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Nishi T, Saito Y, Kitahara H, Nishi T, Fujimoto Y, Kobayashi Y. Coronary Flow Reserve and Glycemic Variability in Patients with Coronary Artery Disease. Intern Med 2021; 60:1151-1158. [PMID: 33132339 PMCID: PMC8112971 DOI: 10.2169/internalmedicine.6158-20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Objective Glycemic variability is being increasingly recognized as an early indicator of glucose metabolic disorder and may contribute to the development of diabetic vascular complications, such as coronary microvascular dysfunction. The present study sought to investigate the relationship between coronary microvascular function assessed by intracoronary thermodilution method and glycemic variability on a continuous glucose monitoring system (CGMS). Methods We prospectively enrolled 40 patients with or without known diabetes mellitus who had epicardial coronary artery disease referred for coronary angiography and were not treated with diabetic medications. Of these, two had a significant stenosis in the left main coronary artery and were therefore excluded from the analyses. In the end, 38 patients were equipped with a CGMS and underwent intracoronary physiological assessments in the unobstructed left anterior descending artery. The mean amplitude of glycemic excursion (MAGE) and standard deviation were calculated from the obtained CGMS data as indicators of glucose variability. Results Coronary flow reserve (CFR) was negatively correlated with MAGE (r=-0.328, p=0.044) and standard deviation (r=-0.339, p=0.037) on CGMS, while the index of microcirculatory resistance showed no such correlation. Multivariable linear regression analyses showed that MAGE on CGMS was significantly associated with CFR after adjusting for age, sex, fractional flow reserve and hemoglobin A1c. Conclusion Higher MAGE on CGMS was associated with reduced CFR in stable patients with coronary artery disease, suggesting a potential effect of glycemic variability on coronary microvascular flow regulation. A further study with a larger sample size needs to be conducted to confirm our findings.
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Affiliation(s)
- Takeshi Nishi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Japan
| | - Yuichi Saito
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Japan
| | - Hideki Kitahara
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Japan
| | - Tomoko Nishi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Japan
| | - Yoshihide Fujimoto
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Japan
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Japan
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2
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Gutiérrez-Barrios A, Noval-Morillas I, Camacho-Freire S, Puche JE, Gheorghe L, Silva E, Alarcon-Lastra I, Cañadas-Pruaño D, Gómez-Menchero A, Calle-Pérez G, Diaz-Fernandez JF, Vázquez-García R. Contrast FFR plus intracoronary injection of nitro-glycerine accurately predicts FFR for coronary stenosis functional assessment. Minerva Cardiol Angiol 2020; 69:449-457. [PMID: 33258564 DOI: 10.23736/s2724-5683.20.05354-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Fractional flow reserve (FFR) is the "gold standard" for assessing the physiological significance of coronary disease. In the last decade, several alternative adenosine-free indexes have been proposed in order to facilitate the dissemination of the functional evaluation of coronary stenosis. Our aim was to investigate whether radiographic contrast plus intracoronary nitroglycerin (cFFR-NTG) can predict functional assessment of coronary stenosis offering superior diagnostic agreement with FFR compared to non-hyperemic indexes and contrast mediated FFR (cFFR). METHODS Three hundred twenty-nine lesions evaluated with pressure wire in 266 patients were prospectively included in this multicenter study. RESULTS The ROC curves for cFFR-NTG using an FFR≤0.80 showed a higher accuracy in predicting FFR (AUC=0.97) than resting Pd/Pa (AUC=0.90, P<0.01) and cFFR (AUC=0.93.5, P<0.01). A significant (P<0.01) strong correlation was found between FFR and the four analyzed indexes: Pd/Pa (r=0.78); iFR/RFR (r=0.73); cFFR(r=0.89) and cFFR-NTG (r=0.93). cFFR-NTG showed the closest agreement at Bland-Altman analysis. The cFFR-NTG cut off value >0.84 showed the highest negative predictive value (88%), specificity (91%), sensitivity (94%) and accuracy (92%) of the studied indexes. CONCLUSIONS Submaximal hyperemic adenosine-free indexes are an efficient alternative to adenosine for the physiological assessment of epicardial coronary disease. The most accurate index in predicting the functional significance of coronary stenosis using FFR as reference was cFFR-NTG.
