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Pruthi S, Siddiqui E, Smilowitz NR. Beyond Coronary Artery Disease: Assessing the Microcirculation. Rheum Dis Clin North Am 2024; 50:519-533. [PMID: 38942582 DOI: 10.1016/j.rdc.2024.03.004] [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: 06/30/2024]
Abstract
Ischemic heart disease (IHD) affects more than 20 million adults in the United States. Although classically attributed to atherosclerosis of the epicardial coronary arteries, nearly half of patients with stable angina and IHD who undergo invasive coronary angiography do not have obstructive epicardial coronary artery disease. Ischemia with nonobstructive coronary arteries is frequently caused by microvascular angina with underlying coronary microvascular dysfunction (CMD). Greater understanding the pathophysiology, diagnosis, and treatment of CMD holds promise to improve clinical outcomes of patients with ischemic heart disease.
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Affiliation(s)
- Sonal Pruthi
- Division of Cardiology, Department of Medicine, NYU Langone Health, 550 First Avenue, New York, NY 10016, USA
| | - Emaad Siddiqui
- Division of Cardiology, Department of Medicine, NYU Langone Health, 550 First Avenue, New York, NY 10016, USA
| | - Nathaniel R Smilowitz
- Division of Cardiology, Department of Medicine, NYU Langone Health, 550 First Avenue, New York, NY 10016, USA; Cardiology Section, Department of Medicine, VA New York Harbor Healthcare System, 423 East 23rd Street, New York, NY 10010, USA; The Leon H. Charney Division of Cardiology, NYU Langone Health, NYU School of Medicine, 423 East 23rd Street, 12-West, New York, NY 10010, USA.
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Qian G, Qin H, Deng D, Feng Y, Zhang C, Qu X, Zhang Z. Prognostic value of angiographic microvascular resistance in patients with ST-segment elevation myocardial infarction. Clinics (Sao Paulo) 2024; 79:100429. [PMID: 39053030 PMCID: PMC11327545 DOI: 10.1016/j.clinsp.2024.100429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 05/24/2024] [Accepted: 06/10/2024] [Indexed: 07/27/2024] Open
Abstract
BACKGROUND The Angiographic Microvascular Resistance (AMR), derived from a solitary angiographic view, has emerged as a viable substitute for the Index of Microcirculatory Resistance (IMR). However, the prognostic significance in ST-Segment Elevation Myocardial Infarction (STEMI) patients is yet to be established. This research endeavors to explore the prognostic capabilities of AMR in patients diagnosed with STEMI. METHODS In this single-center, retrospective study, 232 patients diagnosed with STEMI who received primary Percutaneous Coronary Intervention (PCI) were recruited from January 1, 2018, to June 30, 2022. Utilizing the maximally selected log-rank statistics analysis, participants were divided into two cohorts according to an AMR threshold of 2.55 mmHg*s/cm. The endpoint evaluated was a composite of all-cause mortality or hospital readmission due to heart failure. RESULTS At a median follow-up of 1.74 (1.07, 3.65) years, the composite endpoint event was observed in 28 patients within the higher AMR group and 8 patients within the lower AMR group. The higher AMR group showed a significantly higher risk for composite outcome compared to those within the low-AMR group (HRadj: 3.33; 95% CI 1.30‒8.52; p = 0.03). AMR ≥ 2.55 mmHg*s/cm was an independent predictor of the composite endpoint (HR = 2.33; 95% CI 1.04‒5.21; p = 0.04). Furthermore, a nomogram containing age, sex, left ventricle ejection fraction, post-PCI Quantitative Flow Ratio (QFR), and AMR was developed and indicated a poorer prognosis in the high-risk group for STEMI patients at 3 years. (HR=4.60; 95% CI 1.91‒11.07; p < 0.01). CONCLUSIONS AMR measured after PCI can predict the risk of all-cause death or readmission for heart failure in patients with STEMI. AMR-involved nomograms improved predictive performance over variables alone.
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Affiliation(s)
- Gangzhen Qian
- Department of Cardiovascular Medicine, Center for Circadian Metabolism and Cardiovascular Disease, Southwest Hospital, Army Medical University, Chongqing, China
| | - Haoran Qin
- Department of Cardiovascular Medicine, Center for Circadian Metabolism and Cardiovascular Disease, Southwest Hospital, Army Medical University, Chongqing, China
| | - Dan Deng
- Department of Cardiovascular Medicine, Center for Circadian Metabolism and Cardiovascular Disease, Southwest Hospital, Army Medical University, Chongqing, China
| | - Yue Feng
- Department of Cardiovascular Medicine, Center for Circadian Metabolism and Cardiovascular Disease, Southwest Hospital, Army Medical University, Chongqing, China
| | - Chao Zhang
- Department of Cardiovascular Medicine, Center for Circadian Metabolism and Cardiovascular Disease, Southwest Hospital, Army Medical University, Chongqing, China
| | - Xiaolong Qu
- Department of Cardiovascular Medicine, Center for Circadian Metabolism and Cardiovascular Disease, Southwest Hospital, Army Medical University, Chongqing, China
| | - Zhihui Zhang
- Department of Cardiovascular Medicine, Center for Circadian Metabolism and Cardiovascular Disease, Southwest Hospital, Army Medical University, Chongqing, China.
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Rehan R, Wong CCY, Weaver J, Chan W, Tremmel JA, Fearon WF, Ng MKC, Yong ASC. Multivessel Coronary Function Testing Increases Diagnostic Yield in Patients With Angina and Nonobstructive Coronary Arteries. JACC Cardiovasc Interv 2024; 17:1091-1102. [PMID: 38749588 DOI: 10.1016/j.jcin.2024.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 02/28/2024] [Accepted: 03/05/2024] [Indexed: 07/17/2024]
Abstract
BACKGROUND Invasive CFT is the gold standard for diagnosing coronary vasomotor dysfunction in patients with ANOCA. Most institutions recommend only testing the left coronary circulation. Therefore, it is unknown whether testing multiple coronary territories would increase diagnostic yield. OBJECTIVES The aim of this study was to evaluate the diagnostic yield of multivessel, compared with single-vessel, invasive coronary function testing (CFT) in patients with angina and nonobstructive coronary arteries (ANOCA). METHODS Multivessel CFT was systematically performed in patients with suspected ANOCA. Vasoreactivity testing was performed using acetylcholine provocation in the left (20 to 200 μg) and right (20 to 80μg) coronary arteries. A pressure-temperature sensor guidewire was used for coronary physiology assessment in all three epicardial vessels. RESULTS This multicenter study included a total of 228 vessels from 80 patients (57.8 ± 11.8 years of age, 60% women). Compared with single-vessel CFT, multivessel testing resulted in more patients diagnosed with coronary vasomotor dysfunction (86.3% vs 68.8%; P = 0.0005), coronary artery spasm (60.0% vs 47.5%; P = 0.004), and CMD (62.5% vs 36.3%; P < 0.001). Coronary artery spasm (n = 48) predominated in the left coronary system (n = 38), though isolated right coronary spasm was noted in 20.8% (n = 10). Coronary microvascular dysfunction (CMD), defined by abnormal index of microcirculatory resistance and/or coronary flow reserve, was present 62.5% of the cohort (n = 50). Among the cohort with CMD, 27 patients (33.8%) had 1-vessel CMD, 15 patients (18.8%) had 2-vessel CMD, and 8 patients (10%) had 3-vessel CMD. CMD was observed at a similar rate in the territories supplied by all 3 major coronary vessels (left anterior descending coronary artery = 36.3%, left circumflex coronary artery = 33.8%, right coronary artery = 31.3%; P = 0.486). CONCLUSIONS Multivessel CFT resulted in an increased diagnostic yield in patients with ANOCA compared with single-vessel testing. The results of this study suggest that multivessel CFT has a role in the management of patients with ANOCA.
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Affiliation(s)
- Rajan Rehan
- Royal Prince Alfred Hospital, Sydney, Australia
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Wen X, Wang Z, Zheng B, Gong Y, Huo Y. Ability of the coronary angiography-derived index of microcirculatory resistance to predict microvascular obstruction in patients with ST-segment elevation. Front Cardiovasc Med 2024; 11:1187599. [PMID: 38711790 PMCID: PMC11071667 DOI: 10.3389/fcvm.2024.1187599] [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: 03/16/2023] [Accepted: 03/19/2024] [Indexed: 05/08/2024] Open
Abstract
Background The coronary angiography-derived index of microvascular resistance (caIMR) correlates well with the index of microcirculatory resistance (IMR), which predicts microvascular obstruction (MVO). However, the relationship between caIMR and MVO remains unclear. Aim To evaluate the predictive ability of caIMR of MVO after ST-segment elevation myocardial infarction (STEMI). Methods CaIMR was calculated using computational flow and pressure simulation in patients with STEMI in whom MVO status had been assessed by cardiac magnetic resonance (CMR) after successful primary percutaneous intervention at Peking University First Hospital between December 2016 and August 2019. The clinical, biochemical, echocardiographic, and CMR characteristics were assessed according to MVO status. The predictive value of the clinical parameters and caIMR was evaluated. Results Fifty-three eligible patients were divided into an MVO group (n = 32) and a no-MVO group (n = 21). The caIMR tended to be higher in the MVO group (41.6 U vs. 30.1 U; p = 0.136). CaIMR and peak cardiac troponin-I (cTNI) were independent predictors of MVO (per 1-U increment in caIMR: odds ratio [OR] 1.044, 95% confidence interval [CI] 1.004-1.086, p = 0.030; per 1 ng/L increase in peak cTNI: OR 1.018, 95% CI 1.003-1.033, p = 0.022). In receiver-operating characteristic curve analysis, when a cut-off value of 45.17 U was used, caIMR had some ability to predict MVO (area under the curve 0.622, 95% CI 0.478-0.752, p = 0.127). Conclusions CaIMR and peak cTNI were independent predictors of short-term MVO in patients with STEMI who had undergone successful primary percutaneous coronary intervention and may help to identify those at high risk of MVO.
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Affiliation(s)
| | | | | | - Yanjun Gong
- Department of Cardiology, Peking University First Hospital, Beijing, China
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Karagodin I, Wang S, Wang H, Singh A, Gutbrod J, Landeras L, Patel H, Alvi N, Tang M, Benovoy M, Janich MA, Benjamin HJ, Chung JH, Patel AR. Myocardial Blood Flow Quantified Using Stress Cardiac Magnetic Resonance After Mild COVID-19 Infection. JACC. ADVANCES 2024; 3:100834. [PMID: 38433786 PMCID: PMC10906962 DOI: 10.1016/j.jacadv.2024.100834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 08/22/2023] [Accepted: 09/07/2023] [Indexed: 03/05/2024]
Abstract
BACKGROUND Severe COVID-19 infection is known to alter myocardial perfusion through its effects on the endothelium and microvasculature. However, the majority of patients with COVID-19 infection experience only mild symptoms, and it is unknown if their myocardial perfusion is altered after infection. OBJECTIVES The authors aimed to determine if there are abnormalities in myocardial blood flow (MBF), as measured by stress cardiac magnetic resonance (CMR), in individuals after a mild COVID-19 infection. METHODS We conducted a prospective, comparative study of individuals who had a prior mild COVID-19 infection (n = 30) and matched controls (n = 26) using stress CMR. Stress and rest myocardial blood flow (sMBF, rMBF) were quantified using the dual sequence technique. Myocardial perfusion reserve was calculated as sMBF/rMBF. Unpaired t-tests were used to test differences between the groups. RESULTS The median time interval between COVID-19 infection and CMR was 5.6 (IQR: 4-8) months. No patients with the COVID-19 infection required hospitalization. Symptoms including chest pain, shortness of breath, syncope, and palpitations were more commonly present in the group with prior COVID-19 infection than in the control group (57% vs 7%, P < 0.001). No significant differences in rMBF (1.08 ± 0.27 mL/g/min vs 0.97 ± 0.29 mL/g/min, P = 0.16), sMBF (3.08 ± 0.79 mL/g/min vs 3.06 ± 0.89 mL/g/min, P = 0.91), or myocardial perfusion reserve (2.95 ± 0.90 vs 3.39 ± 1.25, P = 0.13) were observed between the groups. CONCLUSIONS This study suggests that there are no significant abnormalities in rest or stress myocardial perfusion, and thus microvascular function, in individuals after mild COVID-19 infection.
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Affiliation(s)
- Ilya Karagodin
- Department of Medicine, NorthShore University Health System in Evanston, Chicago, Illinois, USA
| | - Shuo Wang
- Division of Cardiovascular Medicine, The University of Virginia Health System, Charlottesville, Virginia, USA
| | | | - Amita Singh
- Department of Cardiology, Central Dupage Hospital, Winfield, Illinois, USA
| | - Joseph Gutbrod
- Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Luis Landeras
- Department of Radiology, University of Chicago, Chicago, Illinois, USA
| | - Hena Patel
- Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Nazia Alvi
- Department of Cardiology, Advent Health Heart and Vascular Institute, Chicago, Illinois, USA
| | - Maxine Tang
- Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | | | | | - Holly J. Benjamin
- Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Jonathan H. Chung
- Department of Radiology, University of Chicago, Chicago, Illinois, USA
| | - Amit R. Patel
- Division of Cardiovascular Medicine, The University of Virginia Health System, Charlottesville, Virginia, USA
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Liu J, Jin J, Yu B, Zhang S, Lu X, Chen G, Yang Y, Dong H. Determinants and Prognoses of Visual-Functional Mismatches After Mechanical Reperfusion in ST-Elevation Myocardial Infarction. Int J Gen Med 2024; 17:693-704. [PMID: 38435112 PMCID: PMC10908277 DOI: 10.2147/ijgm.s444933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 02/09/2024] [Indexed: 03/05/2024] Open
Abstract
Background Discordance between the anatomy and physiology of the coronary has important implications for managing patients with stable coronary disease, but its significance in ST-elevation myocardial infarction has not been fully elucidated. Methods The retrospective study involved patients diagnosed with ST-elevation myocardial infarction (STEMI) who underwent percutaneous coronary intervention (PCI), along with quantitative coronary angiography (QCA) and quantitative flow ratio (QFR) assessments. Patients were stratified into four groups regarding the severity of the culprit vessel, both visually and functionally: concordantly negative (QCA-diameter stenosis [DS] ≤ 50% and QFR > 0.80), mismatch (QCA-DS > 50% and QFR > 0.80), reverse mismatch (QCA-DS ≤ 50% and QFR ≤ 0.80), and concordantly positive (QCA-DS > 50% and QFR ≤ 0.80). Multivariable logistic regression analyses were conducted to identify the clinical factors linked to visual-functional mismatches. Kaplan‒Meier analysis was conducted to estimate the 18-month adverse cardiovascular events (MACE)-free survival between the four groups. Results The study involved 310 patients, with 68 presenting visual-functional mismatch, and 51 exhibiting reverse mismatch. The mismatch was associated with higher angiography-derived microcirculatory resistance (AMR) (adjusted odds ratio [aOR]=1.016, 95% CI: 1.010-1.022, P<0.001). Reverse mismatch was associated with larger area stenosis (aOR=1.044, 95% CI: 1.004-1.086, P=0.032), lower coronary flow velocity (aOR=0.690, 95% CI: 0.567-0.970, P<0.001) and lower AMR (aOR=0.947, 95% CI: 0.924-0.970, P<0.001). Additionally, the mismatch group showed the worst 18-month MACE-free survival among the four groups (Log rank test p = 0.013). Conclusion AMR plays a significant role in the occurrence of visual-functional mismatches between QCA-DS and QFR, and the mismatch group showed the worst prognosis.
