard Ellis
- NIHR Biomedical Research Centre and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, St Thomas' Campus, King's College London, United Kingdom
| | - Antonis Pavlidis
- NIHR Biomedical Research Centre and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, St Thomas' Campus, King's College London, United Kingdom
| | - Simon Redwood
- NIHR Biomedical Research Centre and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, St Thomas' Campus, King's College London, United Kingdom
| | - Brian Clapp
- NIHR Biomedical Research Centre and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, St Thomas' Campus, King's College London, United Kingdom
| | - Divaka Perera
- NIHR Biomedical Research Centre and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, St Thomas' Campus, King's College London, United Kingdom
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28
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Du Y, Liu Y, Cai G, Yang B, Cheng Y, Liu J, Liu W, Liu X, Zhou Z, Zhao Y, Zhou Y. Deferral Versus Performance of Revascularization for Coronary Stenosis With Grey Zone Fractional Flow Reserve Values: A Systematic Review and Meta-Analysis. Angiology 2019; 71:48-55. [PMID: 31315429 DOI: 10.1177/0003319719863174] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
We searched PubMed, EMBASE, Cochrane Library, and Web of Science for studies using fractional flow reserve (FFR) to determine whether revascularization should be performed or deferred for patients with coronary stenosis and grey zone FFR. Meta-analysis was performed using the generic inverse variance method, and hazard ratios (HR) were synthesized with a random-effects model. Of 2766 records, 7 nonrandomized studies including 2683 patients were selected. The pooled results demonstrated, during a median follow-up of 32 months, that revascularization significantly reduced the risk of major adverse cardiac events (MACE; 7 studies: HR [95% confidence interval, CI]: 0.65 [0.45-0.93], P = .02) and target vessel revascularization (TVR; 4 studies: HR [95% CI]: 0.52 [0.36-0.76], P < .01). Whereas revascularization was not significantly superior in terms of all-cause death (3 studies: HR [95% CI]: 0.56 [0.26-1.22], P = .14), cardiac death (2 studies: HR [95% CI]: 0.57 [0.16-2.01], P = .38), myocardial infarction (MI; 4 studies: HR [95% CI]: 1.03 [0.26-4.03]), and all-cause death or MI (3 studies: HR [95% CI]: 0.66 [0.20-2.19], P = .50). Therefore, revascularization appeared to be superior to deferral for patients with grey zone FFR in MACE and TVR, while hard end points did not show such significance. This work was registered in PROSPERO (CRD42019118432).
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Affiliation(s)
- Yu Du
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing, China
| | - Yan Liu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing, China
| | - Gaojun Cai
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing, China
- Department of Cardiology, Wujin Hospital affiliated with Jiangsu University, Changzhou, Jiangsu, China
| | - Bangguo Yang
- Department of Cardiology, Fuwai Yunnan Cardiovascular Hospital, Yunnan, Kunming, China
| | - Yujing Cheng
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing, China
| | - Jinxing Liu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing, China
| | - Wei Liu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing, China
| | - Xiaoli Liu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing, China
| | - Zhiming Zhou
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing, China
| | - Yingxin Zhao
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing, China
| | - Yujie Zhou
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing, China
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29
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Andreou C, Zimmermann FM, Tonino PAL, Maniotis C, Koutouzis M, Poulimenos LE, Triantafyllis AS. Optimal Treatment Strategy for Coronary Artery Stenoses with Grey Zone Fractional Flow Reserve Values. A Systematic Review and Meta-Analysis. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2019; 21:392-397. [PMID: 31227391 DOI: 10.1016/j.carrev.2019.05.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Revised: 05/14/2019] [Accepted: 05/17/2019] [Indexed: 12/26/2022]
Abstract
OBJECTIVES We conducted a review and meta-analysis of published data to compare revascularization to deferral strategy for coronary lesions with grey zone fractional flow reserve (FFR). BACKGROUND Optimal treatment for coronary stenoses with FFR values between 0.75 and 0.80, the so-called grey zone, remains a matter of debate. METHODS We included all studies evaluating revascularization versus deferral for lesions with grey zone FFR. The primary outcome was study-defined major adverse cardiac events (MACE). Secondary outcomes were the composite of death or MI and target vessel revascularization (TVR). A total of 2362 patients were included, of whom 1181 underwent revascularization (revascularization group) and 1181 received medical treatment only (deferral group). RESULTS After a mean follow-up period of 2.4 years, no difference was found for the primary outcome of the study-defined MACE between the two groups [RR = 1.33 (0.73-2.44), p = 0.35]. In addition, there was no difference for the secondary outcomes of death or MI and TVR between the two groups [RR = 1.39 (0.56-3.47), p = 0.48 and RR = 1.49 (0.89-2.51), p = 0.13, respectively]. CONCLUSIONS In this meta-analysis revascularization of coronary stenoses with grey zone FFR showed no advantage over a deferral strategy in terms of study-defined MACE. Case by case judgment should be implemented to guide treatment in this special subset of patients.
