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Ekmejian A, Brieger D, Bhat A, Sritharan H, Nour D, Allahwala U, Ward M, Bhindi R. Vessel-Specific Outcomes of Deferred Revascularization Following Negative Fractional Flow Reserve. Am J Cardiol 2023; 201:320-327. [PMID: 37399598 DOI: 10.1016/j.amjcard.2023.06.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 06/01/2023] [Accepted: 06/05/2023] [Indexed: 07/05/2023]
Abstract
Variations in myocardial supply area and hydrostatic pressure gradients result in greater likelihood of positive fractional flow reserve (FFR) in the left anterior descending (LAD) compared with the circumflex (Cx) and right coronary artery (RCA). However, the same FFR threshold for deferral of revascularization is applied to all arteries, without evidence that this results in equivalent outcomes. We assessed vessel-specific outcomes of deferred revascularization for the 3 major coronary arteries based on FFR > 0.8. In this retrospective study, data were obtained on consecutive patients who underwent indicated FFR assessment across 2 tertiary institutions. Patients with deferred revascularization were followed for 36 months for the primary end point of vessel-specific target lesion failure (TLF). Of 1,916 major coronary arteries (1,579 patients), the odds ratio of positive FFR was highest in the LAD (odds ratio 3.36, p <0.001). In total, 867 vessels (733 patients) with FFR > 0.8 had complete 3-year medical record follow-ups. The TLF rate for deferred vessels was 10.21%, 11.52%, and 10.96% for the LAD, Cx, and RCA respectively. In a multivariate analysis, there was no significant difference in the odds of TLF for the 0.84 (0.53 to 1.33, p = 0.459), 1.17 (0.68 to 2.01, p = 0.582), and 1.11 (0.62 to 2.00, p = 0.715) in the LAD, Cx, and RCA, respectively. In a multivariate analysis, diabetes mellitus was the only baseline characteristic significantly associated at risk of TLF (1.43 [1.01 to 2.02], p = 0.043). In conclusion, despite greater likelihood of positive FFR in the LAD, the FFR threshold for deferred revascularization resulted in equivalent outcomes in all 3 major coronary arteries, and patients with diabetes mellitus may represent a group that requires aggressive surveillance and risk factor modification after deferred revascularization.
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Affiliation(s)
- Avedis Ekmejian
- Department of Cardiology, Royal North Shore Hospital, St Leonards, Australia; Northern Clinical School, Faculty of Medicine, University of Sydney, Camperdown, Australia.
| | - Daniel Brieger
- Department of Cardiology, Royal North Shore Hospital, St Leonards, Australia
| | - Aditya Bhat
- Department of Cardiology, Royal North Shore Hospital, St Leonards, Australia
| | - Hari Sritharan
- Department of Cardiology, Royal North Shore Hospital, St Leonards, Australia; Northern Clinical School, Faculty of Medicine, University of Sydney, Camperdown, Australia
| | - Daniel Nour
- Department of Cardiology, Royal North Shore Hospital, St Leonards, Australia
| | - Usaid Allahwala
- Department of Cardiology, Royal North Shore Hospital, St Leonards, Australia; Northern Clinical School, Faculty of Medicine, University of Sydney, Camperdown, Australia
| | - Michael Ward
- Department of Cardiology, Royal North Shore Hospital, St Leonards, Australia; Northern Clinical School, Faculty of Medicine, University of Sydney, Camperdown, Australia
| | - Ravinay Bhindi
- Department of Cardiology, Royal North Shore Hospital, St Leonards, Australia; Northern Clinical School, Faculty of Medicine, University of Sydney, Camperdown, Australia
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2
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Ekmejian A, Sritharan H, Selvakumar D, Venkateshka V, Allahwala U, Ward M, Bhindi R. Outcomes of deferred revascularisation following negative fractional flow reserve in diabetic and non-diabetic patients: a meta-analysis. Cardiovasc Diabetol 2023; 22:22. [PMID: 36717847 PMCID: PMC9887893 DOI: 10.1186/s12933-023-01751-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 01/23/2023] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Fractional Flow Reserve (FFR) is a widely applied invasive physiological assessment, endorsed by major guidelines to aid in the decision to perform or defer revascularisation. While a threshold of > 0.8 has been applied universally, clinical outcomes may be affected by numerous factors, including the presence of diabetes. This meta-analysis aims to investigate the outcomes of diabetic versus non-diabetic patients in whom revascularisation was deferred based on negative FFR. METHODS We performed a meta-analysis investigating