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Affiliation(s)
- Jieliang Liu
- Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, 510080, People’s Republic of China
| | - Junguo Jin
- Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, 510080, People’s Republic of China
| | - Bingyan Yu
- Department of Cardiology, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong, 510080, People’s Republic of China
| | - Shanghong Zhang
- Department of Cardiology, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong, 510080, People’s Republic of China
| | - Xiaoqi Lu
- Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, 510080, People’s Republic of China
| | - Guoqiang Chen
- Department of Cardiology, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong, 510080, People’s Republic of China
| | - Yi Yang
- Department of Cardiology, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong, 510080, People’s Republic of China
| | - Haojian Dong
- Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, 510080, People’s Republic of China
- Nyingchi People’s Hospital, Nyingchi, Tibet, 860000, People’s Republic of China
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Pruthi S, Siddiqui E, Smilowitz NR. Beyond Coronary Artery Disease: Assessing the Microcirculation. Cardiol Clin 2024; 42:125-135. [PMID: 37949533 PMCID: PMC11090694 DOI: 10.1016/j.ccl.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
Ischemic heart disease (IHD) affects more than 20 million adults in the United States. Although classically attributed to atherosclerosis of the epicardial coronary arteries, nearly half of patients with stable angina and IHD who undergo invasive coronary angiography do not have obstructive epicardial coronary artery disease. Ischemia with nonobstructive coronary arteries is frequently caused by microvascular angina with underlying coronary microvascular dysfunction (CMD). Greater understanding the pathophysiology, diagnosis, and treatment of CMD holds promise to improve clinical outcomes of patients with ischemic heart disease.
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Affiliation(s)
- Sonal Pruthi
- Division of Cardiology, Department of Medicine, NYU Langone Health, 550 First Avenue, New York, NY 10016, USA
| | - Emaad Siddiqui
- Division of Cardiology, Department of Medicine, NYU Langone Health, 550 First Avenue, New York, NY 10016, USA
| | - Nathaniel R Smilowitz
- Division of Cardiology, Department of Medicine, NYU Langone Health, 550 First Avenue, New York, NY 10016, USA; Cardiology Section, Department of Medicine, VA New York Harbor Healthcare System, 423 East 23rd Street, New York, NY 10010, USA; The Leon H. Charney Division of Cardiology, NYU Langone Health, NYU School of Medicine, 423 East 23rd Street, 12-West, New York, NY 10010, USA.
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Ciaramella L, Di Serafino L, Mitrano L, De Rosa ML, Carbone C, Rea FS, Monaco S, Scalamogna M, Cirillo P, Esposito G. Invasive Assessment of Coronary Microcirculation: A State-of-the-Art Review. Diagnostics (Basel) 2023; 14:86. [PMID: 38201395 PMCID: PMC10795746 DOI: 10.3390/diagnostics14010086] [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: 12/01/2023] [Revised: 12/28/2023] [Accepted: 12/28/2023] [Indexed: 01/12/2024] Open
Abstract
A significant proportion of patients presenting with signs and symptoms of myocardial ischemia have no "significant" epicardial disease; thereby, the assessment of coronary microcirculation gained an important role in improving diagnosis and guiding therapy. In fact, coronary microvascular dysfunction (CMD) could be found in a large proportion of these patients, supporting both symptoms and signs of myocardial ischemia. However, CMD represents a diagnostic challenge for two main reasons: (1) the small dimension of the coronary microvasculature prevents direct angiographic visualization, and (2) despite the availability of specific diagnostic tools, they remain invasive and underused in the current clinical practice. For these reasons, CMD remains underdiagnosed, and most of the patients remain with no specific treatment and quality-of-life-limiting symptoms. Of note, recent evidence suggests that a "full physiology" approach for the assessment of the whole coronary vasculature may offer a significant benefit in terms of symptom improvement among patients presenting with ischemia and non-obstructive coronary artery disease. We analyze the pathophysiology of coronary microvascular dysfunction, providing the readers with a guide for the invasive assessment of coronary microcirculation, together with the available evidence supporting its use in clinical practice.
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Affiliation(s)
| | - Luigi Di Serafino
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Via Pansini 5, 80131 Naples, Italy; (L.C.); (L.M.); (M.L.D.R.); (C.C.); (F.S.R.); (S.M.); (M.S.); (P.C.); (G.E.)
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Kest M, Ágoston A, Szabó GT, Kiss A, Üveges Á, Czuriga D, Komócsi A, Hizoh I, Kőszegi Z. Angiography-based coronary microvascular assessment with and without intracoronary pressure measurements: a systematic review. Clin Res Cardiol 2023:10.1007/s00392-023-02338-6. [PMID: 37987840 DOI: 10.1007/s00392-023-02338-6] [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: 08/18/2023] [Accepted: 10/30/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND In recent years, several indices have been proposed for quantifying coronary microvascular resistance. We intended to conduct a comprehensive review that systematically evaluates indices of microvascular resistance derived from angiography. OBJECTIVE The objective of this study was to identify and analyze angiography-derived indices of microvascular resistance that have been validated against an invasive reference method. We aimed to compare their limits of agreement with their reference methods and explore their advantages and inherent limitations. METHODS AND RESULTS We searched PubMed from inception until 2022 for studies on different techniques for quantifying microvascular resistance. Seven studies met the inclusion criteria. Five studies included techniques that applied calculations based solely on invasive angiography, and were validated against invasively measured thermodilution-derived index of microvascular resistance. The remaining two studies combined angiography with invasively measured intracoronary pressure data, and were validated against invasive Doppler measurements. We converted the ± 1.96 standard deviation limits of agreement with the reference method from the seven studies into percentages relative to the cut-off value of the reference method. The lower limits of agreement for angiography-based methods ranged from - 122 to - 60%, while the upper limits ranged from 74 to 135%. The range of the limits of agreement was considerably lower for the two combined angiography- and pressure-based methods, standing at - 52 to 60% and - 25 to 27%. CONCLUSION Our findings suggest that combined angiography- and pressure-based methods provide a more reliable assessment of microvascular resistance compared to methods relying solely on angiography. Central illustration. Comparative assessment of image-based methods quantifying microvascular resistance with and without intracoronary pressure measurements. Angiography-based methods rely on angiography alone to calculate the microvascular resistance by utilizing angiographic frame counting to extrapolate coronary flow (Q) and subsequently deriving distal coronary pressure using fluid dynamic equations. Combined angiography- and pressure-based methods utilize invasive intracoronary pressure gradients measured during rest and maximal vasodilation to determine coronary flow in their calculation of microvascular resistance. The combined methods showed more acceptable levels of agreement with their reference methods compared to angiography-based methods alone.
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Affiliation(s)
- Michael Kest
- Szabolcs-Szatmár-Bereg County Hospitals and University Teaching Hospital, Nyíregyháza, Hungary
| | - András Ágoston
- Szabolcs-Szatmár-Bereg County Hospitals and University Teaching Hospital, Nyíregyháza, Hungary
- Kálmán Laki Doctoral School of Biomedical and Clinical Sciences, University of Debrecen, Debrecen, Hungary
| | - Gábor Tamás Szabó
- Division of Cardiology, Department of Cardiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
- Kálmán Laki Doctoral School of Biomedical and Clinical Sciences, University of Debrecen, Debrecen, Hungary
- Center for Biomedical Research and Translational Surgery, Medical University Vienna, Vienna, Austria
| | - Attila Kiss
- Center for Biomedical Research and Translational Surgery, Medical University Vienna, Vienna, Austria
| | - Áron Üveges
- Szabolcs-Szatmár-Bereg County Hospitals and University Teaching Hospital, Nyíregyháza, Hungary
- Kálmán Laki Doctoral School of Biomedical and Clinical Sciences, University of Debrecen, Debrecen, Hungary
| | - Dániel Czuriga
- Division of Cardiology, Department of Cardiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
- Kálmán Laki Doctoral School of Biomedical and Clinical Sciences, University of Debrecen, Debrecen, Hungary
| | - András Komócsi
- Heart Institute, Medical School, University of Pécs, Pécs, Hungary
| | - István Hizoh
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Zsolt Kőszegi
- Szabolcs-Szatmár-Bereg County Hospitals and University Teaching Hospital, Nyíregyháza, Hungary.
- Division of Cardiology, Department of Cardiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary.
- Kálmán Laki Doctoral School of Biomedical and Clinical Sciences, University of Debrecen, Debrecen, Hungary.
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10
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Schweiger V, Gilhofer T, Fang R, Candreva A, Seifert B, Di Vece D, Wuerdinger M, Koleva I, Rajman K, Cieslik M, Gotschy A, Michel J, Stehli J, Niederseer D, Ryberg L, Ghadri J, Ruschitzka F, Stähli B, Cammann VL, Templin C. Coronary microvascular dysfunction in Takotsubo syndrome: an analysis using angiography-derived index of microcirculatory resistance. Clin Res Cardiol 2023:10.1007/s00392-023-02329-7. [PMID: 37985475 DOI: 10.1007/s00392-023-02329-7] [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: 08/29/2023] [Accepted: 10/18/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND Coronary microvascular dysfunction (CMD) has been proposed as a crucial factor in the pathophysiology of Takotsubo syndrome (TTS). The angiography-derived index of microcirculatory resistance (caIMR) offers an alternative to conventional hyperemic wire-based IMR to assess CMD. We aimed to evaluate CMD's prevalence, transience, and impact on in-hospital outcomes in TTS. METHODS All three coronary arteries of 96 patients with TTS were assessed for their coronary angiography derived Index of microcirculatory Resistance (caIMR) and compared to non-obstructed vessels of matched patients with ST-elevation myocardial infarction. Further, the association between caIMR and the TTS-specific combined in-hospital endpoint of death, cardiac arrest, ventricular arrhythmogenic events and cardiogenic shock was investigated. RESULTS Elevated IMR was present in all TTS patients, with significantly elevated caIMR values in all coronary arteries compared to controls. CaIMR did not differ between apical and midventricular TTS types. CaIMR normalized in TTS patients with follow-up angiographies performed at a median of 28 months (median caIMR at event vs follow-up: LAD 34.8 [29.9-41.1] vs 20.3 [16.0-25.3], p < 0.001; LCX: 38.7 [32.9-50.1] vs 23.7 [19.4-30.5], p < 0.001; RCA: 31.7 [25.0-39.1] vs 19.6 [17.1-24.0], p < 0.001). The extent of caIMR elevation significantly correlated with the combined in-hospital endpoint (p = 0.036). CONCLUSION TTS patients had evidence of elevated caIMR in at least one coronary artery with a trend towards higher LAD caIMR in apical type TTS and normalization after recovery. Furthermore, extent of caIMR elevation was associated with increased risk of in-hospital MACE of TTS patients.
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Affiliation(s)
- Victor Schweiger
- Department of Cardiology, University Heart Centre, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Thomas Gilhofer
- Department of Cardiology, University Heart Centre, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Rick Fang
- Suzhou Rainmed Medical Technology Co., Ltd, Building 31, Northeast District, Nano City, No. 99 Jinji Lake Avenue, Suzhou Industrial Park, Suzhou, China
| | - Alessandro Candreva
- Department of Cardiology, University Heart Centre, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Burkhardt Seifert
- Division of Biostatistics, Epidemiology, Biostatistics, and Prevention Institute, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Davide Di Vece
- Department of Cardiology, University Heart Centre, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Michael Wuerdinger
- Department of Cardiology, University Heart Centre, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Iva Koleva
- Department of Cardiology, University Heart Centre, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Katja Rajman
- Department of Cardiology, University Heart Centre, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Maciej Cieslik
- Department of Cardiology, University Heart Centre, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Alexander Gotschy
- Department of Cardiology, University Heart Centre, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Jonathan Michel
- Department of Cardiology, University Heart Centre, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Julia Stehli
- Department of Cardiology, University Heart Centre, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - David Niederseer
- Department of Cardiology, University Heart Centre, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Linn Ryberg
- Department of Cardiology, University Heart Centre, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Jelena Ghadri
- Department of Cardiology, University Heart Centre, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Frank Ruschitzka
- Department of Cardiology, University Heart Centre, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Barbara Stähli
- Department of Cardiology, University Heart Centre, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Victoria Lucia Cammann
- Department of Cardiology, University Heart Centre, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Christian Templin
- Department of Cardiology, University Heart Centre, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.
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11
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Huang D, Gong Y, Fan Y, Zheng B, Lu Z, Li J, Huo Y, Escaned J, Huo Y, Ge J. Coronary angiography-derived index for assessing microcirculatory resistance in patients with non-obstructed vessels: The FLASH IMR study. Am Heart J 2023; 263:56-63. [PMID: 37054908 DOI: 10.1016/j.ahj.2023.03.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 03/21/2023] [Accepted: 03/31/2023] [Indexed: 06/03/2023]
Abstract
BACKGROUND Assessing index of microcirculatory resistance (IMR) is customarily performed using intracoronary wires fitted with sensors by at least 3 intracoronary injections of 3 to 4 mL of room-temperature saline during sustained hyperemia, which is time- and cost-consuming. METHODS The FLASH IMR study is a prospective, multicenter, randomized study to assess the diagnostic performance of coronary angiography-derived IMR (caIMR) in patients with suspected myocardial ischemia with nonobstructive coronary arteries using wire-based IMR as a reference. The caIMR was calculated by an optimized computational fluid dynamics model simulating hemodynamics during diastole based on coronary angiograms. TIMI frame count and aortic pressure were included in computation. caIMR was determined onsite in real time and compared blind to wire-based IMR by an independent core laboratory, using wire-based IMR ≥25 units as indicative of abnormal coronary microcirculatory resistance. The primary endpoint was the diagnostic accuracy of caIMR, using wire-based IMR as a reference, with a pre-specified performance goal of 82%. RESULTS A total of 113 patients underwent paired caIMR and wire-based IMR measurements. Order of performance of tests was based on randomization. Diagnostic accuracy, sensitivity, specificity, positive and negative predictive values of caIMR were 93.8% (95% CI: 87.7%-97.5%), 95.1% (95% CI: 83.5%- 99.4%), 93.1% (95% CI: 84.5%-97.7%), 88.6% (95% CI: 75.4%-96.2%) and 97.1% (95% CI: 89.9%-99.7%). The receiver-operating curve for caIMR to diagnose abnormal coronary microcirculatory resistance had area under the curve of 0.963 (95% CI: 0.928-0.999). CONCLUSIONS Angiography-based caIMR has a good diagnostic yield with wire-based IMR. CLINICALTRIALS GOV IDENTIFIER NCT05009667.
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Affiliation(s)
- Dong Huang
- Department of Cardiology, Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yanjun Gong
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Yongzhen Fan
- Department of Cardiology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Bo Zheng
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Zhibing Lu
- Department of Cardiology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Jianping Li
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Yunlong Huo
- PKU-HKUST Shenzhen-Hongkong Institution, Shenzhen, Guangdong, China; Institute of Mechanobiology & Medical Engineering, School of Life Sciences & Biotechnology, Shanghai Jiao Tong University, Shanghai, China
| | - Javier Escaned
- Department of Cardiology, Hospital Clinico San Carlos IDISSC, Universidad Complutense de Madrid, Madrid, Spain
| | - Yong Huo
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Junbo Ge
- Department of Cardiology, Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, China.