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Affiliation(s)
| | | | - Pim A L Tonino
- Heart Center, Catharina Hospital Eindhoven, Eindhoven, the Netherlands
| | | | - Michalis Koutouzis
- 2nd Department of Cardiology, Hellenic Red Cross Hospital, Athens, Greece
| | | | - Andreas S Triantafyllis
- Heart Center, Catharina Hospital Eindhoven, Eindhoven, the Netherlands; Department of Cardiology, Asklepeion General Hospital, Athens, Greece
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30
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Biolè C, Huczek Z, Nuñez-Gil I, Boccuzzi G, Autelli M, Montefusco A, Trabattoni D, Ryan N, Venuti G, Imori Y, Takano H, Matsuda J, Shimizu W, Muscoli S, Montabone A, Wojakowski W, Rognoni A, Helft G, Gallo D, Parma R, De Luca L, Figini F, Mitomo S, Pennone M, Mattesini A, Templin C, Quadri G, Wańha W, Cerrato E, Smolka G, Protasiewicz M, Kuliczkowski W, Rolfo C, Cortese B, Capodanno D, Chieffo A, Morbiducci U, Iannaccone M, Gili S, di Mario C, D'Amico M, Romeo F, Lüscher TF, Sheiban I, Escaned J, Varbella F, D'Ascenzo F. Daily risk of adverse outcomes in patients undergoing complex lesions revascularization: A subgroup analysis from the RAIN-CARDIOGROUP VII study (veRy thin stents for patients with left mAIn or bifurcatioN in real life). Int J Cardiol 2019; 290:64-69. [PMID: 30971372 DOI: 10.1016/j.ijcard.2019.03.038] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 02/13/2019] [Accepted: 03/18/2019] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Percutaneous coronary intervention (PCI) for complex lesions, including unprotected left main (ULM) and bifurcations, is gaining a relevant role in treating coronary artery disease with good outcomes, also thanks to new generation stents. The daily risk of adverse cardiovascular events and their temporal distribution after these procedures is not known. METHODS All consecutive patients presenting with a critical lesion of ULM or bifurcation treated with very thin struts stents, enrolled in the RAIN-Cardiogroup VII study, were analyzed. The daily risk of major acute cardiovascular events (MACE), target lesion revascularization (TLR) and stent thrombosis (ST) and their temporal distribution in the first year of follow-up was the primary endpoint. Differences among subgroups (ULM, patient presentation, kind of stent polymer) were the secondary endpoint. RESULTS 2745 patients were included, mean age 68 ± 11 years, 33.3% diabetics, 54.5% had an acute coronary syndrome (ACS); 88.5% of treated lesions were bifurcations, 27.2% ULM. Average daily risk was 0.022% for MACE, 0.005% for TLR and 0.004% for ST, in the first year. Bimodal distribution of adverse events, especially TLR, with an early peak in the first 50 days and a late one after 150 days, was observed. Patients with ULM presented a significantly higher daily risk of events, and ACS patients presented higher MACE risk. No difference emerged according to the type of stent polymer. CONCLUSIONS The daily risk of adverse events in the first year after complex PCI in our study is acceptably low. PCI on ULM carries a higher risk of complications.