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Affiliation(s)
- Alejandro Gutiérrez-Barrios
- Department of Cardiology, Puerta del Mar University Hospital, Cádiz, Spain - .,Instituto de Investigación e Innovación en Ciencias Biomédicas de Cádiz (INiBICA), Cádiz, Spain -
| | - Inmaculada Noval-Morillas
- Department of Cardiology, Puerta del Mar University Hospital, Cádiz, Spain.,Instituto de Investigación e Innovación en Ciencias Biomédicas de Cádiz (INiBICA), Cádiz, Spain
| | | | - Juan E Puche
- Department of Cardiology, Puerta del Mar University Hospital, Cádiz, Spain
| | - Livia Gheorghe
- Department of Cardiology, Puerta del Mar University Hospital, Cádiz, Spain.,Instituto de Investigación e Innovación en Ciencias Biomédicas de Cádiz (INiBICA), Cádiz, Spain
| | - Etelvino Silva
- Department of Cardiology, Juan Ramón Jiménez Hospital, Huelva, Spain
| | | | - Dolores Cañadas-Pruaño
- Department of Cardiology, Puerta del Mar University Hospital, Cádiz, Spain.,Instituto de Investigación e Innovación en Ciencias Biomédicas de Cádiz (INiBICA), Cádiz, Spain
| | | | - Germán Calle-Pérez
- Department of Cardiology, Puerta del Mar University Hospital, Cádiz, Spain.,Instituto de Investigación e Innovación en Ciencias Biomédicas de Cádiz (INiBICA), Cádiz, Spain
| | | | - Rafael Vázquez-García
- Department of Cardiology, Puerta del Mar University Hospital, Cádiz, Spain.,Instituto de Investigación e Innovación en Ciencias Biomédicas de Cádiz (INiBICA), Cádiz, Spain
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Meta-Analysis of Diagnostic Performance of Contrast-Fractional Flow Reserve versus Quantitative Flow Ratio for Functional Assessment of Coronary Stenoses. J Interv Cardiol 2020. [DOI: 10.1155/2020/7352150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background. Use of the fractional flow reserve (FFR) technique is recommended to evaluate coronary stenosis severity and guide revascularization. However, its high cost, time to administer, and the side effects of adenosine reduce its clinical utility. Two novel adenosine-free indices, contrast-FFR (cFFR) and quantitative flow ratio (QFR), can simplify the functional evaluation of coronary stenosis. This study aimed to analyze the diagnostic performance of cFFR and QFR using FFR as a reference index. Methods. We conducted a systematic review and meta-analysis of observational studies in which cFFR or QFR was compared to FFR. A bivariate model was applied to pool diagnostic parameters. Cochran’s Q test and the I2 index were used to assess heterogeneity and identify the potential source of heterogeneity by metaregression and sensitivity analysis. Results. Overall, 2220 and 3000 coronary lesions from 20 studies were evaluated by cFFR and QFR, respectively. The pooled sensitivity and specificity were 0.87 (95% CI: 0.81, 0.91) and 0.92 (95% CI: 0.88, 0.94) for cFFR and 0.87 (95% CI: 0.82, 0.91) and 0.91 (95% CI: 0.87, 0.93) for QFR, respectively. No statistical significance of sensitivity and specificity for cFFR and QFR were observed in the bivariate analysis (P=0.8406 and 0.4397, resp.). The area under summary receiver-operating curve of cFFR and QFR was 0.95 (95% CI: 0.93, 0.97) for cFFR and 0.95 (95% CI: 0.93, 0.97). Conclusion. Both cFFR and QFR have good diagnostic performance in detecting functional severity of coronary arteries and showed similar diagnostic parameters.