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12
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Scoccia A, Neleman T, Ziedses des Plantes AC, Groenland FT, M R Ligthart J, den Dekker WK, Diletti R, Wilschut J, Jan Nuis R, Zijlstra F, Boersma E, Van Mieghem NM, Daemen J. Predictors of discordance between fractional flow reserve (FFR) and diastolic pressure ratio (dPR) in intermediate coronary lesions. IJC HEART & VASCULATURE 2023; 47:101217. [PMID: 37576077 PMCID: PMC10422661 DOI: 10.1016/j.ijcha.2023.101217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 04/24/2023] [Accepted: 04/30/2023] [Indexed: 08/15/2023]
Abstract
Background Recently, non-hyperemic pressure ratios (NHPRs) have been validated as a reliable alternative to fractional flow reserve (FFR). However, a discordance between FFR and NHPRs is observed in 20-25% of cases. The aim of this study is to evaluate predictors of discordance between FFR and diastolic Pressure ratio (dPR). Methods PREDICT is a retrospective, single center, investigator-initiated study including 813 patients (1092vessels) who underwent FFR assessment of intermediate coronary lesions (angiographic 30%-80% stenosis). dPR was calculated using individual pressure waveforms and dedicated software. Clinical, angiographic and hemodynamic variables were compared between patients with concordant and discordant FFR and dPR values. Results Median age was 65 (IQR:59-73) years and 70% were male. Hemodynamically significant lesions, as defined by FFR ≤ 0.80, and dPR ≤ 0.89, were identified in 29.6% and 30.3% of cases, respectively. Overall, FFR and dPR values were discordant in 22.1% patients (17.4% of the vessels). Discordance was related to FFR+/dPR- and FFR-/dPR + in 11.8% and 10.3% of patients, respectively.In case of FFR-dPR discordance, a higher prevalence of left anterior descending arteries lesions was observed (70.5% vs. 53.1%, p < 0.001) and mean values of both FFR and dPR were significantly lower (FFR 0.81 ± 0.05 vs 0.85 ± 0.08, p < 0.001, and dPR 0.89 ± 0.04 vs 0.92 ± 0.08,p < 0.001) as compared to vessels with FFR and dPR concordance. Following multivariable adjustment, dPR delta (defined as the absolute difference between measured dPR to the cut-off value of 0.89) turned out to be the only independent predictor of discordance (OR = 0.74, 95% CI 0.68-0.79, p < 0.001). Conclusion Our study suggests that FFR-to-dPR discordance occurs in approximately one-fifth of patients. Absolute dPR delta appears to be the only independent predictor of discordance.
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Affiliation(s)
- Alessandra Scoccia
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Tara Neleman
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | - Frederik T.W. Groenland
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Jurgen M R Ligthart
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Wijnand K. den Dekker
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Roberto Diletti
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Jeroen Wilschut
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Rutger Jan Nuis
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Felix Zijlstra
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Eric Boersma
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Nicolas M Van Mieghem
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Joost Daemen
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
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13
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Noaman S, Kaye DM, Nanayakkara S, Dart AM, Yong ASC, Ng M, Vizi D, Duffy SJ, Cox N, Chan W. Haemodynamic and metabolic adaptations in coronary microvascular disease. Heart 2023; 109:1166-1174. [PMID: 36931716 DOI: 10.1136/heartjnl-2022-322156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 03/06/2023] [Indexed: 03/19/2023] Open
Abstract
OBJECTIVE We aimed to evaluate the microcirculatory resistance (MR) and myocardial metabolic adaptations at rest and in response to increased cardiac workload in patients with suspected coronary microvascular dysfunction (CMD). METHODS Patients with objective ischaemia and/or myocardial injury and non-obstructive coronary artery disease underwent thermodilution-derived microcirculatory assessment and transcardiac blood sampling during graded exercise with adenosine-mediated hyperaemia. We measured MR at rest and following supine cycle ergometry. Patients (n=24) were stratified by the resting index of MR (IMR) into normal-IMR (IMR<22U, n=12) and high-IMR groups (IMR≥22U, n=12). RESULTS The mean age was 57 years; 67% were males and 38% had hypertension. The normal-IMR group had increased IMR response to exercise (16±5 vs 23±12U, p=0.03) compared with the high-IMR group, who had persistently elevated IMR at rest and following exercise (38±19 vs 33±15U, p=0.39) despite similar exercise duration and rate-pressure product between the groups, both p>0.05. The normal-IMR group had augmented oxygen extraction ratio following exercise (53±18 vs 64±11%, p=0.03) compared with the high-IMR group (65±14 vs 59±11%, p=0.26). The postexercise lactate uptake was greater in the high-IMR (0.04±0.05 vs 0.11±0.07 mmol/L, p=0.004) compared with normal-IMR group (0.08±0.06 vs 0.09±0.09 mmol/L, p=0.67). The high-IMR group demonstrated greater troponin release following exercise compared with the normal-IMR group (0.13±0.12 vs 0.001±0.05 ng/L, p=0.03). CONCLUSIONS Patients with suspected CMD appear to have distinctive microcirculatory resistive and myocardial metabolic profiles at rest and in response to exercise. These differences in phenotypes may permit individualised therapies targeting microvascular responsiveness (normal-IMR group) and/or myocardial metabolic adaptations (normal-IMR and high-IMR groups).
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Affiliation(s)
- Samer Noaman
- Cardiology, Alfred Health, Melbourne, Victoria, Australia
- Heart Failure Research Group, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
- Western Health, Footscray, Victoria, Australia
| | - David M Kaye
- Cardiology, Alfred Health, Melbourne, Victoria, Australia
- Heart Failure Research Group, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Shane Nanayakkara
- Cardiology, Alfred Health, Melbourne, Victoria, Australia
- Heart Failure Research Group, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Anthony M Dart
- Cardiology, Alfred Health, Melbourne, Victoria, Australia
| | - Andy S C Yong
- Cardiology, Concord Hospital, Sydney, New South Wales, Australia
| | - Martin Ng
- Medicine, The University of Sydney, Sydney, New South Wales, Australia
- Cardiology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Donna Vizi
- Cardiology, Alfred Health, Melbourne, Victoria, Australia
| | | | | | - William Chan
- Cardiology, Alfred Health, Melbourne, Victoria, Australia
- Heart Failure Research Group, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
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14
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Gallinoro E, Bertolone DT, Fernandez-Peregrina E, Paolisso P, Bermpeis K, Esposito G, Gomez-Lopez A, Candreva A, Mileva N, Belmonte M, Mizukami T, Fournier S, Vanderheyden M, Wyffels E, Bartunek J, Sonck J, Barbato E, Collet C, De Bruyne B. Reproducibility of bolus versus continuous thermodilution for assessment of coronary microvascular function in patients with ANOCA. EUROINTERVENTION 2023; 19:e155-e166. [PMID: 36809253 PMCID: PMC10242662 DOI: 10.4244/eij-d-22-00772] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 01/04/2023] [Indexed: 02/23/2023]
Abstract
BACKGROUND A bolus thermodilution-derived index of microcirculatory resistance (IMR) has emerged as the standard for assessing coronary microvascular dysfunction (CMD). Continuous thermodilution has recently been introduced as a tool to quantify absolute coronary flow and microvascular resistance directly. Microvascular resistance reserve (MRR) derived from continuous thermodilution has been proposed as a novel metric of microvascular function, which is independent of epicardial stenoses and myocardial mass. AIMS We aimed to assess the reproducibility of bolus and continuous thermodilution in assessing coronary microvascular function. METHODS Patients with angina and non-obstructive coronary artery disease (ANOCA) at angiography were prospectively enrolled. Bolus and continuous intracoronary thermodilution measurements were obtained in duplicate in the left anterior descending artery (LAD). Patients were randomly assigned in a 1:1 ratio to undergo either bolus thermodilution first or continuous thermodilution first. RESULTS A total of 102 patients were enrolled. The mean fractional flow reserve (FFR) was 0.86±0.06. Coronary flow reserve (CFR) calculated with continuous thermodilution (CFRcont) was significantly lower than bolus thermodilution-derived CFR (CFRbolus; 2.63±0.65 vs 3.29±1.17; p<0.001). CFRcont showed a higher reproducibility than CFRbolus (variability: 12.7±10.4% continuous vs 31.26±24.85% bolus; p<0.001). MRR showed a higher reproducibility than IMR (variability 12.4±10.1% continuous vs 24.2±19.3% bolus; p<0.001). No correlation was found between MRR and IMR (r=0.1, 95% confidence interval: -0.09 to 0.29; p=0.305). CONCLUSIONS In the assessment of coronary microvascular function, continuous thermodilution demonstrated significantly less variability on repeated measurements than bolus thermodilution.
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Affiliation(s)
- Emanuele Gallinoro
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium
- Department of Translational Medical Sciences, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - Dario Tino Bertolone
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium
- Department of Advanced Biomedical Sciences, University Federico II, Naples, Turin, Italy
| | | | - Pasquale Paolisso
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium
- Department of Advanced Biomedical Sciences, University Federico II, Naples, Turin, Italy
| | | | - Giuseppe Esposito
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium
- Department of Advanced Biomedical Sciences, University Federico II, Naples, Turin, Italy
| | | | - Alessandro Candreva
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium
- Department of Cardiology, Zurich University Hospital, Zurich, Switzerland
- Department of Mechanical and Aerospace Engineering, PolitoBIO Med Lab, Politecnico di Torino, Italy
| | - Niya Mileva
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium
| | | | | | - Stephane Fournier
- Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
| | | | - Eric Wyffels
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium
| | | | - Jeroen Sonck
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium
| | - Emanuele Barbato
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium
- Department of Advanced Biomedical Sciences, University Federico II, Naples, Turin, Italy
| | - Carlos Collet
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium
| | - Bernard De Bruyne
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium
- Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
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15
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Nicolaisen J, Karim SR, Rasmussen LD, Winther S, Bøttcher M, Eftekhari A, Christiansen EH, Westra J. Interterritorial Variation in Myocardial Microcirculatory Function. JACC Cardiovasc Interv 2023:S1936-8798(23)00681-7. [PMID: 37354164 DOI: 10.1016/j.jcin.2023.03.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 03/24/2023] [Accepted: 03/28/2023] [Indexed: 06/26/2023]
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16
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Factors Associated with Impaired Resistive Reserve Ratio and Microvascular Resistance Reserve. Diagnostics (Basel) 2023; 13:diagnostics13050950. [PMID: 36900097 PMCID: PMC10000988 DOI: 10.3390/diagnostics13050950] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 02/22/2023] [Accepted: 03/01/2023] [Indexed: 03/06/2023] Open
Abstract
Coronary microvascular dysfunction (CMD) is described as an important subset of ischemia with no obstructive coronary artery disease. Resistive reserve ratio (RRR) and microvascular resistance reserve (MRR) have been proposed as novel physiological indices evaluating coronary microvascular dilation function. The aim of this study was to explore factors associated with impaired RRR and MRR. Coronary physiological indices were invasively evaluated in the left anterior descending coronary artery using the thermodilution method in patients suspected of CMD. CMD was defined as a coronary flow reserve <2.0 and/or index of microcirculatory resistance ≥25. Of 117 patients, 26 (24.1%) had CMD. RRR (3.1 ± 1.9 vs. 6.2 ± 3.2, p < 0.001) and MRR (3.4 ± 1.9 vs. 6.9 ± 3.5, p < 0.001) were lower in the CMD group. In the receiver operating characteristic curve analysis, RRR (area under the curve 0.84, p < 0.001) and MRR (area under the curve 0.85, p < 0.001) were both predictive of the presence of CMD. In the multivariable analysis, previous myocardial infarction, lower hemoglobin, higher brain natriuretic peptide levels, and intracoronary nicorandil were identified as factors associated with lower RRR and MRR. In conclusion, the presence of previous myocardial infarction, anemia, and heart failure was associated with impaired coronary microvascular dilation function. RRR and MRR may be useful to identify patients with CMD.
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17
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Wang B, Gao Y, Zhao Y, Xu C, Zhao S, Li H, Zhang Y, Xu Y. The spectrum of angiography-derived IMR according to morphological and physiological coronary stenosis in patients with suspected myocardial ischemia. Clin Cardiol 2023; 46:502-511. [PMID: 36855931 DOI: 10.1002/clc.23999] [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: 10/17/2022] [Revised: 02/09/2023] [Accepted: 02/11/2023] [Indexed: 03/02/2023] Open
Abstract
BACKGROUND Coronary microvascular dysfunction is crucial in determining myocardial ischemia; however, the relationship between epicardial coronary diameter stenosis (DS) and the index of microcirculatory resistance (IMR) remains unclear. We sought to explore the distribution of coronary angiography-derived IMR (angio-IMR) in patients with suspected myocardial ischemia. METHODS The study included 480 patients with suspected myocardial ischemia, all of whom underwent coronary angiography. According to the severity of coronary DS, patients were divided into three groups: mild (DS < 50%), intermediate (DS 50%-70%), and severe (DS > 70%). Angio-IMR and fractional flow reserve (FFR) were calculated based on coronary angiography images through the principle of computational flow and pressure simulation. RESULTS Of the 480 patients, the mean age was 67.23 ± 9.44 years, with 55.4% male. There were 193 (40.2%) patients in the mild group, 189 (39.4%) patients in the intermediate group, and 98 (20.4%) patients in the severe group. The average angio-IMR of the mild group was 30.8 ± 14.9, which was significantly higher than those of the intermediate group (26.7 ± 13.0) and the severe group (17.9 ± 8.4) (p < .001). In the correlation analysis, angio-IMR was negatively correlated with DS (rho = -0.331, p = .001) and positively correlated with angio-FFR (rho = 0.483, p < .001). By multivariate logistic regression analysis, angio-FFR ≤ 0.8 (odds ratio, 0.184; 95% confidence interval, 0.106-0.321) was the only independent predictor of coronary microvascular dysfunction. CONCLUSION In patients with suspected myocardial ischemia, coronary microcirculation is significantly associated with morphological and physiological coronary stenosis. (ClinicalTrials.gov: NCT05435898).
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Affiliation(s)
- Bo Wang
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yue Gao
- Department of Cardiology, North Station Hospital of Jing'an District, Shanghai, China
| | - Yifan Zhao
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Chong Xu
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Song Zhao
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Hailing Li
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yi Zhang
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yawei Xu
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
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18
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Pruthi S, Siddiqui E, Smilowitz NR. Beyond Coronary Artery Disease: Assessing the Microcirculation. Interv Cardiol Clin 2023; 12:119-129. [PMID: 36372455 PMCID: PMC10019932 DOI: 10.1016/j.iccl.2022.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Ischemic heart disease (IHD) affects more than 20 million adults in the United States. Although classically attributed to atherosclerosis of the epicardial coronary arteries, nearly half of patients with stable angina and IHD who undergo invasive coronary angiography do not have obstructive epicardial coronary artery disease. Ischemia with nonobstructive coronary arteries is frequently caused by microvascular angina with underlying coronary microvascular dysfunction (CMD). Greater understanding the pathophysiology, diagnosis, and treatment of CMD holds promise to improve clinical outcomes of patients with ischemic heart disease.
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Affiliation(s)
- Sonal Pruthi
- Division of Cardiology, Department of Medicine, NYU Langone Health, 550 First Avenue, New York, NY 10016, USA
| | - Emaad Siddiqui
- Division of Cardiology, Department of Medicine, NYU Langone Health, 550 First Avenue, New York, NY 10016, USA
| | - Nathaniel R Smilowitz
- Division of Cardiology, Department of Medicine, NYU Langone Health, 550 First Avenue, New York, NY 10016, USA; Cardiology Section, Department of Medicine, VA New York Harbor Healthcare System, 423 East 23rd Street, New York, NY 10010, USA; The Leon H. Charney Division of Cardiology, NYU Langone Health, NYU School of Medicine, 423 East 23rd Street, 12-West, New York, NY 10010, USA.
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19
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Zavadovsky KV, Mochula AV, Maltseva AN, Shipulin VV, Sazonova SI, Gulya MO, Liga R, Gimelli A. The current status of CZT SPECT myocardial blood flow and reserve assessment: Tips and tricks. J Nucl Cardiol 2022; 29:3137-3151. [PMID: 33939162 DOI: 10.1007/s12350-021-02620-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 03/29/2021] [Accepted: 03/29/2021] [Indexed: 01/18/2023]
Abstract
Cardiac PET-derived measurements of myocardial blood flow (MBF) and myocardial flow reserve (MFR) are proven robust indexes of the severity of coronary artery disease (CAD). They facilitate the diagnosis of diffuse epicardial and microvascular disease and are also of prognostic significance. However, low availability and high cost have limited their wide clinical implementation. Over the last 15 years, cadmium zinc telluride (CZT)-based detectors have been implemented into SPECT imaging devices. Myocardial perfusion scintigraphy can be performed faster and with less radiation exposure as compared with standard gamma cameras. Rapid dynamic SPECT studies with higher count rates can be performed. This technological breakthrough has renewed the interest in SPECT MBF assessment in patients with CAD. Currently, two cardiac-centered CZT gamma cameras are available commercially-Discovery NM530c and D-SPECT. They differ in parameters such as collimator design, number of detectors, sensitivity, spatial resolution and image reconstruction. A number of publications have focused on the feasibility of dynamic CZT SPECT and on the correlation with cardiac PET and invasive coronary angiography measurements of fractional flow reserve. Current study reviews the present status of MBF and MFR assessment with CZT SPECT. It also aims to provide an overview of specific issues related to acquisition, processing and interpretation of quantitative studies in patients with CAD.