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Affiliation(s)
- Carloalberto Biolè
- Division of Cardiology, Departement of Internal Medicine, Città della Salute e della Scienza, Turin, Italy.
| | | | - Ivan Nuñez-Gil
- Department of Cardiology, Hospital Clinico San Carlos, Madrid, Spain
| | | | - Michele Autelli
- Division of Cardiology, Departement of Internal Medicine, Città della Salute e della Scienza, Turin, Italy
| | - Antonio Montefusco
- Division of Cardiology, Departement of Internal Medicine, Città della Salute e della Scienza, Turin, Italy
| | - Daniela Trabattoni
- Department of Cardiovascular Sciences, IRCCS Centro Cardiologico Monzino, Milan, Italy; University of Milan, Milan, Italy
| | - Nicola Ryan
- Department of Cardiology, Hospital Clinico San Carlos, Madrid, Spain
| | - Giuseppe Venuti
- Division of Cardiology, Cardio-Thoracic-Vascular Department, Azienda Ospedaliero Universitaria "Policlinico-Vittorio Emanuele", Catania, Italy
| | - Yoichi Imori
- Department of Cardiovascular Medicine, Nippon Medical School, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, Japan
| | - Hitoshi Takano
- Department of Cardiovascular Medicine, Nippon Medical School, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, Japan
| | - Junya Matsuda
- Department of Cardiovascular Medicine, Nippon Medical School, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, Japan
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, Japan
| | - Saverio Muscoli
- San Raffaele Scientific Institute, Milan, Italy; Department of Medicine, Università degli Studi di Roma 'Tor Vergata', Rome, Italy
| | - Andrea Montabone
- Structural Interventional Cardiology, Careggi University Hospital, Florence, Italy
| | | | - Andrea Rognoni
- Coronary Care Unit and Catheterization Laboratory, A.O.U. Maggiore della Carità, Novara, Italy
| | - Gerard Helft
- Pierre and Marie Curie University, Paris, France
| | - Diego Gallo
- Polito(BIO)Med Lab, Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Italy
| | | | - Leonardo De Luca
- Division of Cardiology, S. Giovanni Evangelista Hospital, Tivoli, Rome, Italy
| | | | | | - Mauro Pennone
- Division of Cardiology, Departement of Internal Medicine, Città della Salute e della Scienza, Turin, Italy
| | - Alessio Mattesini
- Structural Interventional Cardiology, Careggi University Hospital, Florence, Italy
| | | | - Giorgio Quadri
- Department of Cardiology, Infermi Hospital, Rivoli, Italy; Department of Cardiology, San Luigi Gonzaga Hospital, Orbassano, Turin, Italy
| | - Wojciech Wańha
- Department of Cardiology, Medical University of Silesia, Katowice, Poland
| | - Enrico Cerrato
- Department of Cardiology, Infermi Hospital, Rivoli, Italy; Department of Cardiology, San Luigi Gonzaga Hospital, Orbassano, Turin, Italy
| | - Grzegorz Smolka
- Department of Cardiology, Medical University of Silesia, Katowice, Poland
| | | | | | - Cristina Rolfo
- Department of Cardiology, Infermi Hospital, Rivoli, Italy; Department of Cardiology, San Luigi Gonzaga Hospital, Orbassano, Turin, Italy
| | - Bernardo Cortese
- Interventional Cardiology, ASST Fatebenefratelli-Sacco, Milano, Italy
| | - Davide Capodanno
- Division of Cardiology, Cardio-Thoracic-Vascular Department, Azienda Ospedaliero Universitaria "Policlinico-Vittorio Emanuele", Catania, Italy
| | | | - Umberto Morbiducci
- Polito(BIO)Med Lab, Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Italy
| | - Mario Iannaccone
- Division of Cardiology, Departement of Internal Medicine, Città della Salute e della Scienza, Turin, Italy
| | - Sebastiano Gili
- Division of Cardiology, Universityszpital of Zurich, Switzerland
| | - Carlo di Mario
- Structural Interventional Cardiology, Careggi University Hospital, Florence, Italy
| | - Maurizio D'Amico