the outcomes of diabetic and non-diabetic patients in whom revascularisation was deferred based on negative FFR. A search was performed on MEDLINE, PubMed and EMBASE, and peer-reviewed studies that reported MACE for diabetic and non-diabetic patients with deferred revascularisation based on FFR > 0.8 were included. The primary end point was MACE. RESULTS The meta-analysis included 7 studies in which 4275 patients had revascularisation deferred based on FFR > 0.8 (1250 diabetic). Follow up occurred over a mean of 3.2 years. Diabetes was associated with a higher odds of MACE (OR = 1.66, 95% CI 1.35-2.04, p = < 0.001), unplanned revascularisation (OR = 1.48, 95% CI 1.06-2.06, p = 0.02), all-cause mortality (OR = 1.74, 95% CI 1.20-2.52, p = 0.004) and cardiovascular mortality (OR = 2.08, 95% CI 1.07-4.05, p = 0.03). CONCLUSIONS For patients with stable coronary syndromes and deferred revascularisation based on FFR > 0.8, the presence of diabetes portends an increased long-term risk of MACE compared to non-diabetic patients. Trail registration URL: https://www.crd.york.ac.uk/PROSPERO/ ; Unique identifier: CRD42022367312.
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Affiliation(s)
- Avedis Ekmejian
- Department of Cardiology, Interventional Cardiologist, Royal North Shore Hospital, Reserve Rd, St Leonards, Sydney, 2065, Australia. .,University of Sydney, Camperdown, Australia.
| | - Hari Sritharan
- grid.412703.30000 0004 0587 9093Department of Cardiology, Interventional Cardiologist, Royal North Shore Hospital, Reserve Rd, St Leonards, Sydney, 2065 Australia ,grid.1013.30000 0004 1936 834XUniversity of Sydney, Camperdown, Australia
| | - Dinesh Selvakumar
- grid.412703.30000 0004 0587 9093Department of Cardiology, Interventional Cardiologist, Royal North Shore Hospital, Reserve Rd, St Leonards, Sydney, 2065 Australia
| | - Venkateshka Venkateshka
- grid.482157.d0000 0004 0466 4031Northern Sydney Local Health District Executive, Hornsby, Australia
| | - Usaid Allahwala
- grid.412703.30000 0004 0587 9093Department of Cardiology, Interventional Cardiologist, Royal North Shore Hospital, Reserve Rd, St Leonards, Sydney, 2065 Australia ,grid.1013.30000 0004 1936 834XUniversity of Sydney, Camperdown, Australia
| | - Michael Ward
- grid.412703.30000 0004 0587 9093Department of Cardiology, Interventional Cardiologist, Royal North Shore Hospital, Reserve Rd, St Leonards, Sydney, 2065 Australia ,grid.1013.30000 0004 1936 834XUniversity of Sydney, Camperdown, Australia
| | - Ravinay Bhindi
- grid.412703.30000 0004 0587 9093Department of Cardiology, Interventional Cardiologist, Royal North Shore Hospital, Reserve Rd, St Leonards, Sydney, 2065 Australia ,grid.1013.30000 0004 1936 834XUniversity of Sydney, Camperdown, Australia
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3
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Zdzierak B, Zasada W, Krawczyk-Ożóg A, Rakowski T, Bartuś S, Surdacki A, Dziewierz A. Comparison of Fractional Flow Reserve with Resting Non-Hyperemic Indices in Patients with Coronary Artery Disease. J Cardiovasc Dev Dis 2023; 10:jcdd10020034. [PMID: 36826530 PMCID: PMC9959762 DOI: 10.3390/jcdd10020034] [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: 12/27/2022] [Revised: 01/14/2023] [Accepted: 01/16/2023] [Indexed: 01/20/2023] Open
Abstract
Guidelines recommend using hyperemic (FFR) and non-hyperemic (iFR/RFR) methods of evaluating coronary artery stenoses in patients with coronary artery disease. However, in some cases, achieved results indicating significant ischemia may differ between those methods. Thus, we sought to identify predictors of such a discrepancy. Data were collected on all consecutive patients with chronic coronary syndrome hospitalized between 2020 and 2021. For 279 patients (417 vessels), results for both FFR and iFR/RFR were available. Values of ≤0.80 for FFR and ≤0.89 for iFR/RFR were considered positive for ischemia. Discordant measurements of FFR and iFR/RFR were observed in 80 (19.2%) patients. Atrial fibrillation was the only predictor of the overall FFR and iFR/RFR discordance - OR (95%CI) 1.90 (1.02-3.51); p = 0.040. The chance of positive FFR and negative iFR/RFR decreased independently with age - OR (95%CI) 0.96 (0.93-0.99); p = 0.024. On the contrary, insulin-treated diabetes mellitus was the predictor of negative FFR and positive iFR/RFR discrepancy - OR (95%CI) 4.61 (1.38-15.40); p = 0.013. In everyday clinical practice, iFR/FFR correlates well with FFR. However, discordance between these methods is quite common. Physicians should be aware of the risk of such discordance in patients with atrial fibrillation, advanced age, and insulin-treated diabetes mellitus.