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Affiliation(s)
- Konstantin V Zavadovsky
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Kievskaya Str 111A, Tomsk, 634012, Russia.
- Siberian State Medical University, Tomsk, Russia.
| | - Andrew V Mochula
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Kievskaya Str 111A, Tomsk, 634012, Russia
| | - Alina N Maltseva
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Kievskaya Str 111A, Tomsk, 634012, Russia
| | - Vladimir V Shipulin
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Kievskaya Str 111A, Tomsk, 634012, Russia
| | - Svetlana I Sazonova
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Kievskaya Str 111A, Tomsk, 634012, Russia
| | - Marina O Gulya
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Kievskaya Str 111A, Tomsk, 634012, Russia
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20
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Travieso A, Jeronimo-Baza A, Faria D, Shabbir A, Mejia-Rentería H, Escaned J. Invasive evaluation of coronary microvascular dysfunction. J Nucl Cardiol 2022; 29:2474-2486. [PMID: 35618991 PMCID: PMC9553758 DOI: 10.1007/s12350-022-02997-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 04/10/2022] [Indexed: 12/02/2022]
Abstract
Coronary microvascular dysfunction (CMD) is a prevalent cause of ischemic heart disease and is associated with poorer quality of life and worse patient outcomes. Both functional and structural abnormalities of the microcirculation can generate ischemia in the absence of epicardial stenosis or worsen concomitant obstructive coronary artery disease (CAD). The invasive assessment of CMD allows for the evaluation of the entirety of the coronary vascular tree, from the large epicardial vessels to the microcirculation, and enables the study of vasomotor function through vasoreactivity testing. The standard evaluation of CMD includes vasomotor assessment with acetylcholine, as well as flow- and resistance-derived indices calculated with either thermodilution or Doppler guidewires. Tailored treatment based upon the information gathered from the invasive evaluation of CMD has been demonstrated to reduce the burden of angina; therefore, a thorough understanding of these procedures is warranted with the aim of improving the quality of life of the patient. This review summarizes the most widespread approaches for the invasive evaluation of CMD, with a focus on patients with ischemia and non-obstructive CAD.
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Affiliation(s)
- Alejandro Travieso
- Hospital Clinico San Carlos IDISSC, Complutense University of Madrid, c/ Profesor Martin Lagos, s/n, 28040, Madrid, Spain
| | - Adrian Jeronimo-Baza
- Hospital Clinico San Carlos IDISSC, Complutense University of Madrid, c/ Profesor Martin Lagos, s/n, 28040, Madrid, Spain
| | - Daniel Faria
- Hospital Clinico San Carlos IDISSC, Complutense University of Madrid, c/ Profesor Martin Lagos, s/n, 28040, Madrid, Spain
| | - Asad Shabbir
- Hospital Clinico San Carlos IDISSC, Complutense University of Madrid, c/ Profesor Martin Lagos, s/n, 28040, Madrid, Spain
| | - Hernan Mejia-Rentería
- Hospital Clinico San Carlos IDISSC, Complutense University of Madrid, c/ Profesor Martin Lagos, s/n, 28040, Madrid, Spain
| | - Javier Escaned
- Hospital Clinico San Carlos IDISSC, Complutense University of Madrid, c/ Profesor Martin Lagos, s/n, 28040, Madrid, Spain.
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21
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Aguiar Rosa S, Mota Carmo M, Rocha Lopes L, Oliveira E, Thomas B, Baquero L, Cruz Ferreira R, Fiarresga A. Index of microcirculatory resistance in the assessment of coronary microvascular dysfunction in hypertrophic cardiomyopathy. Rev Port Cardiol 2022; 41:761-767. [DOI: 10.1016/j.repc.2021.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 06/22/2021] [Accepted: 07/27/2021] [Indexed: 10/17/2022] Open
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22
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Zhou J, Onuma Y, Garg S, Kotoku N, Kageyama S, Masuda S, Ninomiya K, Huo Y, Reiber JHC, Tu S, Piek JJ, Escaned J, Perera D, Bourantas C, Yan H, Serruys PW. Angiography derived assessment of the coronary microcirculation: is it ready for prime time? Expert Rev Cardiovasc Ther 2022; 20:549-566. [PMID: 35899781 DOI: 10.1080/14779072.2022.2098117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Non-obstructive coronary arteries (NOCA) are present in 39.7% to 62.4% of patients who undergo elective angiography. Coronary microcirculation (<400 µm) is not visible on angiography therefore functional assessment, invasive or non-invasive plays a prior role to help provide a more personalized diagnosis of angina. AREA COVERED In this review, we revise the pathophysiology, clinical importance and invasive assessment of the coronary microcirculation, and discuss angiography-derived indices of microvascular resistance. A comprehensive literature review over four decades is also undertaken. EXPERT OPINION The coronary microvasculature plays an important role in flow autoregulation and metabolic regulation. Invasive assessment of microvascular resistance is a validated modality with independent prognostic value, nevertheless, its routine application is hampered by the requirement of intravascular instrumentation and hyperaemic agents. The angiography-derived index of microvascular resistance has emerged as a promising surrogate in pilot studies, however, more data are needed to validate and compare the diagnostic and prognostic accuracy of different equations as well as to illustrate the relationship between angiography-derived parameters for epicardial coronary arteries and those for the microvasculature.
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Affiliation(s)
- Jinying Zhou
- National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China.,Department of Cardiology, National University of Ireland Galway (NUIG), Galway, Ireland
| | - Yoshinobu Onuma
- Department of Cardiology, National University of Ireland Galway (NUIG), Galway, Ireland
| | - Scot Garg
- Department of CardiologyRoyal Blackburn Hospital, Blackburn, United Kingdom
| | - Nozomi Kotoku
- Department of Cardiology, National University of Ireland Galway (NUIG), Galway, Ireland
| | - Shigetaka Kageyama
- Department of Cardiology, National University of Ireland Galway (NUIG), Galway, Ireland
| | - Shinichiro Masuda
- Department of Cardiology, National University of Ireland Galway (NUIG), Galway, Ireland
| | - Kai Ninomiya
- Department of Cardiology, National University of Ireland Galway (NUIG), Galway, Ireland
| | - Yunlong Huo
- PKU-HKUST Shenzhen-Hong Kong Institution, Shenzhen, China; Department of Cardiology, Peking University First Hospital, Beijing, China; Institute of Mechanobiology & Medical Engineering, School of Life Sciences & Biotechnology, Shanghai Jiao Tong University, Shanghai, China
| | - Johan H C Reiber
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Shengxian Tu
- School of Biomedical Engineering,Biomedical Instrument Institute Shanghai Jiao Tong University, Shanghai, China
| | - Jan J Piek
- Department of Cardiology, Academic Medical Center of Amsterdam, Amsterdam, The Netherlands
| | - Javier Escaned
- Complutense University of Madrid Hospital Clinico San Carlos IDISCC, Madrid, Spain
| | - Divaka Perera
- Cardiovascular Division, King's College London, London, UK
| | - Christos Bourantas
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, UK; Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, UK; Institute of Cardiovascular Sciences, University College London, London, UK
| | - Hongbing Yan
- Chinese Academy of Medical Sciences, Shenzhen, China; Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital,, Beijing, China
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23
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Geng Y, Liu H, Wang X, Zhang J, Gong Y, Zheng D, Jiang J, Xia L. Effect of microcirculatory dysfunction on coronary hemodynamics: A pilot study based on computational fluid dynamics simulation. Comput Biol Med 2022; 146:105583. [DOI: 10.1016/j.compbiomed.2022.105583] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 04/21/2022] [Accepted: 04/30/2022] [Indexed: 01/09/2023]
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24
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Jiang J, Li C, Hu Y, Li C, He J, Leng X, Xiang J, Ge J, Wang J. A novel CFD-based computed index of microcirculatory resistance (IMR) derived from coronary angiography to assess coronary microcirculation. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2022; 221:106897. [PMID: 35636354 DOI: 10.1016/j.cmpb.2022.106897] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 05/13/2022] [Accepted: 05/16/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVES This study sought to present a novel approach for computation of the index of microcirculatory resistance (IMR) and to evaluate its diagnostic performance. BACKGROUND IMR is a quantitative assessment to identify coronary microvascular dysfunction. However, its clinical use remains extremely limited. Calculation of IMR from coronary angiography images may increase the utility of coronary microvasculature assessment. METHODS 203 patients with 203 vessels were included in this study. Physiology measurements were obtained with pressure-wire in the whole cohort. The computational fluid dynamics (CFD)-based AccuIMR was computed and evaluated in a blinded fashion using wire-based IMR as the reference standard. RESULTS The overall diagnostic accuracy, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of AccuIMR for detecting coronary microvascular disease were 91.1% (95% CI: 86.4% to 94.7%), 89.4% (95% CI: 80.9% to 95.0%), 92.4% (95% CI: 86.0% to 96.5%), 89.4% (95% CI: 81.8% to 94.1%), and 92.2% (95% CI: 86.7% to 95.8%), respectively. The correlation coefficient equaled to 0.81 (p < 0.001) between AccuIMR and wire-based IMR with the receiver-operating curve had area under the curve of 0.924 (95% CI: 0.878 to 0.956). CONCLUSIONS AccuIMR is a novel pressure-wire free approach to assess coronary microvascular disease with great diagnostic performance, which can be a valid, efficient, and cost-reducing tool to provide an easier routine assessment of coronary microcirculation.
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Affiliation(s)
- Jun Jiang
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Chenguang Li
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China; National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Yumeng Hu
- ArteryFlow Technology Co., Ltd., Hangzhou, China
| | - Changling Li
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jingsong He
- ArteryFlow Technology Co., Ltd., Hangzhou, China
| | | | | | - Junbo Ge
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China; National Clinical Research Center for Interventional Medicine, Shanghai, China.
| | - Jian'an Wang
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
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25
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Geng Y, Wu X, Liu H, Zheng D, Xia L. Index of microcirculatory resistance: state-of-the-art and potential applications in computational simulation of coronary artery disease. J Zhejiang Univ Sci B 2022; 23:123-140. [PMID: 35187886 DOI: 10.1631/jzus.b2100425] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
The dysfunction of coronary microcirculation is an important cause of coronary artery disease (CAD). The index of microcirculatory resistance (IMR) is a quantitative evaluation of coronary microcirculatory function, which provides a significant reference for the prediction, diagnosis, treatment, and prognosis of CAD. IMR also plays a key role in investigating the interaction between epicardial and microcirculatory dysfunctions, and is closely associated with coronary hemodynamic parameters such as flow rate, distal coronary pressure, and aortic pressure, which have been widely applied in computational studies of CAD. However, there is currently a lack of consensus across studies on the normal and pathological ranges of IMR. The relationships between IMR and coronary hemodynamic parameters have not been accurately quantified, which limits the application of IMR in computational CAD studies. In this paper, we discuss the research gaps between IMR and its potential applications in the computational simulation of CAD. Computational simulation based on the combination of IMR and other hemodynamic parameters is a promising technology to improve the diagnosis and guide clinical trials of CAD.
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Affiliation(s)
- Yingyi Geng
- Key Laboratory for Biomedical Engineering of Ministry of Education, Institute of Biomedical Engineering, Zhejiang University, Hangzhou 310027, China
| | - Xintong Wu
- Key Laboratory for Biomedical Engineering of Ministry of Education, Institute of Biomedical Engineering, Zhejiang University, Hangzhou 310027, China
| | - Haipeng Liu
- Research Centre of Intelligent Healthcare, Faculty of Health and Life Science, Coventry University, Coventry CV1 5FB, UK
| | - Dingchang Zheng
- Research Centre of Intelligent Healthcare, Faculty of Health and Life Science, Coventry University, Coventry CV1 5FB, UK.
| | - Ling Xia
- Key Laboratory for Biomedical Engineering of Ministry of Education, Institute of Biomedical Engineering, Zhejiang University, Hangzhou 310027, China.
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26
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Wong CCY, Javadzadegan A, Ada C, Lau JK, Bhindi R, Fearon WF, Kritharides L, Ng MKC, Yong ASC. Fractional Flow Reserve and Instantaneous Wave-Free Ratio Predict Pathological Wall Shear Stress in Coronary Arteries: Implications for Understanding the Pathophysiological Impact of Functionally Significant Coronary Stenoses. J Am Heart Assoc 2022; 11:e023502. [PMID: 35043698 PMCID: PMC9238496 DOI: 10.1161/jaha.121.023502] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Background The pathophysiological mechanism behind adverse outcomes associated with ischemia‐inducing epicardial coronary stenoses and microcirculatory dysfunction remains unclear. Wall shear stress (WSS) plays an important role in atherosclerotic plaque progression and vulnerability. We aimed to evaluate the relationship between WSS, functionally significant epicardial coronary stenoses, and microcirculatory dysfunction. Methods and Results Patients undergoing invasive coronary physiology testing were included. Fractional flow reserve, instantaneous wave‐free ratio, and the index of microcirculatory resistance were measured. Quantitative coronary angiography was used to obtain the lesion percentage diameter stenosis. Computational fluid dynamics analysis was performed to calculate WSS parameters. Multiple regression analysis was performed to calculate the standardized regression coefficient (β) for the coronary physiology indices. A total of 107 vessels from 88 patients were included. Fractional flow reserve independently predicted the total area of low WSS (β=−0.44; 95% CI, −0.62 to −0.25; P<0.001) and maximum lesion WSS (β=−0.53; 95% CI, −0.70 to −0.36; P<0.001) after adjusting for percentage diameter stenosis and index of microcirculatory resistance. Similarly, instantaneous wave‐free ratio also independently predicted the total area of low WSS (β=−0.45; 95% CI, −0.62 to −0.28; P<0.001) and maximum lesion WSS (β=−0.58; 95% CI, −0.73 to −0.43; P<0.001). The index of microcirculatory resistance did not predict either low or high WSS. Conclusions Fractional flow reserve and instantaneous wave‐free ratio independently predicted the total burden of low WSS and maximum lesion WSS in coronary arteries. No relationship was found between microcirculatory dysfunction and WSS.