- Division of Cardiology, Departement of Internal Medicine, Città della Salute e della Scienza, Turin, Italy
| | - Francesco Romeo
- Department of Medicine, Università degli Studi di Roma 'Tor Vergata', Rome, Italy
| | - Thomas F Lüscher
- Division of Cardiology, Universityszpital of Zurich, Switzerland
| | | | - Javier Escaned
- Department of Cardiology, Hospital Clinico San Carlos, Madrid, Spain
| | - Ferdinando Varbella
- Department of Cardiology, Infermi Hospital, Rivoli, Italy; Department of Cardiology, San Luigi Gonzaga Hospital, Orbassano, Turin, Italy
| | - Fabrizio D'Ascenzo
- Division of Cardiology, Departement of Internal Medicine, Città della Salute e della Scienza, Turin, Italy
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Kitabata H, Kubo T, Shiono Y, Shimamura K, Ino Y, Tanimoto T, Hayashi Y, Komukai K, Sougawa H, Kimura K, Gohda M, Hashizume T, Obana M, Maeda K, Yamaguchi J, Akasaka T. Comparison of clinical outcomes following percutaneous coronary intervention versus optimal medical therapy based on gray-zone fractional flow reserve in stable angina patients with intermediate coronary artery stenosis (COMFORTABLE prospective study): Study protocol for a multicenter randomized controlled trial. Trials 2019; 20:84. [PMID: 30691507 PMCID: PMC6350281 DOI: 10.1186/s13063-019-3182-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 01/07/2019] [Indexed: 01/26/2023] Open
Abstract
Background Even in the current drug-eluting stent era, revascularization for coronary stenosis with fractional flow reserve (FFR) between 0.75 and 0.80, the so-called “gray zone,” is a matter of debate. Previous studies have reported conflicting results regarding outcomes of revascularization versus deferral for coronary stenosis when FFR values are in the gray zone, but these studies have had differing designs and populations. We therefore will investigate whether medical therapy plus percutaneous coronary intervention (PCI) is superior to medical therapy alone in reducing major cardiovascular events in patients presenting with coronary stenosis with gray zone FFR values. Methods/design This is a prospective, multicenter, open-label, parallel group, randomized, controlled, superiority study. A total of 410 eligible participants will be recruited and randomized to either the medical therapy plus PCI group or the medical therapy alone group. The primary endpoint is 1-year major adverse cardiac events (MACEs), defined as a combined endpoint of all-cause death, nonfatal myocardial infarction (MI), or unplanned target vessel revascularization (TVR). Secondary endpoints include MACE at 2 and 5 years. Moreover, each individual component of the primary endpoint, cardiovascular death, target vessel-related and non-target vessel-related MI, all MI, clinically driven TVR or non-TVR, all revascularization, stent thrombosis, and angina symptom status will be evaluated at 1, 2, and 5 years. Discussion This is the first prospective, multicenter, randomized, controlled study to investigate the superiority of medical therapy plus PCI over medical therapy by itself in reducing major cardiovascular events in patients presenting with coronary stenosis with “gray zone” FFR values. The results will help interventional cardiologists in making revascularization decisions regarding coronary stenosis with gray zone FFR values. Trial registration University Hospital Medical Information Network Clinical Trials Registry, UMIN000031526. Registered on 1 March 2018. Electronic supplementary material The online version of this article (10.1186/s13063-019-3182-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Hironori Kitabata
- Department of Cardiovascular Medicine, Wakayama Medical University, 811-1, Kimiidera, Wakayama, Wakayama, 641-8509, Japan.