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Affiliation(s)
- Barbara Zdzierak
- Clinical Department of Cardiology and Cardiovascular Interventions, University Hospital, 30-688 Krakow, Poland
| | - Wojciech Zasada
- Clinical Department of Cardiology and Cardiovascular Interventions, University Hospital, 30-688 Krakow, Poland
- KCRI, 30-347 Krakow, Poland
| | - Agata Krawczyk-Ożóg
- Clinical Department of Cardiology and Cardiovascular Interventions, University Hospital, 30-688 Krakow, Poland
- Department of Anatomy, HEART-Heart Embryology and Anatomy Research Team, Jagiellonian University Medical College, 33-332 Krakow, Poland
| | - Tomasz Rakowski
- Clinical Department of Cardiology and Cardiovascular Interventions, University Hospital, 30-688 Krakow, Poland
- 2nd Department of Cardiology, Institute of Cardiology, Jagiellonian University Medical College, 30-688 Krakow, Poland
| | - Stanisław Bartuś
- Clinical Department of Cardiology and Cardiovascular Interventions, University Hospital, 30-688 Krakow, Poland
- 2nd Department of Cardiology, Institute of Cardiology, Jagiellonian University Medical College, 30-688 Krakow, Poland
| | - Andrzej Surdacki
- Clinical Department of Cardiology and Cardiovascular Interventions, University Hospital, 30-688 Krakow, Poland
- 2nd Department of Cardiology, Institute of Cardiology, Jagiellonian University Medical College, 30-688 Krakow, Poland
| | - Artur Dziewierz
- Clinical Department of Cardiology and Cardiovascular Interventions, University Hospital, 30-688 Krakow, Poland
- 2nd Department of Cardiology, Institute of Cardiology, Jagiellonian University Medical College, 30-688 Krakow, Poland
- Correspondence: ; Tel.: +48-12-400-2250
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4
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Peper J, Becker LM, van Kuijk JP, Leiner T, Swaans MJ. Fractional Flow Reserve: Patient Selection and Perspectives. Vasc Health Risk Manag 2021; 17:817-831. [PMID: 34934324 PMCID: PMC8684425 DOI: 10.2147/vhrm.s286916] [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: 08/13/2021] [Accepted: 11/30/2021] [Indexed: 01/10/2023] Open
Abstract
The aim of this review was to discuss the current practice and patient selection for invasive FFR, new techniques to estimate invasive FFR and future of coronary physiology tests. We elaborate on the indication and application of FFR and on the contraindications and concerns in certain patient populations.