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Affiliation(s)
| | - Ashkan Javadzadegan
- Department of Cardiology Concord HospitalUniversity of Sydney Australia.,Faculty of Medicine and Health Sciences Macquarie University Sydney Australia
| | - Cuneyt Ada
- Department of Cardiology Concord HospitalUniversity of Sydney Australia
| | - Jerrett K Lau
- Department of Cardiology Royal Adelaide HospitalUniversity of Adelaide Australia
| | - Ravinay Bhindi
- Department of Cardiology Royal North Shore HospitalUniversity of Sydney Australia
| | - William F Fearon
- Division of Cardiovascular Medicine Stanford University Stanford CA
| | | | - Martin K C Ng
- Department of Cardiology Royal Prince Alfred HospitalUniversity of Sydney Australia
| | - Andy S C Yong
- Department of Cardiology Concord HospitalUniversity of Sydney Australia.,Faculty of Medicine and Health Sciences Macquarie University Sydney Australia
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27
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Feng C, Abdu FA, Mohammed AQ, Zhang W, Liu L, Yin G, Feng Y, Mohammed AA, Mareai RM, Lv X, Shi T, Xu Y, Yu X, Che W. Prognostic impact of coronary microvascular dysfunction assessed by caIMR in overweight with chronic coronary syndrome patients. Front Endocrinol (Lausanne) 2022; 13:922264. [PMID: 36034462 PMCID: PMC9399838 DOI: 10.3389/fendo.2022.922264] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 07/25/2022] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVE Coronary microvascular dysfunction (CMD) may associate with adverse cardiovascular events in obese patients. Coronary angiography-derived index of microcirculatory resistance (caIMR) is proposed as a less-invasive and pressure-wire-free index to assess CMD. We aimed to investigate the impact of coronary microvascular function assessed by caIMR in patients with overweight and chronic coronary syndrome (CCS). METHODS CCS patients who underwent coronary angiography between 2015 to 2018 were included. Overweight was defined as BMI≥24.0kg/m². Impaired coronary microvascular function was defined as caIMR≥25U. The patients were classified according to BMI and caIMR. The primary endpoint was major adverse cardiac events (MACE). Kaplan-Meier and Cox regression analyses evaluated the association between caIMR and MACE. RESULTS Two hundred and eighty-two CCS patients were enrolled. Among these, 169 (59.93%) were overweight. Impaired coronary microvascular function was higher in overweight patients than in patients with normal weight (49.70% vs. 38.05%; P=0.035). During 35 months of follow-up, 33 MACE had occurred. Among the total CCS population, MACE was higher in patients with high caIMR than in low caIMR (18.11% vs. 6.45%, P=0.003). In subgroups analysis, MACE was higher in overweight patients with high caIMR than low caIMR (20.24% vs. 7.06%, P=0.014), while there were no significant differences in normal-weight patients. Multivariate Cox analysis demonstrated that caIMR≥25 was independently associated with MACE in overweight patients (HR, 2.87; 95% CI, 1.12-7.30; P=0.027) but not in the normal-weight patients. In addition, caIMR showed a significant predictive value for adverse outcomes in overweight patients and provided an incremental prediction when added to a prediction model with BMI. CONCLUSIONS Impaired coronary microvascular function assessed by caIMR was common and is an independent predictor of MACE in overweight patients with CCS.
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Affiliation(s)
- Cailin Feng
- Department of Cardiology, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Fuad A. Abdu
- Department of Cardiology, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Abdul-Quddus Mohammed
- Department of Cardiology, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Wen Zhang
- Department of Cardiology, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Lu Liu
- Department of Cardiology, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Guoqing Yin
- Department of Cardiology, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | | | - Ayman A. Mohammed
- Department of Cardiology, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Redhwan M. Mareai
- Department of Cardiology, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xian Lv
- Department of Cardiology, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Tingting Shi
- Department of Cardiology, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yawei Xu
- Department of Cardiology, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xuejing Yu
- Department of Cardiology, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
- *Correspondence: Wenliang Che, ; Xuejing Yu,
| | - Wenliang Che
- Department of Cardiology, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
- Department of Cardiology, Shanghai Tenth People’s Hospital Chongming Branch, Shanghai, China
- *Correspondence: Wenliang Che, ; Xuejing Yu,
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28
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Lee JM, Choi KH, Choi JO, Shin D, Park Y, Kim J, Lee SH, Kim D, Yang JH, Cho YH, Sung K, Choi JY, Park M, Kim JS, Park TK, Song YB, Hahn JY, Choi SH, Gwon HC, Oh JK, Jeon ES. Coronary Microcirculatory Dysfunction and Acute Cellular Rejection After Heart Transplantation. Circulation 2021; 144:1459-1472. [PMID: 34474597 DOI: 10.1161/circulationaha.121.056158] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Acute cellular rejection is a major determinant of mortality and retransplantation after heart transplantation. We sought to evaluate the prognostic implications of coronary microcirculatory dysfunction assessed by index of microcirculatory resistance (IMR) for the risk of acute cellular rejection after heart transplantation. METHODS The present study prospectively enrolled 154 heart transplant recipients who underwent scheduled coronary angiography and invasive coronary physiological assessment 1 month after transplantation. IMR is microcirculatory resistance under maximal hyperemia. By measuring hyperemic mean transit time using 3 injections (4 mL each) of room-temperature saline under maximal hyperemia, IMR was calculated as hyperemic distal coronary pressure×hyperemic mean transit time. The primary end point was biopsy-proven acute cellular rejection of grade ≥2R during 2 years of follow-up after transplantation and was compared by using multivariable Cox proportional hazards regression according to IMR. The incremental prognostic value of IMR, in addition to the model with clinical factors, was evaluated by comparison of C-index, net reclassification index, and integrated discrimination index. RESULTS The mean age of recipients was 51.2±13.1 years (81.2% male), and the cumulative incidence of acute cellular rejection was 19.0% at 2 years. Patients with acute cellular rejection had significantly higher IMR values at 1 month than those without acute cellular rejection (23.1±8.6 versus 16.8±11.1, P=0.002). IMR was significantly associated with the risk of acute cellular rejection (per 5-U increase: adjusted hazard ratio, 1.18 [95% CI, 1.04-1.34], P=0.011) and the optimal cutoff value of IMR to predict acute cellular rejection was 15. Patients with IMR≥15 showed significantly higher risk of acute cellular rejection than those with IMR<15 (34.4% versus 3.8%; adjusted hazard ratio, 15.3 [95% CI 3.6-65.7], P<0.001). Addition of IMR to clinical variables showed significantly higher discriminant and reclassification ability for risk of acute cellular rejection (C-index 0.87 versus 0.74, P<0.001; net reclassification index 1.05, P<0.001; integrated discrimination index 0.20, P<0.001). CONCLUSIONS Coronary microcirculatory dysfunction assessed by IMR measured early after heart transplantation showed significant association with the risk of acute cellular rejection. In addition to surveillance endomyocardial biopsy, early stratification using IMR could be a clinically useful tool to identify patients at higher risk of future acute cellular rejection after heart transplantation. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02798731.
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Affiliation(s)
- Joo Myung Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute (J.M.L., K.H.C., J.-O.C., Y.P., J.K., S.H.L., D.K., J.H.Y., M.P., T.K.P., Y.B.S., J.-Y.H., S.-H.C., H.-C.G., J.K.O., E.-S.J.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ki Hong Choi
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute (J.M.L., K.H.C., J.-O.C., Y.P., J.K., S.H.L., D.K., J.H.Y., M.P., T.K.P., Y.B.S., J.-Y.H., S.-H.C., H.-C.G., J.K.O., E.-S.J.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jin-Oh Choi
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute (J.M.L., K.H.C., J.-O.C., Y.P., J.K., S.H.L., D.K., J.H.Y., M.P., T.K.P., Y.B.S., J.-Y.H., S.-H.C., H.-C.G., J.K.O., E.-S.J.), 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 (D.S.)
| | - Yoonjee Park
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute (J.M.L., K.H.C., J.-O.C., Y.P., J.K., S.H.L., D.K., J.H.Y., M.P., T.K.P., Y.B.S., J.-Y.H., S.-H.C., H.-C.G., J.K.O., E.-S.J.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Juwon Kim
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute (J.M.L., K.H.C., J.-O.C., Y.P., J.K., S.H.L., D.K., J.H.Y., M.P., T.K.P., Y.B.S., J.-Y.H., S.-H.C., H.-C.G., J.K.O., E.-S.J.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung Hun Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute (J.M.L., K.H.C., J.-O.C., Y.P., J.K., S.H.L., D.K., J.H.Y., M.P., T.K.P., Y.B.S., J.-Y.H., S.-H.C., H.-C.G., J.K.O., E.-S.J.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.,Department of Internal Medicine and Cardiovascular Center, Chonnam National University Hospital, Gwangju, Korea (S.H.L.)
| | - Darae Kim
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute (J.M.L., K.H.C., J.-O.C., Y.P., J.K., S.H.L., D.K., J.H.Y., M.P., T.K.P., Y.B.S., J.-Y.H., S.-H.C., H.-C.G., J.K.O., E.-S.J.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jeong Hoon Yang
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute (J.M.L., K.H.C., J.-O.C., Y.P., J.K., S.H.L., D.K., J.H.Y., M.P., T.K.P., Y.B.S., J.-Y.H., S.-H.C., H.-C.G., J.K.O., E.-S.J.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.,Department of Medicine and Critical Care Medicine (J.H.Y.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yang Hyun Cho
- Department of Thoracic and Cardiovascular Surgery (Y.H.C., K.S., J.Y.C.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kiick Sung
- Department of Thoracic and Cardiovascular Surgery (Y.H.C., K.S., J.Y.C.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ji Yeon Choi
- Department of Thoracic and Cardiovascular Surgery (Y.H.C., K.S., J.Y.C.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Meesoon Park
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute (J.M.L., K.H.C., J.-O.C., Y.P., J.K., S.H.L., D.K., J.H.Y., M.P., T.K.P., Y.B.S., J.-Y.H., S.-H.C., H.-C.G., J.K.O., E.-S.J.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jung-Sun Kim
- Department of Pathology and Translational Genomics (J.-S.K.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Taek Kyu Park
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute (J.M.L., K.H.C., J.-O.C., Y.P., J.K., S.H.L., D.K., J.H.Y., M.P., T.K.P., Y.B.S., J.-Y.H., S.-H.C., H.-C.G., J.K.O., E.-S.J.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young Bin Song
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute (J.M.L., K.H.C., J.-O.C., Y.P., J.K., S.H.L., D.K., J.H.Y., M.P., T.K.P., Y.B.S., J.-Y.H., S.-H.C., H.-C.G., J.K.O., E.-S.J.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joo-Yong Hahn
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute (J.M.L., K.H.C., J.-O.C., Y.P., J.K., S.H.L., D.K., J.H.Y., M.P., T.K.P., Y.B.S., J.-Y.H., S.-H.C., H.-C.G., J.K.O., E.-S.J.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung-Hyuk Choi
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute (J.M.L., K.H.C., J.-O.C., Y.P., J.K., S.H.L., D.K., J.H.Y., M.P., T.K.P., Y.B.S., J.-Y.H., S.-H.C., H.-C.G., J.K.O., E.-S.J.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyeon-Cheol Gwon
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute (J.M.L., K.H.C., J.-O.C., Y.P., J.K., S.H.L., D.K., J.H.Y., M.P., T.K.P., Y.B.S., J.-Y.H., S.-H.C., H.-C.G., J.K.O., E.-S.J.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae K Oh
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute (J.M.L., K.H.C., J.-O.C., Y.P., J.K., S.H.L., D.K., J.H.Y., M.P., T.K.P., Y.B.S., J.-Y.H., S.-H.C., H.-C.G., J.K.O., E.-S.J.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.,Division of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, MN (J.K.O.)
| | - Eun-Seok Jeon
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute (J.M.L., K.H.C., J.-O.C., Y.P., J.K., S.H.L., D.K., J.H.Y., M.P., T.K.P., Y.B.S., J.-Y.H., S.-H.C., H.-C.G., J.K.O., E.-S.J.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Yoon GS, Ahn SG, Woo SI, Yoon MH, Lee MJ, Choi SH, Seo JY, Kwon SW, Park SD, Seo KW. The Index of Microcirculatory Resistance after Primary Percutaneous Coronary Intervention Predicts Long-Term Clinical Outcomes in Patients with ST-Segment Elevation Myocardial Infarction. J Clin Med 2021; 10:jcm10204752. [PMID: 34682875 PMCID: PMC8538070 DOI: 10.3390/jcm10204752] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 10/11/2021] [Accepted: 10/14/2021] [Indexed: 11/16/2022] Open
Abstract
The index of microcirculatory resistance (IMR) is a simple method that can measure microvascular function after primary percutaneous coronary intervention (PCI) in patients with ST-segment Elevation Myocardial Infarction (STEMI). This study is to find out whether IMR predicts clinical long-term outcomes in STEMI patients. A total of 316 patients with STEMI who underwent primary PCI from 2005 to 2015 were enrolled. The IMR was measured using pressure sensor/thermistor-tipped guidewire after primary PCI. The primary endpoint was the rate of death or hospitalization for heart failure (HF) over a mean follow-up period of 65 months. The mean corrected IMR was 29.4 ± 20.0. Patients with an IMR > 29 had a higher rate of the primary endpoint compared to patients with an IMR ≤ 29 (10.3% vs. 2.1%, p = 0.001). During the follow-up period, 13 patients (4.1%) died and 6 patients (1.9%) were hospitalized for HF. An IMR > 29 was associated with an increased risk of death or hospitalization for HF (OR 5.378, p = 0.004). On multivariable analysis, IMR > 29 (OR 3.962, p = 0.022) remained an independent predictor of death or hospitalization for HF with age (OR 1.048, p = 0.049) and symptom-to-balloon time (OR 1.002, p = 0.049). High IMR was an independent predictor for poor long-term clinical outcomes in STEMI patients after primary PCI.
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Affiliation(s)
- Gwang-Seok Yoon
- Division of Cardiology, Department of Internal Medicine, Inha University College of Medicine, Incheon 22332, Korea; (G.-S.Y.); (M.-J.L.); (S.H.C.); (S.W.K.); (S.-D.P.)
| | - Sung Gyun Ahn
- Division of Cardiology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju 26426, Korea;
| | - Seong-Ill Woo
- Division of Cardiology, Department of Internal Medicine, Inha University College of Medicine, Incheon 22332, Korea; (G.-S.Y.); (M.-J.L.); (S.H.C.); (S.W.K.); (S.-D.P.)
- Correspondence: (S.-I.W.); (M.H.Y.); Tel.: +82-32-890-2445 (S.I.W.); Fax: 82-32-890-2447 (S.-I.W.)
| | - Myeong Ho Yoon
- Department of Cardiology, Ajou University School of Medicine, Suwon 16499, Korea; (J.-Y.S.); (K.-W.S.)
- Correspondence: (S.-I.W.); (M.H.Y.); Tel.: +82-32-890-2445 (S.I.W.); Fax: 82-32-890-2447 (S.-I.W.)
| | - Man-Jong Lee
- Division of Cardiology, Department of Internal Medicine, Inha University College of Medicine, Incheon 22332, Korea; (G.-S.Y.); (M.-J.L.); (S.H.C.); (S.W.K.); (S.-D.P.)
| | - Seong Huan Choi
- Division of Cardiology, Department of Internal Medicine, Inha University College of Medicine, Incheon 22332, Korea; (G.-S.Y.); (M.-J.L.); (S.H.C.); (S.W.K.); (S.-D.P.)
| | - Ji-Yeon Seo
- Department of Cardiology, Ajou University School of Medicine, Suwon 16499, Korea; (J.-Y.S.); (K.-W.S.)
| | - Sung Woo Kwon
- Division of Cardiology, Department of Internal Medicine, Inha University College of Medicine, Incheon 22332, Korea; (G.-S.Y.); (M.-J.L.); (S.H.C.); (S.W.K.); (S.-D.P.)
| | - Sang-Don Park
- Division of Cardiology, Department of Internal Medicine, Inha University College of Medicine, Incheon 22332, Korea; (G.-S.Y.); (M.-J.L.); (S.H.C.); (S.W.K.); (S.-D.P.)
| | - Kyoung-Woo Seo
- Department of Cardiology, Ajou University School of Medicine, Suwon 16499, Korea; (J.-Y.S.); (K.-W.S.)