| | - Takashi Kubo
- Department of Cardiovascular Medicine, Wakayama Medical University, 811-1, Kimiidera, Wakayama, Wakayama, 641-8509, Japan
| | - Yasutsugu Shiono
- Department of Cardiovascular Medicine, Wakayama Medical University, 811-1, Kimiidera, Wakayama, Wakayama, 641-8509, Japan
| | - Kunihiro Shimamura
- Department of Cardiovascular Medicine, Wakayama Medical University, 811-1, Kimiidera, Wakayama, Wakayama, 641-8509, Japan
| | - Yasushi Ino
- Department of Cardiovascular Medicine, Wakayama Medical University, 811-1, Kimiidera, Wakayama, Wakayama, 641-8509, Japan
| | - Takashi Tanimoto
- Department of Cardiovascular Medicine, Shingu Municipal Medical Center, 18-7 Hachibuse, Shingu, Wakayama, 647-0072, Japan
| | - Yasushi Hayashi
- Department of Cardiovascular Medicine, Wakayama Rosai Hospital, 93-1 Kinomoto, Wakayama, Wakayama, 640-8505, Japan
| | - Kenichi Komukai
- Department of Cardiovascular Medicine, Hidaka General Hospital, 116-2 Sono, Gobo, Wakayama, 644-0002, Japan
| | - Hiromichi Sougawa
- Department of Cardiovascular Medicine, Hashimoto Municipal Hospital, 2-8-1Ominedai, Hashimoto, Wakayama, 648-0005, Japan
| | - Keizo Kimura
- Department of Cardiovascular Medicine, Kinan Hospital, 46-7 Shinjocho, Tanabe, Wakayama, 646-8588, Japan
| | - Masahiro Gohda
- Department of Cardiovascular Medicine, Seiyu Memorial Hospital, 391 Nishitai, Wakayama, 649-6335, Japan
| | - Toshikazu Hashizume
- Department of Cardiovascular Medicine, Minami Wakayama Medical Center, 27-1 Takinaicho, Tanabe, Wakayama, 646-8558, Japan
| | - Masahiro Obana
- Department of Cardiovascular Medicine, Saiseikai Wakayama Hospital, 45 Junibancho, Wakayama, 640-8158, Japan
| | - Kazuisa Maeda
- Department of Cardiovascular Medicine, Naga Municipal Hospital, 1282 Uchita, Kinokawa, 649-6414, Japan
| | - Junichi Yamaguchi
- Department of Cardiology, The Heart Institute of Japan, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Takashi Akasaka
- Department of Cardiovascular Medicine, Wakayama Medical University, 811-1, Kimiidera, Wakayama, Wakayama, 641-8509, Japan
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Lüscher TF. Assessing myocardial ischaemia in epicardial coronaries and the microcirculation. Eur Heart J 2018; 39:4047-4050. [PMID: 30535019 DOI: 10.1093/eurheartj/ehy816] [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] [Indexed: 12/30/2022] Open
Affiliation(s)
- Thomas F Lüscher
- Imperial College and Director of Research, Education & Development, Royal Brompton and Harefield Hospitals London, UK.,Center for Molecular Cardiology, University of Zurich, Switzerland.,EHJ Editorial Office, Zurich Heart House, Hottingerstreet 14, Zurich, Switzerland
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33
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Fairbairn TA, Nieman K, Akasaka T, Nørgaard BL, Berman DS, Raff G, Hurwitz-Koweek LM, Pontone G, Kawasaki T, Sand NP, Jensen JM, Amano T, Poon M, Øvrehus K, Sonck J, Rabbat M, Mullen S, De Bruyne B, Rogers C, Matsuo H, Bax JJ, Leipsic J, Patel MR. Real-world clinical utility and impact on clinical decision-making of coronary computed tomography angiography-derived fractional flow reserve: lessons from the ADVANCE Registry. Eur Heart J 2018; 39:3701-3711. [PMID: 30165613 PMCID: PMC6215963 DOI: 10.1093/eurheartj/ehy530] [Citation(s) in RCA: 211] [Impact Index Per Article: 35.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 08/09/2018] [Indexed: 11/18/2022] Open
Abstract
AIMS Non-invasive assessment of stable chest pain patients is a critical determinant of resource utilization and clinical outcomes. Increasingly coronary computed tomography angiography (CCTA) with selective CCTA-derived fractional flow reserve (FFRCT) is being used. The ADVANCE Registry, is a large prospective examination of using a CCTA and FFRCT diagnostic pathway in real-world settings, with the aim of determining the impact of this pathway on decision-making, downstream invasive coronary angiography (ICA), revascularization, and major adverse cardiovascular events (MACE). METHODS AND RESULTS A total of 5083 patients with symptoms concerning for coronary artery disease (CAD) and atherosclerosis on CCTA were enrolled at 38 international sites from 15 July 2015 to 20 October 2017. Demographics, symptom status, CCTA and FFRCT findings, treatment plans, and 90 days outcomes were recorded. The primary endpoint of reclassification between core lab CCTA alone and CCTA plus FFRCT-based management plans occurred in 66.9% [confidence interval (CI): 64.8-67.6] of patients. Non-obstructive coronary disease was significantly lower in ICA patients with FFRCT ≤0.80 (14.4%) compared to patients with FFRCT >0.80 (43.8%, odds ratio 0.19, CI: 0.15-0.25, P < 0.001). In total, 72.3% of subjects undergoing ICA with FFRCT ≤0.80 were revascularized. No death/myocardial infarction (MI) occurred within 90 days in patients with FFRCT >0.80 (n = 1529), whereas 19 (0.6%) MACE [hazard ratio (HR) 19.75, CI: 1.19-326, P = 0.0008] and 14 (0.3%) death/MI (HR 14.68, CI 0.88-246, P = 0.039) occurred in subjects with an FFRCT ≤0.80. CONCLUSIONS In a large international multicentre population, FFRCT modified treatment recommendation in two-thirds of subjects as compared to CCTA alone, was associated with less negative ICA, predicted revascularization, and identified subjects at low risk of adverse events through 90 days.