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Regional layer-specific longitudinal peak systolic strain using exercise stress two-dimensional speckle-tracking echocardiography for the detection of functionally significant coronary artery disease. Heart Vessels 2019; 34:1394-1403. [PMID: 30798411 DOI: 10.1007/s00380-019-01361-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 02/15/2019] [Indexed: 12/14/2022]
Abstract
The present study aimed to investigate whether layer-specific regional peak-systolic longitudinal strain (LS) measurement on transthoracic echocardiogram (TTE) with exercise stress can be useful for the detection of functionally significant coronary artery disease as confirmed by invasive fractional flow reserve (FFR) in stable patients. This is a prospective analysis of 88 coronary arteries in 30 stable patients undergoing invasive FFR measurement and ergometer exercise stress TTE. Regional LS in the mid, endocardial and epicardial layers was calculated at rest, peak stress and early and late recovery phases after the exercise stress test. The endocardial-to-epicardial LS ratio was calculated as an indicator of endocardial-layer dependency of the left ventricular myocardium. Ischemic FFR defined as FFR ≤ 0.80 was observed in 33 of 88 coronary arteries. The mid-, endocardial- and epicardial-layer LS at early recovery (- 15.4 ± 5.2 vs. - 13.0 ± 4.4%, P = 0.040; - 15.7 ± 5.1 vs. - 13.2 ± 4.5%, P = 0.029; - 14.6 ± 5.1 vs. - 12.4 ± 4.0%, P = 0.038, respectively) and the percent change in the endocardial-to-epicardial LS ratio from baseline to peak stress, early recovery, and late recovery phases (1.5 ± 11.2% vs. 6.6 ± 10.5%, P = 0.009; 2.8 ± 8.9% vs. 7.1 ± 12.6%, P = 0.002; 5.2 ± 8.8% vs. 8.5 ± 13.7%, P = 0.026; respectively) were significantly more impaired in the ischemic territories (FFR ≤ 0.80) compared with the non-ischemic territories (FFR > 0.80). According to the receiver operating characteristic curve analysis, a combination of endocardial LS and percent change in the endocardial-to-epicardial LS ratio at early recovery phase plus visual evaluation of LV wall motion had incremental diagnostic value for the detection of the ischemic territory compared with visual evaluation alone (area under the curve = 0.752 and 0.618, P = 0.006). The results of this study suggested that assessing layer-specific LS and the endocardial-to-epicardial LS ratio after exercise stress on speckle-tracking TTE may have potential for objective and quantitative evaluation in the assessment of myocardial ischemia. Further studies in a larger population are needed to confirm these findings.
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Contrast Fractional Flow Reserve (cFFR): A pragmatic response to the call for simplification of invasive functional assessment. Int J Cardiol 2018; 268:45-50. [DOI: 10.1016/j.ijcard.2018.04.048] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 03/31/2018] [Accepted: 04/10/2018] [Indexed: 01/29/2023]
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Shah SV, Zimmermann FM, Johnson NP, Nishi T, Kobayashi Y, Witt N, Berry C, Jeremias A, Koo BK, Esposito G, Rioufol G, Park SJ, Oldroyd KG, Barbato E, Pijls NHJ, De Bruyne B, Fearon WF. Sex Differences in Adenosine-Free Coronary Pressure Indexes: A CONTRAST Substudy. JACC Cardiovasc Interv 2018; 11:1454-1463. [PMID: 30031722 DOI: 10.1016/j.jcin.2018.03.030] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 03/21/2018] [Accepted: 03/21/2018] [Indexed: 01/18/2023]
Abstract
OBJECTIVES The goal of this study was to investigate sex differences in adenosine-free coronary pressure indexes. BACKGROUND Several adenosine-free coronary pressure wire indexes have been proposed to assess the functional significance of coronary artery lesions; however, there is a theoretical concern that sex differences may affect diagnostic performance because of differences in resting flow and distal myocardial mass. METHODS In this CONTRAST (Can Contrast Injection Better Approximate FFR Compared to Pure Resting Physiology?) substudy, contrast fractional flow reserve (cFFR), obtained during contrast-induced submaximal hyperemia, the instantaneous wave-free ratio (iFR), and distal/proximal coronary pressure ratio (Pd/Pa) were compared with fractional flow reserve (FFR) in 547 men and 216 women. Using FFR ≤0.8 as a reference, the diagnostic performance of each index was compared. RESULTS Men and women had similar diameter stenosis (p = 0.78), but women were less likely to have FFR ≤0.80 than men (42.5% vs. 51.5%, p = 0.04). Sensitivity was similar among cFFR, iFR, and Pd/Pa when comparing women and men, respectively (cFFR, 77.5% vs. 75.3%; p = 0.69; iFR, 84.9% vs. 79.4%; p = 0.30; Pd/Pa, 78.8% vs. 77.3%; p = 0.78). cFFR was more specific than iFR or Pd/Pa regardless of sex (cFFR, 94.3% vs. 95.8%; p = 0.56; iFR, 75.6% vs. 80.1%; p = 0.38; Pd/Pa, 80.6% vs. 78.7%; p = 0.69). By receiver-operating characteristic curve analysis, cFFR provided better diagnostic accuracy than resting indexes irrespective of sex (p ≤ 0.0001). CONCLUSIONS Despite the theoretical concern, the diagnostic sensitivity and specificity of cFFR, iFR, and Pd/Pa did not differ between the sexes. Irrespective of sex, cFFR provides the best diagnostic performance.