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Affiliation(s)
- Joyce Peper
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands.,Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Leonie M Becker
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands.,Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jan-Peter van Kuijk
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Tim Leiner
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Martin J Swaans
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
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5
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Van Belle E, Cosenza A, Baptista SB, Vincent F, Henderson J, Santos L, Ramos R, Pouillot C, Calé R, Cuisset T, Jorge E, Teiger E, Machado C, Belle L, Costa M, Barreau D, Oliveira E, Hanssen M, Costa J, Besnard C, Nunes L, Dallongeville J, Sideris G, Bretelle C, Fonseca N, Lhoest N, Guardado J, Silva B, Sousa MJ, Barnay P, Silva JC, Leborgne L, Rodrigues A, Porouchani S, Seca L, Fernandes R, Dupouy P, Raposo L. Usefulness of Routine Fractional Flow Reserve for Clinical Management of Coronary Artery Disease in Patients With Diabetes. JAMA Cardiol 2021; 5:272-281. [PMID: 31913433 DOI: 10.1001/jamacardio.2019.5097] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Approximately one-third of patients considered for coronary revascularization have diabetes, which is a major determinant of clinical outcomes, often influencing the choice of the revascularization strategy. The usefulness of fractional flow reserve (FFR) to guide treatment in this population is understudied and has been questioned. Objective To evaluate the usefulness and rate of major adverse cardiovascular events (MACE) of integrating FFR in management decisions for patients with diabetes who undergo coronary angiography. Design, Setting, and Participants This cross-sectional study used data from the PRIME-FFR study derived from the merger of the POST-IT study (Portuguese Study on the Evaluation of FFR-Guided Treatment of Coronary Disease [March 2012-November 2013]) and R3F study (French Study of FFR Integrated Multicenter Registries Implementation of FFR in Routine Practice [October 2008-June 2010]), 2 prospective multicenter registries that shared a common design. A population of all-comers for whom angiography disclosed ambiguous lesions was analyzed for rates, patterns, and outcomes associated with management reclassification, including revascularization deferral, in patients with vs without diabetes. Data analysis was performed from June to August 2018. Main Outcomes and Measures Death from any cause, myocardial infarction, or unplanned revascularization (MACE) at 1 year. Results Among 1983 patients (1503 [77%] male; mean [SD] age, 65 [10] years), 701 had diabetes, and FFR was performed for 1.4 lesions per patient (58.2% of lesions in the left anterior descending artery; mean [SD] stenosis, 56% [11%]; mean [SD] FFR, 0.81 [0.01]). Reclassification by FFR was high and similar in patients with and without diabetes (41.2% vs 37.5%, P = .13), but reclassification from medical treatment to revascularization was more frequent in the former (142 of 342 [41.5%] vs 230 of 730 [31.5%], P = .001). There was no statistical difference between the 1-year rates of MACE in reclassified (9.7%) and nonreclassified patients (12.0%) (P = .37). Among patients with diabetes, FFR-based deferral identified patients with a lower risk of MACE at 12 months (25 of 296 [8.4%]) compared with those undergoing revascularization (47 of 257 [13.1%]) (P = .04), and the rate was of the same magnitude of the observed rate among deferred patients without diabetes (7.9%, P = .87). Status of insulin treatment had no association with outcomes. Patients (6.6% of the population) in whom FFR was disregarded had the highest MACE rates regardless of diabetes status. Conclusions and Relevance Routine integration of FFR for the management of coronary artery disease in patients with diabetes may be associated with a high rate of treatment reclassification. Management strategies guided by FFR, including revascularization deferral, may be useful for patients with diabetes.