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Affiliation(s)
| | - Koen Nieman
- Stanford and Erasmus Medical Center, Rotterdam, Netherlands
| | - Takashi Akasaka
- Wakayama Medical University, 811-1 Kimiidera Wakayama, Wakayama, Japan
| | - Bjarne L Nørgaard
- Aarhus University Hospital, Department Cardiology B, Palle Juul-Jensens Boulevard 99, Aarhus N, Denmark
| | - Daniel S Berman
- Cedars Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA, USA
| | - Gilbert Raff
- William Beaumont Hospital, 3601 West 13 Mile Road, Royal Oak, MI, USA
| | | | - Gianluca Pontone
- Centro Cardiologico Monzino, IRCCS, University of Milan, Via Carlo Parea 4, Milan, Italy
| | | | - Niels Peter Sand
- University of Southern Denmark, Sdr Boulevard 29, Odense, Denmark
| | - Jesper M Jensen
- Aarhus University Hospital, Department Cardiology B, Palle Juul-Jensens Boulevard 99, Aarhus N, Denmark
| | - Tetsuya Amano
- Aichi Medical University, 1-1 Yazakokarimata Nagakute, Aichi, Japan
| | - Michael Poon
- Northwell Health, 100 E 77th Street, New York, NY, USA
| | - Kristian Øvrehus
- University of Southern Denmark, Sdr Boulevard 29, Odense, Denmark
| | - Jeroen Sonck
- UZ Brussels, Laarbeeklaan 101, Brussels, Belgium
| | - Mark Rabbat
- Loyola University Medical Center, 2160 South First Avenue, Maywood, IL, USA
| | - Sarah Mullen
- HeartFlow Inc., 1400 Seaport Blvd, Bldg B, Redwood City, CA, USA
| | | | - Campbell Rogers
- HeartFlow Inc., 1400 Seaport Blvd, Bldg B, Redwood City, CA, USA
| | - Hitoshi Matsuo
- Gifu Heart Center, 4-14-4 Yabutaminami, Gifu Gifu, Japan
| | - Jeroen J Bax
- Leiden University Medical Center, Albinusdreef 2, Leiden, AZ, Netherlands
| | - Jonathon Leipsic
- Department of Radiology, University of British Columbia, 1081 Burrard Street, Vancouver, BC, Canada
| | - Manesh R Patel
- Duke University School of Medicine, 2301 Erwin Road, Durham, NC, USA
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Lønborg J, Engstrøm T. Borderline multivessel coronary artery disease assessed by fractional flow reserve-affecting practice? J Thorac Dis 2018; 10:S3078-S3080. [PMID: 30370083 DOI: 10.21037/jtd.2018.07.129] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Jacob Lønborg
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Thomas Engstrøm
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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35
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Kubo T, Takahata M, Terada K, Mori K, Arita Y, Ino Y, Matsuo Y, Kitabata H, Shiono Y, Shimamura K, Kameyama T, Emori H, Katayama Y, Tanimoto T, Akasaka T. Retrospective Comparison of Long-Term Clinical Outcomes Between Percutaneous Coronary Intervention and Medical Therapy in Stable Coronary Artery Disease With Gray Zone Fractional Flow Reserve - COMFORTABLE Retrospective Study. Circ J 2018; 82:3044-3051. [PMID: 30318503 DOI: 10.1253/circj.cj-18-0672] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND A fractional flow reserve (FFR) between 0.75 and 0.80 constitutes a "gray zone" for clinical decision-making in coronary artery disease. We compared long-term outcomes of percutaneous coronary intervention (PCI) using drug-eluting stents vs. medical therapy for coronary stenosis with gray zone FFR. Methods and Results: We retrospectively investigated the clinical outcomes of 263 patients with gray zone FFR: 78 patients in the PCI group and 185 patients in the medical therapy group. During a median follow-up of 3.7 years, the frequency of target vessel failure (TVF, defined as a composite of cardiac death, myocardial