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Affiliation(s)
- Sonia V Shah
- Stanford University School of Medicine, Stanford, California; Stanford Cardiovascular Institute, Stanford, California
| | | | - Nils P Johnson
- McGovern Medical School at UTHealth and Memorial Hermann Hospital, Houston, Texas
| | - Takeshi Nishi
- Stanford University School of Medicine, Stanford, California; Stanford Cardiovascular Institute, Stanford, California
| | - Yuhei Kobayashi
- Stanford University School of Medicine, Stanford, California; Stanford Cardiovascular Institute, Stanford, California
| | - Nils Witt
- Karolinska Institutet, Södersjukhuset, Stockholm, Sweden
| | - Colin Berry
- West of Scotland Heart and Lung Center, Golden Jubilee National Hospital, Clydebank, United Kingdom; British Heart Foundation Glasgow Cardiovascular Research Center, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Allen Jeremias
- Division of Cardiovascular Medicine, Stony Brook University Medical Center, Stony Brook, New York; Cardiovascular Research Foundation, New York, New York
| | - Bon-Kwon Koo
- Seoul National University Hospital, Seoul, South Korea
| | | | | | - Seung-Jung Park
- University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Keith G Oldroyd
- West of Scotland Heart and Lung Center, Golden Jubilee National Hospital, Clydebank, United Kingdom
| | - Emanuele Barbato
- University of Naples Federico II, Naples, Italy; Cardiovascular Center Aalst, Aalst, Belgium
| | - Nico H J Pijls
- Catharina Hospital, Eindhoven, the Netherlands; Eindhoven University of Technology, Eindhoven, the Netherlands
| | | | - William F Fearon
- Stanford University School of Medicine, Stanford, California; Stanford Cardiovascular Institute, Stanford, California.
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Nishi T, Kitahara H, Fujimoto Y, Nakayama T, Nagashima K, Hanaoka H, Kobayashi Y. Intravenous nicorandil versus adenosine for fractional flow reserve measurement: a crossover, randomized study. Heart Vessels 2018; 33:1570-1575. [PMID: 29858919 DOI: 10.1007/s00380-018-1197-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 05/25/2018] [Indexed: 11/25/2022]
Abstract
Nicorandil has vasodilatory effects on both the epicardial coronary arteries and the coronary microvasculature, thereby increasing coronary blood flow. The objective of the present study was to investigate the effectiveness of intravenous (IV) nicorandil infusion for fractional flow reserve (FFR) measurement. In this crossover randomized study, 49 patients underwent FFR measurement with a consecutive randomized order of patient-blind infusions of continuous IV adenosine administration and a single bolus IV administration of nicorandil. The primary endpoint was the difference between the FFR by nicorandil and the FFR by adenosine, as assessed by the Bland-Altman method. The mean FFR value measured by nicorandil was not significantly different from that measured by adenosine [0.8125 ± 0.1349 vs. 0.7978 ± 0.124; mean difference, 0.0147 (95% confidence interval - 0.0373, 0.0667); P = 0.58]. There was no clinically significant diagnostic discordance, with the FFR by nicorandil > 0.80 and that by adenosine < 0.75. Hyperemia was achieved earlier using nicorandil than adenosine (34 ± 13 vs. 58 ± 15, P < 0.001). The duration of hyperemia after IV nicorandil was variable (6-570 s, mean 89 ± 98 s). IV nicorandil decreased systolic blood pressure by 32 ± 16 mm Hg (24 ± 10%) from baseline. Linear regression analysis showed that the average FFR value and the difference in systolic blood pressure were significantly associated with the bias in the FFR value between the two drugs. In conclusions, the results of the present study suggest that IV nicorandil can achieve maximal hyperemia easily and rapidly, providing an acceptable diagnostic performance for FFR assessment. However, a wide range of variation in hyperemic plateau and a decrease in blood pressure are the major limitations of this method.
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Affiliation(s)
- Takeshi Nishi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba, 260-8677, Japan.
| | - Hideki Kitahara
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba, 260-8677, Japan
| | - Yoshihide Fujimoto
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba, 260-8677, Japan
| | - Takashi Nakayama
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba, 260-8677, Japan
| | - Kengo Nagashima
- Department of Global Clinical Research, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Hideki Hanaoka
- Clinical Research Center, University Hospital, Chiba University School of Medicine, Chiba, Japan
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba, 260-8677, Japan
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