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Affiliation(s)
- Eric Van Belle
- Département de Cardiologie, Institut Coeur-Poumon, Centre Hospitalier Universitaire de Lille, Lille, France.,Institut national de la santé et de la recherche médicale INSERM U1011, Lille-II-University, Lille, France
| | - Alessandro Cosenza
- Département de Cardiologie, Institut Coeur-Poumon, Centre Hospitalier Universitaire de Lille, Lille, France.,Institut national de la santé et de la recherche médicale INSERM U1011, Lille-II-University, Lille, France
| | - Sergio Bravo Baptista
- Serviço de Cardiologia, Hospital Prof Doutor Fernando da Fonseca, Amadora, Portugal.,University Clinic of Cardiology-Faculty of Medicine at University of Lisbon, Lisbon, Portugal
| | - Flavien Vincent
- Département de Cardiologie, Institut Coeur-Poumon, Centre Hospitalier Universitaire de Lille, Lille, France.,Institut national de la santé et de la recherche médicale INSERM U1011, Lille-II-University, Lille, France
| | - John Henderson
- Statistical Department, St. Jude Medical Inc, St Paul, Minnesota
| | - Lino Santos
- Serviço de Cardiologie, Centro Hospitalar Vila Nova de Gaia, Vila Nova de Gaia, Portugal
| | - Ruben Ramos
- Serviço de Cardiologia, Hospital Santa Marta-Centro Hospitalar Lisboa Central, Lisboa, Portugal
| | - Christophe Pouillot
- Department de Cardiologia, Clinique Sainte Clotilde, Saint Denis de la Réunion, France
| | - Rita Calé
- Serviço de Cardiologia, Hospital Garcia de Orta, Almada, Portugal
| | - Thomas Cuisset
- Department de Cardiologie, Centre Hospitalar Universitaire, La Timone, Marseille, France
| | - Elisabete Jorge
- Serviço de Cardiologia, Centro Hospitalar Universitário, Coimbra, Coimbra, Portugal
| | - Emmanuel Teiger
- Department of Cardiologie, Centre Hospitalar Universitaire Mondor, Créteil, France
| | - Carina Machado
- Serviço de Cardiologia, Hospital Divino Espirito Santo, Ponta Delgada, Portugal
| | - Loic Belle
- Department de Cardiologie, Centre Hospitalier d'Annecy, Annecy, France
| | - Marco Costa
- Serviço de Cardiologia, Hospital Geral dos Covões-Centro Hospitalar Coimbra, Coimbra, Portugal
| | - Didier Barreau
- Department of Cardiologie, Centre Hospitalier Intercommunal Toulon La Seyne sur Mer-Hôpital Sainte Musse, Toulon, France
| | - Eduardo Oliveira
- Serviço de Cardiologia, Hospital Santa Maria-Centro Hospitalar Lisboa Norte, Lisboa, Portugal
| | - Michel Hanssen
- Department de Cardiologie, Centre Hospitalier Haguenau, Haguenau, France
| | - João Costa
- Serviço de Cardiologia, Hospital de Braga, Braga, Portugal
| | - Cyril Besnard
- Department of Cardiologie, Hôpital de la Croix-Rousse, Lyon, France
| | - Luis Nunes
- Serviço de Cardiologia, Hospital São Teotónio, Viseu, Portugal
| | - Jean Dallongeville
- Institut Pasteur de Lille, Institut national de la santé et de la recherche médicale INSERM, Lille, France
| | | | | | - Nuno Fonseca
- Serviço de Cardiologia, Centro Hospitalar Setúbal, Setúbal, Portugal
| | - Nicolas Lhoest
- Department of Cardiologie, Hôpital Albert Schweizer, Colmar, France
| | - Jorge Guardado
- Serviço de Cardiologia, Hospital Santo André-Centro Hospitalar Leiria-Pombal, Leiria, Portugal
| | - Bruno Silva
- Serviço de Cardiologia, Hospital Dr Nélio Mendonça, Funchal, Portugal
| | - Maria-João Sousa
- Serviço de Cardiologia, Hospital Geral Santo António-Centro Hospitalar do Porto, Porto, Portugal
| | - Pierre Barnay
- Department of Cardiologie, Centre Hospitalier La Durance, Avignon, France
| | | | - Laurent Leborgne
- Department of Cardiologie, Centre Hospitalier Amiens Sud, Amiens, France
| | - Alberto Rodrigues
- Serviço de Cardiologia, Centro Hospitalar Tâmega e Sousa, Penafiel, Portugal
| | - Sina Porouchani
- Département de Cardiologie, Institut Coeur-Poumon, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Luís Seca
- Serviço de Cardiologia, Centro Hospitalar Trás-os-Montes e Alto Douro-Unidade Hospitalar Vila Real, Vila Real, Portugal
| | - Renato Fernandes
- Serviço de Cardiologia, Hospital Espírito Santo, Évora, Portugal
| | - Patrick Dupouy
- Department of Cardiologie, Hôpital Privé d'Antony, Antony, France
| | - Luís Raposo
- Serviço de Cardiologia, Hospital de Santa Cruz-Centro Hospitalar de Lisboa Ocidental, Carnaxide, Portugal