infarction [MI], or ischemia-driven target vessel revascularization [TVR]) was significantly lower in the PCI group compared with the medical therapy group (6% vs. 19%, hazard ratio [HR]:0.33, 95% confidence interval [CI]: 0.13-0.84, P=0.008). The frequency of a composite of cardiac death or MI was not different between the 2 groups (1% vs. 2%, HR: 0.61, 95% CI: 0.07-5.49, P=0.645). The frequency of ischemia-driven TVR was significantly lower in the PCI group compared with the medical therapy group (5% vs. 18%, HR: 0.28, 95% CI: 0.10-0.79, P=0.005). CONCLUSIONS In patients with gray zone FFR, compared with medical therapy, PCI decreased the frequency of TVF, which was mainly driven by a reduction in the frequency of angina or myocardial ischemia without any difference in the frequency of cardiac death or MI.
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Affiliation(s)
- Takashi Kubo
- Department of Cardiovascular Medicine, Wakayama Medical University
| | | | - Kosei Terada
- Department of Cardiovascular Medicine, Shingu Municipal Medical Center
| | - Kazuya Mori
- Department of Cardiovascular Medicine, Shingu Municipal Medical Center
| | - Yu Arita
- Department of Cardiovascular Medicine, Shingu Municipal Medical Center
| | - Yasushi Ino
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Yoshiki Matsuo
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Hironori Kitabata
- Department of Cardiovascular Medicine, Shingu Municipal Medical Center
| | - Yasutsugu Shiono
- Department of Cardiovascular Medicine, Wakayama Medical University
| | | | | | - Hiroki Emori
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Yosuke Katayama
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Takashi Tanimoto
- Department of Cardiovascular Medicine, Shingu Municipal Medical Center
| | - Takashi Akasaka
- Department of Cardiovascular Medicine, Wakayama Medical University
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36
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Lüscher TF. Assessing coronary plaques: non-invasive and intracoronary imaging and haemodynamic measurements. Eur Heart J 2018; 39:3265-3268. [PMID: 30219879 DOI: 10.1093/eurheartj/ehy588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Thomas F Lüscher
- Consultant and Director of Research, Education & Development, Royal Brompton and Harefield Hospital Trust and Imperial College, London, UK.,Chairman, Center for Molecular Cardiology, University of Zurich, Switzerland.,Editor-in-Chief, EHJ Editorial Office, Zurich Heart House, Hottingerstreet 14, Zurich, Switzerland
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37
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Johnson NP, Zimmermann FM. Yellow traffic lights and grey zone fractional flow reserve values: stop or go? Eur Heart J 2018; 39:1620-1622. [PMID: 29579188 DOI: 10.1093/eurheartj/ehy151] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Nils P Johnson
- Department of Medicine, Division of Cardiology, Weatherhead PET Center, McGovern Medical School at UTHealth and Memorial Hermann Hospital, Room MSB 4.256, 6431 Fannin Street, Houston, TX 77030, USA
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38
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Affiliation(s)
- Thomas F Lüscher
- Editorial Office, Zurich Heart House, 8032 Zurich, Center for Molecular Cardiology, Schlieren Campus, University of Zurich, Switzerland and Royal Brompton and Harefield Hospital Trust and Imperial College, London, SW3 6NP, UK
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