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30
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Asakura M, Hibi K, Shimizu W, Fujii K, Suwa S, Okumura Y, Mano T, Igeta M, Okamoto R, Ishihara M. Design and rationale of the EVOCATION trial: A prospective, randomized, exploratory study comparing the effect of evolocumab on coronary microvascular function after percutaneous coronary intervention in patients with stable coronary artery disease. J Cardiol 2021; 79:105-109. [PMID: 34518072 DOI: 10.1016/j.jjcc.2021.08.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 07/16/2021] [Accepted: 08/08/2021] [Indexed: 01/13/2023]
Abstract
Percutaneous coronary intervention (PCI) is a standard treatment in patients with stable coronary artery disease (CAD); however, periprocedural myocardial infarction (PMI) remains a common complication of PCI. Aggressive lipid-lowering therapy with statin has shown to reduce the incidence of PMI by preventing coronary microvascular dysfunction. It is unclear whether evolocumab, a potent lipid-lowering agent, could diminish microvascular damage after PCI. The EVOCATION trial (jRCTs051180022) is a multicenter, randomized, open-label, active-controlled, parallel-group, exploratory, investigator-initiated clinical study to evaluate whether pretreatment with evolocumab could decrease the index of microvascular resistance (IMR) after PCI in patients with stable CAD. This study population consists of 100 patients with stable CAD who will undergo PCI and have high low-density lipoprotein cholesterol levels despite administration of maximum tolerated dose of statins for at least 2 weeks. Eligible patients are randomized in a 1:1 ratio to receive either evolocumab 140 mg every 2 weeks in addition to standard of care treatment or standard of care treatment only for 2-6 weeks before PCI. The primary endpoint is IMR after PCI. The EVOCATION trial will evaluate whether pretreatment with evolocumab reduces periprocedural microvascular damage in patients with stable CAD undergoing PCI.
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Affiliation(s)
- Masanori Asakura
- Department of Cardiovascular and Renal Medicine, Hyogo College of Medicine, Hyogo, Japan
| | - Kiyoshi Hibi
- Division of Cardiology, Yokohama City University Medical Center, Kanagawa, Japan
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - Kenshi Fujii
- Cardiovascular Center, Sakurabashi-Watanabe Hospital, Osaka, Japan
| | - Satoru Suwa
- Department of Cardiology, Juntendo University Shizuoka Hospital, Shizuoka, Japan
| | - Yasuo Okumura
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Toshiaki Mano
- Cardiovascular Center, Kansai Rosai Hospital, Hyogo, Japan
| | - Masataka Igeta
- Department of Biostatistics, Hyogo College of Medicine, Hyogo, Japan
| | - Rika Okamoto
- Center for Clinical Research and Education, Hyogo College of Medicine, Hyogo, Japan
| | - Masaharu Ishihara
- Department of Cardiovascular and Renal Medicine, Hyogo College of Medicine, Hyogo, Japan.
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31
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Zhang H, Li G, Hou Q, Yang Y, Wei H, Yang Y, Qu Z, Xie J, Qiao A. Research on the Method of Predicting Fractional Flow Reserve Based on Multiple Independent Risk Factors. Front Physiol 2021; 12:716877. [PMID: 34483970 PMCID: PMC8414807 DOI: 10.3389/fphys.2021.716877] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Accepted: 07/06/2021] [Indexed: 11/16/2022] Open
Abstract
The use of diameter stenosis (DS), as revealed by coronary angiography, for predicting fractional flow reserve (FFR) usually results in a high error rate of detection. In this study, we investigated a method for predicting FFR in patients with coronary stenosis based on multiple independent risk factors. The aim of the study was to improve the accuracy of detection. First, we searched the existing literature to identify multiple independent risk factors and then calculated the corresponding odds ratios. The improved analytic hierarchy process (IAHP) was then used to determine the weighted value of each independent risk factor, based on the corresponding odds ratio. Next, we developed a novel method, based on the top seven independent risk factors with the highest weighted values, to predict FFR. This model was then used to predict the FFR of 253 patients with coronary stenosis, and the results were then compared with previous methods (DS alone and a simplified scoring system). In addition to DS, we identified a range of other independent risk factors, with the highest weighted values, for predicting FFR, including gender, body mass index, location of stenosis, type of coronary artery distribution, left ventricular ejection fraction, and left myocardial mass. The area under the receiver-operating characteristic curve (AUC) for the newly developed method was 84.3% (95% CI: 79.2–89.4%), which was larger than 65.3% (95% CI: 61.5–69.1%) of DS alone and 74.8% (95% CI: 68.4–81.2%) of the existing simplified scoring system. The newly developed method, based on multiple independent risk factors, effectively improves the prediction accuracy for FFR.
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Affiliation(s)
- Honghui Zhang
- Faculty of Environment and Life, Beijing University of Technology, Beijing, China.,College of Engineering, Inner Mongolia University for Nationalities, Tongliao, China
| | - Gaoyang Li
- Institute of Fluid Science, Tohoku University, Miyagi, Japan
| | - Qianwen Hou
- Faculty of Environment and Life, Beijing University of Technology, Beijing, China
| | - Yinlong Yang
- Faculty of Environment and Life, Beijing University of Technology, Beijing, China
| | - Hongge Wei
- Faculty of Environment and Life, Beijing University of Technology, Beijing, China
| | - Yujia Yang
- Faculty of Environment and Life, Beijing University of Technology, Beijing, China
| | - Zhuoran Qu
- Faculty of Environment and Life, Beijing University of Technology, Beijing, China
| | - Jinjie Xie
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Aike Qiao
- Faculty of Environment and Life, Beijing University of Technology, Beijing, China
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Prognostic Links Between OCT-Delineated Coronary Morphologies and Coronary Functional Abnormalities in Patients With INOCA. JACC Cardiovasc Interv 2021; 14:606-618. [PMID: 33736768 DOI: 10.1016/j.jcin.2020.12.025] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 12/10/2020] [Accepted: 12/15/2020] [Indexed: 12/27/2022]
Abstract
OBJECTIVES Whether there are prognostic links between coronary morphologies and coronary functional abnormalities was examined in ischemia and nonobstructive coronary artery disease (INOCA) patients. BACKGROUND Although INOCA has attracted much attention, little is known about the prognostic impact of coronary morphologies in this disorder. METHODS A total of 329 consecutive INOCA patients were enrolled and underwent spasm provocation testing combined with lactate sampling for diagnosis of epicardial and microvascular spasm (MVS). On the basis of the functional tests, the patients were classified into 4 groups: a control group without epicardial spasm or MVS (n = 32), MVS alone (n = 51), diffuse spasm in ≥2 coronary segments (n = 204), and focal spasm in 1 segment (n = 42). In this population, optical coherence tomography imaging of the left anterior descending coronary artery was performed for evaluation of adventitial vasa vasorum (AVV) and intraplaque neovessels (IPN). Index of microcirculatory resistance was also measured. RESULTS MVS frequently coexisted with diffuse (70%) and focal spasm (68%) with a good correlation between AVV and index of microcirculatory resistance (R = 0.353; p = 0.022). For a median follow-up of 1,043 days, focal spasm showed the worst prognosis (log rank p = 0.005), for which IPN was a significant prognostic factor. By contrast, diffuse spasm showed the greatest AVV with an intermediate prognosis. The prognostic value of INOCA was significantly enhanced by adding AVV and IPN to the physiological indices (area under the curve = 0.88 vs. 0.76; p = 0.048). CONCLUSIONS These results provide the first evidence that there are important prognostic links between coronary morphologies (evaluated by optical coherence tomography) and coronary functional abnormalities in patients with INOCA, indicating the importance of both evaluations in this population.
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Bakar SN, Hayman S, McCarty D, Thain AP, McLellan A, Wagner C, Lavi S. Invasive Assessment of Microvascular Resistance in Hypertrophic Cardiomyopathy With Echocardiographic Correlates. Heart Lung Circ 2021; 31:194-198. [PMID: 34332889 DOI: 10.1016/j.hlc.2021.07.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 04/18/2021] [Accepted: 07/02/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Hypertrophic cardiomyopathy (HCM) is often associated with ischaemia despite lack of focal epicardial coronary stenosis. Our aim was to assess invasive coronary microvascular circulation and correlate findings with echocardiography. METHODS We prospectively enrolled patients with HCM and controls who were referred for diagnostic coronary angiography. A pressure-temperature sensor coronary guidewire was used with intracoronary injections of room-temperature saline to measure mean coronary transit time during rest and hyperaemia induced with intravenous adenosine. The index of microvascular resistance (IMR) was calculated. Left ventricular mass was calculated during echocardiographic studies. RESULTS Patients with HCM (n=12) and controls (n=7), had similar demographics. Left ventricular ejection fraction was higher in HCM (76.7%±11.0% vs 55.0%±15.9%, p=0.003). IMR was non-significantly higher in HCM (21.7±10.2 vs 15.3±4.8, p=0.16). Only patients with HCM had abnormal IMR (>25). Coronary flow reserve was non-significantly higher in HCM (2.7±1.6 vs 2.1±1.2, p=0.34). IMR correlated with left ventricular mass in hypertrophic cardiomyopathy subjects (Pearson r=0.68, p=0.02). CONCLUSIONS Microvascular dysfunction as assessed by IMR may be abnormal in HCM and is correlated with left ventricular mass.
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Affiliation(s)
- Shahrukh N Bakar
- Division of Cardiology, Department of Medicine, Western University and London Health Sciences Centre, London, Ontario, Canada
| | - Samual Hayman
- Division of Cardiology, Department of Medicine, Western University and London Health Sciences Centre, London, Ontario, Canada
| | - David McCarty
- Division of Cardiology, Department of Medicine, Western University and London Health Sciences Centre, London, Ontario, Canada
| | - Andrew P Thain
- Division of Cardiology, Department of Medicine, Western University and London Health Sciences Centre, London, Ontario, Canada
| | - Andrew McLellan
- Division of Cardiology, Department of Medicine, Western University and London Health Sciences Centre, London, Ontario, Canada
| | - Cassandra Wagner
- Division of Cardiology, Department of Medicine, Western University and London Health Sciences Centre, London, Ontario, Canada
| | - Shahar Lavi
- Division of Cardiology, Department of Medicine, Western University and London Health Sciences Centre, London, Ontario, Canada.
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Mejia-Renteria H, Lee JM, Choi KH, Lee SH, Wang L, Kakuta T, Koo BK, Escaned J. Coronary microcirculation assessment using functional angiography: Development of a wire-free method applicable to conventional coronary angiograms. Catheter Cardiovasc Interv 2021; 98:1027-1037. [PMID: 34242489 DOI: 10.1002/ccd.29863] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 06/01/2021] [Accepted: 06/18/2021] [Indexed: 01/27/2023]
Abstract
OBJECTIVES We aimed to develop a novel wire- and adenosine-free microcirculatory resistive index from functional angiography (angio-IMR) to estimate coronary microcirculatory resistance, and to investigate how this method can improve clinical interpretation of physiological stenosis assessment with quantitative flow ratio (QFR). BACKGROUND Hyperemic index of coronary microcirculatory resistance (IMR) is a widely used tool to assess microcirculatory dysfunction. However, the need of dedicated intracoronary wire and hyperemia limits its adoption in clinical practice. METHODS We performed our study in two separate stages: (1) development of a formula (angio-IMR) to estimate IMR from resting angiograms and aortic pressure (Pa), and (2) validation of the method in a clinical population using invasively measured IMR as reference. Additionally, QFR diagnostic performance was assessed considering angio-IMR values. RESULTS We developed the formula: angio-IMR = (Pa-[0.1*Pa])*QFR*e-Tmn (where e-Tmn is an estimation of hyperaemic mean transit time) and validated it in 115 vessels (104 patients). Angio-IMR correlated well with IMR (Spearman's rho = 0.70, p < 0.001). Sensitivity, specificity, positive and negative predictive value, accuracy and area under the curve of angio-IMR to predict IMR were 87.5% (73.2-95.8), 85.3% (75.3-92.4), 76.1% (64.5-84.8), 92.8% (84.9-96.7), 85% and 0.90 (0.83-0.95), respectively. False positive QFR measurements decreased from 19.5% to 8.5% when angio-IMR was incorporated into the QFR interpretation workflow. CONCLUSIONS Estimation of IMR without physiology wire and adenosine is feasible. Coronary microcirculatory dysfunction causing high IMR can be ruled-out with high confidence in vessels with low angio-IMR. Awareness of angio-IMR contributes to a better clinical interpretation of functional stenosis assessment with QFR.
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Affiliation(s)
- Hernan Mejia-Renteria
- Department of Cardiology, Hospital Clínico San Carlos IDISSC and Universidad Complutense de Madrid, Madrid, Spain
| | - Joo Myung Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Ki-Hong Choi
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Seung-Hun Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Lin Wang
- Department of Cardiology, Hospital Clínico San Carlos IDISSC and Universidad Complutense de Madrid, Madrid, Spain
| | - Tsunekazu Kakuta
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Bon-Kwon Koo
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, South Korea
- The Institute on Aging, Seoul National University, Seoul, South Korea
| | - Javier Escaned
- Department of Cardiology, Hospital Clínico San Carlos IDISSC and Universidad Complutense de Madrid, Madrid, Spain
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Characteristic findings of microvascular dysfunction on coronary computed tomography angiography in patients with intermediate coronary stenosis. Eur Radiol 2021; 31:9198-9210. [PMID: 34009414 DOI: 10.1007/s00330-021-07909-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 02/19/2021] [Accepted: 03/18/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVES We aimed to assess the prevalence of coexistence of coronary microvascular dysfunction (CMD) in patients with intermediate epicardial stenosis and to explore coronary computed tomography angiography (CCTA)-derived lesion-, vessel-, and cardiac fat-related characteristic findings associated with CMD. METHODS A retrospective cross-sectional single-center study included a total of 177 patients with intermediate stenosis in the left anterior descending artery (LAD) who underwent CCTA and invasive physiological measurements. The 320-slice CCTA analysis included qualitative and quantitative assessments of plaque, vessel, epicardial fat volume (ECFV) and epicardial fat attenuation (ECFA), and pericoronary fat attenuation (FAI). CMD was defined by the index of microcirculatory resistance (IMR) ≥ 25. RESULTS In the entire cohort, median fractional flow reserve (FFR) and median IMR values were 0.77 (0.69-0.84) and 19.0 (13.7-27.7), respectively. The prevalence of CMD was 32.8 % (58/177) in the total cohort. The coexistence of CMD and functionally significant stenosis was 34.3 % (37/108), whereas CMD in nonsignificant intermediate stenosis was 30.4 % (21/69). CMD was significantly associated with greater lumen volume (p = 0.031), greater fibrofatty and necrotic component (FFNC) volume (p = 0.030), and greater ECFV (p = 0.030), but not with FAI (p = 0.832) and ECFA (p = 0.445). On multivariable logistic regression analysis, vessel volume, vessel lumen volume, lesion remodeling index, ECFV, and lesion FFNC volume were independent predictors of CMD. CONCLUSIONS The prevalence of CMD was about one-third in patients with intermediate stenosis in LAD regardless of the presence or absence of functional stenosis significance. The integrated CCTA assessment may help in the identification of CMD. KEY POINTS • The coexistence of coronary microvascular dysfunction (CMD) and functionally significant stenosis was 34.3 %, whereas CMD in nonsignificant intermediate stenosis was 30.4 %. • Coronary computed tomography angiography (CCTA)-derived CMD characteristics were vessel volume, vessel lumen volume, remodeling index, epicardial fat volume, and fibrofatty necrotic core volume. • Integrated CCTA assessment may help identify the coexistence of CMD and epicardial stenosis.
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Kunadian V, Chieffo A, Camici PG, Berry C, Escaned J, Maas AHEM, Prescott E, Karam N, Appelman Y, Fraccaro C, Louise Buchanan G, Manzo-Silberman S, Al-Lamee R, Regar E, Lansky A, Abbott JD, Badimon L, Duncker DJ, Mehran R, Capodanno D, Baumbach A. An EAPCI Expert Consensus Document on Ischaemia with Non-Obstructive Coronary Arteries in Collaboration with European Society of Cardiology Working Group on Coronary Pathophysiology & Microcirculation Endorsed by Coronary Vasomotor Disorders International Study Group. Eur Heart J 2021; 41:3504-3520. [PMID: 32626906 DOI: 10.1093/eurheartj/ehaa503] [Citation(s) in RCA: 378] [Impact Index Per Article: 126.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 05/29/2020] [Accepted: 06/01/2020] [Indexed: 12/17/2022] Open
Abstract
This consensus document, a summary of the views of an expert panel organized by the European Association of Percutaneous Cardiovascular Interventions (EAPCI), appraises the importance of ischaemia with non-obstructive coronary arteries (INOCA). Angina pectoris affects approximately 112 million people globally. Up to 70% of patients undergoing invasive angiography do not have obstructive coronary artery disease, more common in women than in men, and a large proportion have INOCA as a cause of their symptoms. INOCA patients present with a wide spectrum of symptoms and signs that are often misdiagnosed as non-cardiac leading to under-diagnosis/investigation and under-treatment. INOCA can result from heterogeneous mechanism including coronary vasospasm and microvascular dysfunction and is not a benign condition. Compared to asymptomatic individuals, INOCA is associated with increased incidence of cardiovascular events, repeated hospital admissions, as well as impaired quality of life and associated increased health care costs. This consensus document provides a definition of INOCA and guidance to the community on the diagnostic approach and management of INOCA based on existing evidence from research and best available clinical practice; noting gaps in knowledge and potential areas for further investigation.
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Affiliation(s)
- Vijay Kunadian
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University and Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne NHS Foundation Trust, M4:146 4th Floor William Leech Building, Newcastle upon Tyne NE2 4HH, UK
| | | | - Paolo G Camici
- Vita Salute University and San Raffaele Hospital, Milan, Italy
| | - Colin Berry
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Javier Escaned
- Hospital Clinico San Carlos IDISSC, Complutense University, Madrid, Spain
| | - Angela H E M Maas
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Eva Prescott
- Department of Cardiology, Bispebjerg University Hospital, Copenhagen, Denmark
| | - Nicole Karam
- European Hospital Georges Pompidou (Cardiology Department), Paris University and Paris Cardiovascular Research Center (INSERMU970), Paris, France
| | - Yolande Appelman
- Department of Cardiology, Amsterdam UMC, Location VU University Medical Center, Amsterdam, the Netherlands
| | - Chiara Fraccaro
- Department of Cardiac, Thoracic and Vascular Science and Public Health, Padova, Italy
| | | | | | - Rasha Al-Lamee
- National Heart and Lung Institute, Imperial College London, London, UK
| | | | - Alexandra Lansky
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA.,Bart's Heart Centre, St Bartholomew's Hospital, West Smithfield, London, UK
| | - J Dawn Abbott
- Lifespan Cardiovascular Institute and Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Lina Badimon
- Cardiovascular Program-ICCC, IR-Hospital de la Santa Creu i Sant Pau, CiberCV, Barcelona, Spain
| | - Dirk J Duncker
- Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Roxana Mehran
- Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Hospital, New York, NY, USA
| | - Davide Capodanno
- CardioThoracic-Vascular and Transplant Department, A.O.U. 'Policlinico-Vittorio Emanuele', University of Catania, Catania, Italy
| | - Andreas Baumbach
- Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London and Barts Heart Centre, London, UK.,Yale University School of Medicine, New Haven, CT, USA
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Kunadian V, Chieffo A, Camici P, Berry C, Escaned J, Maas A, Prescott E, Karam N, Appelman Y, Fraccaro C, Buchanan G, Manzo-Silberman S, Al-Lamee R, Regar E, Lansky A, Abbott J, Badimon L, Duncker D, Mehran R, Capodanno D, Baumbach A. An EAPCI Expert Consensus Document on Ischaemia with Non-Obstructive Coronary Arteries in Collaboration with European Society of Cardiology Working Group on Coronary Pathophysiology & Microcirculation Endorsed by Coronary Vasomotor Disorders International Study Group. EUROINTERVENTION 2021; 16:1049-1069. [PMID: 32624456 PMCID: PMC9707543 DOI: 10.4244/eijy20m07_01] [Citation(s) in RCA: 84] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 06/01/2020] [Indexed: 11/23/2022]
Abstract
This consensus document, a summary of the views of an expert panel organized by the European Association of Percutaneous Cardiovascular Interventions (EAPCI), appraises the importance of ischaemia with non-obstructive coronary arteries (INOCA). Angina pectoris affects approximately 112 million people globally. Up to 70% of patients undergoing invasive angiography do not have obstructive coronary artery disease, more common in women than in men, and a large proportion have INOCA as a cause of their symptoms. INOCA patients present with a wide spectrum of symptoms and signs that are often misdiagnosed as non-cardiac leading to under-diagnosis/investigation and under-treatment. INOCA can result from heterogeneous mechanism including coronary vasospasm and microvascular dysfunction and is not a benign condition. Compared to asymptomatic individuals, INOCA is associated with increased incidence of cardiovascular events, repeated hospital admissions, as well as impaired quality of life and associated increased health care costs. This consensus document provides a definition of INOCA and guidance to the community on the diagnostic approach and management of INOCA based on existing evidence from research and best available clinical practice; noting gaps in knowledge and potential areas for further investigation.
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Affiliation(s)
- Vijay Kunadian
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University and Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | | | - Paolo Camici
- Vita Salute University and San Raffaele Hospital, Milan, Italy
| | - Colin Berry
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Javier Escaned
- Hospital Clinico San Carlos IDISSC, Complutense University, Madrid, Spain
| | - Angela Maas
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Eva Prescott
- Department of Cardiology, Bispebjerg University Hospital, Copenhagen, Denmark
| | - Nicole Karam
- European Hospital Georges Pompidou (Cardiology Department), Paris University and Paris Cardiovascular Research Center (INSERMU970), Paris, France
| | - Yolande Appelman
- Department of Cardiology, Amsterdam UMC, Location VU University Medical Center, Amsterdam, the Netherlands
| | - Chiara Fraccaro
- Department of Cardiac, Thoracic and Vascular Science and Public Health, Padova, Italy
| | - Gill Buchanan
- North Cumbria Integrated Care NHS Foundation Trust, Cumbria, United Kingdom
| | | | - Rasha Al-Lamee
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | | | - Alexandra Lansky
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
- Bart’s Heart Centre, St Bartholomew’s Hospital, West Smithfield, London, United Kingdom
| | - J. Abbott
- Lifespan Cardiovascular Institute and Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Lina Badimon
- Cardiovascular Program-ICCC, IR-Hospital de la Santa Creu i Sant Pau, CiberCV, Barcelona, Spain
| | - Dirk Duncker
- Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Roxana Mehran
- Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Hospital, New York, NY, USA
| | - Davide Capodanno
- CardioThoracic-Vascular and Transplant Department, A.O.U. ‘Policlinico-Vittorio Emanuele’, University of Catania, Catania, Italy
| | - Andreas Baumbach
- Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London and Barts Heart Centre, London, United Kingdom
- Yale University School of Medicine, New Haven, CT, USA
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Ai H, Feng Y, Gong Y, Zheng B, Jin Q, Zhang HP, Sun F, Li J, Chen Y, Huo Y, Huo Y. Coronary Angiography-Derived Index of Microvascular Resistance. Front Physiol 2020; 11:605356. [PMID: 33391020 PMCID: PMC7772433 DOI: 10.3389/fphys.2020.605356] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Accepted: 11/16/2020] [Indexed: 01/10/2023] Open
Abstract
A coronary angiography-derived index of microvascular resistance (caIMR) is proposed for physiological assessment of microvasular diseases in coronary circulation. The aim of the study is to assess diagnostic performance of caIMR, using wire-derived index of microvascular resistance (IMR) as the reference standard. IMR was demonstrated in 56 patients (57 vessels) with stable/unstable angina pectoris and no obstructive coronary arteries in three centers using the Certus pressure wire. Based on the aortic pressure wave and coronary angiograms from two projections, the caIMR was computed and assessed in blinded fashion against the IMR at an independent core laboratory. Diagnostic accuracy, sensitivity, specificity, positive predictive value and negative predictive value of the caIMR with a cutoff value of 25 were 84.2% (95% CI: 72.1% to 92.5%), 86.1% (95% CI: 70.5% to 95.3%), 81.0% (95% CI: 58.1% to 94.6%), 88.6% (95% CI: 76.1% to 95.0%), and 77.3% (95% CI: 59.5% to 88.7%) against the IMR with a cutoff value of 25. The receiver-operating curve had area under the curve of 0.919 and the correlation coefficient equaled to 0.746 between caIMR and wire-derived IMR. Hence, caIMR could eliminate the need of a pressure wire, reduce technical error, and potentially increase adoption of physiological assessment of microvascular diseases in patients with ischemic heart disease.
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Affiliation(s)
- Hu Ai
- Department of Cardiology, Beijing Hospital, Beijing, China.,National Center of Gerontology, Beijing, China
| | - Yundi Feng
- PKU-HKUST Shenzhen-Hong Kong Institution, Shenzhen, China
| | - Yanjun Gong
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Bo Zheng
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Qinhua Jin
- Department of Cardiovascular, PLA General Hospital, Beijing, China
| | - Hui-Ping Zhang
- Department of Cardiology, Beijing Hospital, Beijing, China.,National Center of Gerontology, Beijing, China
| | - Fucheng Sun
- Department of Cardiology, Beijing Hospital, Beijing, China.,National Center of Gerontology, Beijing, China
| | - Jianping Li
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Yundai Chen
- Department of Cardiovascular, PLA General Hospital, Beijing, China
| | - Yunlong Huo
- PKU-HKUST Shenzhen-Hong Kong Institution, Shenzhen, China.,Department of Cardiology, Peking University First Hospital, Beijing, China.,Institute of Mechanobiology & Medical Engineering, School of Life Sciences & Biotechnology, Shanghai Jiao Tong University, Shanghai, China
| | - Yong Huo
- Department of Cardiology, Peking University First Hospital, Beijing, China
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Cho SG, Lee SJ, Na MH, Choi YY, Bom HHS. Comparison of diagnostic accuracy of PET-derived myocardial blood flow parameters: A meta-analysis. J Nucl Cardiol 2020; 27:1955-1966. [PMID: 30390243 DOI: 10.1007/s12350-018-01476-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Accepted: 09/24/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND Although absolute quantification of myocardial blood flow (MBF) by positron emission tomography provides additive diagnostic value to visual analysis of perfusion defect, diagnostic accuracy of different MBF parameters remain unclear. METHODS Clinical studies regarding the diagnostic accuracy of hyperemic MBF (hMBF), myocardial flow reserve (MFR) and/or relative flow reserve (RFR) were searched and systematically reviewed. On a per-vessel basis, pooled measures of the parameters' diagnostic performances were analyzed, regarding significant coronary stenosis defined by fractional flow reserve or diameter stenosis. RESULTS Ten studies (2,522 arteries from 1,099 patients) were finally included. Pooled sensitivity [95% confidence interval (CI)] was 0.853 (0.821-0.881) for hMBF, 0.755 (0.713-0.794) for MFR, and 0.636 (0.539-0.726) for RFR. Pooled specificity (95% CI) was 0.844 (0.827-0.860) for hMBF, 0.804 (0.784-0.824) for MFR, and 0.897 (0.860-0.926) for RFR. Pooled area under the curve ± standard error was 0.900 ± 0.020 for hMBF, 0.830 ± 0.026 for MFR, and 0.873 ± 0.048 for RFR. CONCLUSIONS hMBF showed the best sensitivity while RFR showed the best specificity in the diagnosis of significant coronary stenosis. MFR was less sensitive than hMBF and less specific than hMBF and RFR.
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Affiliation(s)
- Sang-Geon Cho
- Department of Nuclear Medicine, Chonnam National University Hospital, 42, Jebong-ro, Dong-gu, Gwangju, 61469, Republic of Korea.
| | - Soo Jin Lee
- Department of Nuclear Medicine, Hanyang University Medical Center, 222-1, Wangsimni-ro Seongdong-gu, Seoul, 04763, Republic of Korea
| | - Myung Hwan Na
- Department of Statistics, Chonnam National University, 45, Yongbong-ro, Buk-gu, Kwangju, 61186, Republic of Korea
| | - Yun Young Choi
- Department of Nuclear Medicine, Hanyang University Medical Center, 222-1, Wangsimni-ro Seongdong-gu, Seoul, 04763, Republic of Korea.
| | - Henry Hee-Seung Bom
- Department of Nuclear Medicine, Chonnam National University Hwasun Hospital, 322, Seoyang-ro Hwasun-eup, Hwasun-gun, Jeonnam, 58128, Republic of Korea.
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Blood haemoglobin, renal insufficiency, fractional flow reserve and plasma NT-proBNP is associated with index of microcirculatory resistance in chronic coronary syndrome. Int J Cardiol 2020; 317:1-6. [PMID: 32464253 DOI: 10.1016/j.ijcard.2020.05.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 04/22/2020] [Accepted: 05/13/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Coronary microvascular dysfunction (CMVD) is associated with adverse cardiovascular outcome. We aimed to determine the prevalence of CMVD and factors related to index of microcirculatory resistance (IMR) in consecutive patients with chronic coronary syndrome (CCS) undergoing elective coronary angiography. METHODS AND RESULTS Non-interventional physicians enrolled 274 patients with CCS before angiography, to minimize selection bias by PCI-operators. Fractional flow reserve (FFR) and IMR were measured in the LAD. Subjects with extensively diseased LAD, no measures due to technical reasons or violation of protocol were excluded from the analysis (n = 54). The proportion of patients with IMR corrected for collateral flow (IMRcorr) >25 units was 25% (95% confidence interval [CI] 19%-31%) in all 220 patients. In subjects with FFR ≤0.80 in the LAD the proportion of IMRcorr > 25 units was 21% (95% CI 13%-30%) as compared to subjects with FFR >0.80, 29% (95% CI 21%-36%), p = .268. Haemoglobin (p < .005; r2 = 0.084), FFR in the LAD (p = .001; r2 = 0.049), creatinine clearance (p = .001; r2 = 0.049; inversely), and NT-proBNP (p = .038; r2 = 0.021) were independently associated with IMRcorr in multivariate linear regression analysis. CONCLUSIONS We report that IMRcorr is associated with renal dysfunction, NT-proBNP, FFR in the LAD and, for the first time, blood haemoglobin. One in four of patients referred for coronary angiography due to CCS have CMVD defined as IMRcorr > 25 in the LAD.
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Hwang D, Zhang J, Myung Lee J, Doh JH, Nam CW, Shin ES, Hoshino M, Murai T, Yonetsu T, Mejía-Rentería H, Kakuta T, Escaned J, Koo BK. Implicaciones pronósticas de los índices fisiológicos coronarios en pacientes con diabetes mellitus. Rev Esp Cardiol 2020. [DOI: 10.1016/j.recesp.2020.05.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Mejía-Rentería H, Lee JM, van der Hoeven NW, Gonzalo N, Jiménez-Quevedo P, Nombela-Franco L, Núñez-Gil IJ, Salinas P, Del Trigo M, Cerrato E, van Royen N, Knaapen P, Koo BK, Macaya C, Fernández-Ortiz A, Escaned J. Coronary Microcirculation Downstream Non-Infarct-Related Arteries in the Subacute Phase of Myocardial Infarction: Implications for Physiology-Guided Revascularization. J Am Heart Assoc 2020; 8:e011534. [PMID: 31014181 PMCID: PMC6512122 DOI: 10.1161/jaha.118.011534] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background Concerns exist about reliability of pressure‐wire‐guided coronary revascularization of non‐infarct‐related arteries (non‐IRA). We investigated whether physiological assessment of non‐IRA during the subacute phase of myocardial infarction might be flawed by microcirculatory dysfunction. Methods and Results We analyzed non‐IRA that underwent fractional flow reserve, coronary flow reserve, and the index of microcirculatory resistance assessment. Microcirculation and hyperemic response were evaluated in 49 acute myocardial infarction patients (59 non‐IRA) and compared with a matched control group of 46 stable angina (SA) patients (59 vessels). Time between acute myocardial infarction to physiological interrogation was 5.9±2.4 days. Fractional flow reserve was similar in both groups (0.79±0.11 in non‐IRA versus 0.80±0.13 in SA vessels, P=0.527). Lower coronary flow reserve values were found in non‐IRA compared with SA vessels (1.77 [1.25–2.76] versus 2.44 [1.63–4.00], P=0.018), primarily driven by an increased baseline flow in non‐IRA (rest mean transit time 0.58 [0.32–0.83] versus 0.65 s [0.39–1.20], P=0.045), whereas the hyperemic flow was similar (hyperemic mean transit time 0.26 [0.20–0.42] versus 0.26 s [0.18–0.35], P=0.873). No differences were found regarding index of microcirculatory resistance (15.6 [10.4–21.8] in non‐IRA versus 16.7 [11.6–23.6] U in SA vessels, P=0.559). During adenosine infusion, the hyperemic response was similar in both groups (non‐IRA versus SA vessels) in terms of the resistive reserve ratio (3.1±2.1 versus 3.7±2.2, P=0.118). Conclusions In the subacute phase of myocardial infarction, non‐IRA show an increased baseline flow that may cause abnormal coronary flow reserve despite preserved hyperemic flow. In non‐IRA, microcirculatory resistance and adenosine‐induced hyperemic response are similar to those found in SA patients. From a physiological perspective, these findings support the use of fractional flow reserve to interrogate non‐IRA during the subacute phase of myocardial infarction. See Editorial Koh and Samady
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Affiliation(s)
- Hernán Mejía-Rentería
- 1 Hospital Clínico San Carlos IDISSC and Universidad Complutense de Madrid Madrid Spain
| | - Joo Myung Lee
- 2 Division of Cardiology Department of Internal Medicine Heart Vascular Stroke Institute Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Korea
| | | | - Nieves Gonzalo
- 1 Hospital Clínico San Carlos IDISSC and Universidad Complutense de Madrid Madrid Spain
| | - Pilar Jiménez-Quevedo
- 1 Hospital Clínico San Carlos IDISSC and Universidad Complutense de Madrid Madrid Spain
| | - Luis Nombela-Franco
- 1 Hospital Clínico San Carlos IDISSC and Universidad Complutense de Madrid Madrid Spain
| | - Iván J Núñez-Gil
- 1 Hospital Clínico San Carlos IDISSC and Universidad Complutense de Madrid Madrid Spain
| | - Pablo Salinas
- 1 Hospital Clínico San Carlos IDISSC and Universidad Complutense de Madrid Madrid Spain
| | - María Del Trigo
- 1 Hospital Clínico San Carlos IDISSC and Universidad Complutense de Madrid Madrid Spain
| | - Enrico Cerrato
- 4 Interventional Cardiology San Luigi Gonzaga University Hospital Orbassano and Rivoli Infermi Hospital Turin Italy
| | - Niels van Royen
- 3 Department of Cardiology VU University Medical Center Amsterdam The Netherlands
| | - Paul Knaapen
- 3 Department of Cardiology VU University Medical Center Amsterdam The Netherlands
| | - Bon-Kwon Koo
- 5 Department of Internal Medicine and Cardiovascular Center Seoul National University Hospital Seoul Korea.,6 Institute on Aging Seoul National University Seoul Korea
| | - Carlos Macaya
- 1 Hospital Clínico San Carlos IDISSC and Universidad Complutense de Madrid Madrid Spain
| | | | - Javier Escaned
- 1 Hospital Clínico San Carlos IDISSC and Universidad Complutense de Madrid Madrid Spain
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Hwang D, Zhang J, Lee JM, Doh JH, Nam CW, Shin ES, Hoshino M, Murai T, Yonetsu T, Mejía-Rentería H, Kakuta T, Escaned J, Koo BK. Prognostic implications of coronary physiological indices in patients with diabetes mellitus. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2020; 74:682-690. [PMID: 32680779 DOI: 10.1016/j.rec.2020.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 05/29/2020] [Indexed: 12/21/2022]
Abstract
INTRODUCTION AND OBJECTIVES Has been performed of the prognostic value of coronary physiological indices in patients with diabetes mellitus (DM) after coronary revascularization deferral. METHODS We analyzed 714 patients (235 with DM) with deferred revascularization according to fractional flow reserve (> 0.80). A comprehensive physiological evaluation including coronary flow reserve (CFR), index of microcirculatory resistance, and fractional flow reserve was performed at the time of revascularization deferral. The median values of the CFR (2.88), fractional flow reserve (0.88), and index of microcirculatory resistance (17.85) were used to classify patients into high- or low-index groups. The primary outcome was the patient-oriented composite outcome (POCO) at 5 years, comprising all-cause death, any myocardial infarction, and any revascularization. RESULTS Compared with the non-DM population, the DM population showed higher risk of POCO (HR, 2.49; 95%CI, 1.64-3.78; P<.001). In the DM population, the low-CFR group had a higher risk of POCO than the high-CFR group (HR, 3.22; 95%CI, 1.74-5.97; P <.001). In contrast, CFR values could not differentiate the risk of POCO in the non-DM population. There was a significant interaction between CFR and the presence of DM regarding the risk of POCO (P for interaction=.025). Independent predictors of POCO were a low CFR and family history of coronary artery disease in the DM population and percent diameter stenosis and multivessel disease in the non-DM population. CONCLUSIONS The association between coronary physiological indices and clinical outcomes differs according to the presence of DM. In deferred patients, CFR is the most important prognostic factor in patients with DM, but not in those without DM.
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Affiliation(s)
- Doyeon Hwang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, South Korea
| | - Jinlong Zhang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, South Korea
| | - Joo Myung Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Joon-Hyung Doh
- Department of Medicine, Inje University Ilsan Paik Hospital, Goyang, South Korea
| | - Chang-Wook Nam
- Department of Medicine, Keimyung University Dongsan Medical Center, Daegu, South Korea
| | - Eun-Seok Shin
- Division of Cardiology, Ulsan Hospital, Ulsan, South Korea and Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, South 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
- Instituto Cardiovascular, Hospital Clínico San Carlos, Madrid, Spain; Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain
| | - Bon-Kwon Koo
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, South Korea; Institute of Aging, Seoul National University, Seoul, Korea.
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Index of Microcirculatory Resistance Measured during Intracoronary Adenosine-Induced Hyperemia. J Interv Cardiol 2020; 2020:4829647. [PMID: 32508541 PMCID: PMC7243016 DOI: 10.1155/2020/4829647] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 03/09/2020] [Accepted: 03/19/2020] [Indexed: 11/24/2022] Open
Abstract
Background The index of microcirculatory resistance is an invasive measure of coronary microvascular function that has to be calculated during maximal hyperemia, classically achieved with intravenous adenosine (IV). The aim of this study was to evaluate the use of intracoronary (IC) adenosine for the calculation of IMR. Methods and Results 31 patients with stable coronary artery disease were included in the study. Coronary pressure and thermodilution measurements were obtained at rest and during maximal hyperemia using a pressure-temperature sensor-tipped coronary guidewire. Duplicate measurements were performed using first IC and then IV adenosine. Dispersion of transit times was comparable for IC and IV adenosine. IMR values based on IC vs IV adenosine showed a high level of agreement and an intraclass correlation coefficient of 0.90. Applying an upper normal limit of 25, misclassification of IMR using IC adenosine was seen in just one patient in whom IC adenosine resulted in a lower value. A simplified procedure based on a single bolus dose of saline did not change the level of agreement or the rate of misclassification. Conclusions We found an excellent agreement between IMR values measured during hyperemia induced by IC as compared to IV adenosine. The use of IC adenosine may facilitate invasive assessment of microvascular function and is potentially time- and cost-saving with less patient discomfort as compared to IV infusion. The trail is registered with NCT03369184.
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Lee JM, Choi KH, Doh JH, Nam CW, Shin ES, Hoshino M, Murai T, Yonetsu T, Mejía-Rentería H, Kakuta T, Escaned J, Koo BK. Long-term Patient Prognostication by Coronary Flow Reserve and Index of Microcirculatory Resistance: International Registry of Comprehensive Physiologic Assessment. Korean Circ J 2020; 50:890-903. [PMID: 32725991 PMCID: PMC7515763 DOI: 10.4070/kcj.2020.0083] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 04/04/2020] [Accepted: 05/13/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Recent guideline recommends evaluation using of coronary flow reserve (CFR) and index of microcirculatory resistance (IMR) in patients with functionally insignificant stenosis. We evaluated clinical implications of CFR and IMR in patients with high fractional flow reserve (FFR) and deferred revascularization. METHODS A total of 867 patients (1,152 vessels) consigned to deferred revascularization who underwent comprehensive physiologic assessments were enrolled. Patients with high FFR (>0.80) were categorized by CFR (≤2) and IMR (≥23 U). Clinical outcome was assessed by patient-oriented composite outcome (POCO), a composite of any death, myocardial infarction (MI), and revascularization at 5 years. RESULTS Patients with low CFR (≤2) showed significantly greater risk of POCO than those with high CFR (>2) in both high-FFR (p=0.024) and low-FFR (p=0.034) groups. In patients with high FFR, those with low CFR and high IMR (overt microvascular disease) displayed the greatest risk of POCO overall (p=0.015), surpassing those with high CFR and low IMR (HR, 2.873; 95% CI, 1.476-5.594; p=0.002) and showing significantly greater risk of cardiac death or MI (HR, 5.662; 95% CI, 1.984-16.154; p=0.001). Overt microvascular disease was independently associated with POCO in the high-FFR population (HR, 2.282; 95% CI, 1.176-4.429; p=0.015). CONCLUSION Among patients with deferred revascularization, those with low CFR showed significantly greater risk of POCO than those with high CFR, regardless of FFR. In patients with high FFR, those with overt microvascular disease showed significantly greater risk of POCO and cardiac death or MI at 5-year, compared with the others. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03690713.
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Affiliation(s)
- Joo Myung Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ki Hong Choi
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joon Hyung Doh
- Department of Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Chang Wook Nam
- Department of Medicine, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Eun Seok Shin
- Division of Cardiology, Ulsan Hospital, Ulsan, Korea and Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, 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, Seoul, Korea.,Institute on Aging, Seoul National University, Seoul, Korea.
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Zavadovsky KV, Maltseva AN, Grakova EV, Kopeva KV, Gulya MO, Saushkin VV, Mochula AV, Liga R, Gimelli A. Relationships between myocardial perfusion abnormalities and integrated indices of atherosclerotic burden: clinical impact of combined anatomic-functional evaluation. RUSSIAN OPEN MEDICAL JOURNAL 2020. [DOI: 10.15275/rusomj.2020.0105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Aim to evaluate the relationships between functional and anatomical information obtained by myocardial perfusion imaging (MPI) and coronary computed tomography angiography (CCTA) in a series of consecutive patients at intermediate probability of coronary artery disease (CAD). Material and Methods — The study group comprised 139 patients (83 men, age of 61.6±7.5 years) who underwent CCTA and single-photon emission computed tomography myocardial perfusion imaging (SPECT-MPI). Based on CCTA results patients were divided into three groups: 1) with the absence of coronary atherosclerosis on CCTA; 2) with non-obstructive CAD (<50%); 3) with obstructive (≥50%) CAD. The Segment Involvement Score, Segment Stenosis Score (SSS) and CTA Risk Score were calculated as measures of global atherosclerosis burden. MPI studies were considered abnormal in the presence of SSS≥4. Results — Abnormal myocardial perfusion was detected in 60% of cases in group 1 and 2; in 75% of cases in group 3. The overall frequencies of normal and abnormal MPI studies differed significantly only in obstructive CAD patients and did not differ in group 1 and 2. There were no significant correlations between calcium score, atherosclerotic lesion length, positive remodelling index and MPI results in patients with non-obstructive as well as in patients with obstructive CAD. In group of patients with obstructive CAD Segment Stenosis Score correlated wekly with SSS (r=0.39, p=0.001) and SDS (r=0.28; p=0.012); the CTA Risk Score showed correlationes with SSS (r=0.38, p=0.002) and SDS (r=0.30, p=0.020). Conclusion — Myocardial perfusion abnormalities may develop even in the absence of critical coronary artery lesions. The extent of myocardial ischemia correlates with measures of global CAD burden only in patients with obstructive CAD.
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Mizukami T, Tanaka K, Sonck J, Vandeloo B, Roosens B, Lochy S, Argacha JF, Schoors D, Suzuki H, Belsack D, Andreini D, Barbato E, De Mey J, De Bruyne B, Cosyns B, Collet C. Evaluation of epicardial coronary resistance using computed tomography angiography: A Proof of Concept. J Cardiovasc Comput Tomogr 2020; 14:177-184. [DOI: 10.1016/j.jcct.2019.09.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 07/20/2019] [Accepted: 09/21/2019] [Indexed: 11/16/2022]
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Fukuoka S, Kurita T, Takasaki A, Nakata T, Fujimoto N, Masuda J, Hoshino K, Tanigawa T, Koyabu S, Ito M, Dohi K. Clinical usefulness of instantaneous wave-free ratio for the evaluation of coronary artery lesion with prior myocardial infarction: A multi-center study. IJC HEART & VASCULATURE 2020; 26:100431. [PMID: 31890864 PMCID: PMC6931066 DOI: 10.1016/j.ijcha.2019.100431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 09/23/2019] [Accepted: 10/08/2019] [Indexed: 01/10/2023]
Abstract
Background Fractional flow reserve (FFR) is useful for assessing the functional significance of coronary artery stenosis, even in lesions with prior myocardial infarction (pMI). Instantaneous wave-free ratio (iFR) is a vasodilator-free alternative for the physiological assessment of coronary artery stenosis. In addition, iFR shows good diagnostic agreement with FFR and an iFR-guided revascularization strategy was non-inferior to an FFR-guided revascularization strategy. However, the clinical usefulness of iFR for the evaluation of a coronary artery lesions with pMI has not been evaluated. Methods and Results A total of 200 lesions from 200 patients (44 pMI territories lesions and 156 non-pMI coronary artery lesions) were analyzed retrospectively. Major adverse cardiac events (MACE) were defined as cardiovascular death, non-fatal MI, unstable angina pectoris, fatal arrhythmia and heart failure during 12 months follow-up after the physiological assessment of coronary artery stenosis. iFR was closely correlated with FFR in pMI and non-pMI lesions (r = 0.81 and 0.72; P < 0.001, respectively). In pMI lesions, an iFR cut-off of 0.89 was optimal against a clinical FFR cut-off of 0.80 according to receiver operating characteristics (ROC) curve analysis, whereas in non-pMI lesions, the iFR cut-off value was 0.92 without statistical significance. In addition, the event rate of MACE was similar between pMI and non-pMI patients during follow-up even in the presence or absence of an PCI procedure. Conclusions iFR may be a useful alternative method compared with FFR for clinical decision-making even in pMI patients.
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Weir-McCall JR, Fairbairn TA. Fractional Flow Reserve Derived from CT: The State of Play in 2020. Radiol Cardiothorac Imaging 2020; 2:e190153. [PMID: 33778538 PMCID: PMC7977733 DOI: 10.1148/ryct.2019190153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 10/19/2019] [Accepted: 10/23/2019] [Indexed: 06/12/2023]
Abstract
Fractional flow reserve derived from CT is a rapidly developing technique, with an increasing burden of literature supporting its potential role in the workup of patients suspected of having coronary artery disease.
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Affiliation(s)
- Jonathan R. Weir-McCall
- From the Department of Radiology, University of Cambridge School of Clinical Medicine, Box 219, Level 5, Biomedical Campus, Cambridge CB2 0QQ, England (J.R.W.); Royal Papworth Hospital, Cambridge, England (J.R.W.); and Department of Cardiology, Liverpool Heart and Chest Hospital, Liverpool, England (T.A.F.)
| | - Timothy A. Fairbairn
- From the Department of Radiology, University of Cambridge School of Clinical Medicine, Box 219, Level 5, Biomedical Campus, Cambridge CB2 0QQ, England (J.R.W.); Royal Papworth Hospital, Cambridge, England (J.R.W.); and Department of Cardiology, Liverpool Heart and Chest Hospital, Liverpool, England (T.A.F.)
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Dorobantu M, Calmac L. Coronary Microcirculatory Dysfunction Evaluation in Chronic Angina. Microcirculation 2020. [DOI: 10.1007/978-3-030-28199-1_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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