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6
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Lee JM, Choi KH, Koo BK, Dehbi HM, Doh JH, Nam CW, Shin ES, Cook CM, Al-Lamee R, Petraco R, Sen S, Malik IS, Nijjer SS, Mejía-Rentería H, Alegria-Barrero E, Alghamdi A, Altman J, Baptista SB, Bhindi R, Bojara W, Brugaletta S, Silva PC, Di Mario C, Erglis A, Gerber RT, Going O, Härle T, Hellig F, Indolfi C, Janssens L, Jeremias A, Kharbanda RK, Khashaba A, Kikuta Y, Krackhardt F, Laine M, Lehman SJ, Matsuo H, Meuwissen M, Niccoli G, Piek JJ, Ribichini F, Samady H, Sapontis J, Seto AH, Sezer M, Sharp ASP, Singh J, Takashima H, Talwar S, Tanaka N, Tang K, Van Belle E, van Royen N, Vinhas H, Vrints CJ, Walters D, Yokoi H, Samuels B, Buller C, Patel MR, Serruys P, Escaned J, Davies JE. Comparison of Major Adverse Cardiac Events Between Instantaneous Wave-Free Ratio and Fractional Flow Reserve-Guided Strategy in Patients With or Without Type 2 Diabetes: A Secondary Analysis of a Randomized Clinical Trial. JAMA Cardiol 2020; 4:857-864. [PMID: 31314045 DOI: 10.1001/jamacardio.2019.2298] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Importance Invasive physiologic indices such as fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) are used in clinical practice. Nevertheless, comparative prognostic outcomes of iFR-guided and FFR-guided treatment in patients with type 2 diabetes have not yet been fully investigated. Objective To compare 1-year clinical outcomes of iFR-guided or FFR-guided treatment in patients with and without diabetes in the Functional Lesion Assessment of Intermediate Stenosis to Guide Revascularization (DEFINE-FLAIR) trial. Design, Setting, and Participants The DEFINE-FLAIR trial is a multicenter, international, randomized, double-blinded trial that randomly assigned 2492 patients in a 1:1 ratio to undergo either iFR-guided or FFR-guided coronary revascularization. Patients were eligible for trial inclusion if they had intermediate coronary artery disease (40%-70% diameter stenosis) in at least 1 native coronary artery. Data were analyzed between January 2014 and December 2015. Interventions According to the study protocol, iFR of 0.89 or less and FFR of 0.80 or less were used as criteria for revascularization. When iFR or FFR was higher than the prespecified threshold, revascularization was deferred. Main Outcomes and Measures The primary end point was major adverse cardiac events (MACE), defined as the composite of all-cause death, nonfatal myocardial infarction, or unplanned revascularization at 1 year. The incidence of MACE was compared according to the presence of diabetes in iFR-guided and FFR-guided groups. Results Among the total trial population (2492 patients), 758 patients (30.4%) had diabetes. Mean age of the patients was 66 years, 76% were men (1868 of 2465), and 80% of patients presented with stable angina (1983 of 2465). In the nondiabetes population (68.5%; 1707 patients), iFR guidance was associated with a significantly higher rate of deferral of revascularization than the FFR-guided group (56.5% [n = 477 of 844] vs 46.6% [n = 402 of 863]; P < .001). However, it was not different between the 2 groups in the diabetes population (42.1% [n = 161 of 382] vs 47.1% [n = 177 of 376]; P = .15). At 1 year, the diabetes population showed a significantly higher rate of MACE than the nondiabetes population (8.6% vs 5.6%; adjusted hazard ratio [HR], 1.88; 95% CI, 1.28-2.64; P < .001). However, there was no significant difference in MACE rates between iFR-guided and FFR-guided groups in both the diabetes (10.0% vs 7.2%; adjusted HR, 1.33; 95% CI, 0.78-2.25; P = .30) and nondiabetes population (4.7% vs 6.4%; HR, 0.83; 95% CI, 0.51-1.35; P = .45) (interaction P = .25). Conclusions and Relevance The diabetes population showed significantly higher risk of MACE than the nondiabetes population, even with the iFR-guided or FFR-guided treatment. The iFR-guided and FFR-guided treatment showed comparable risk of MACE and provided equal safety in selecting revascularization target among patients with diabetes. Trial Registration ClinicalTrials.gov identifier: NCT02053038.
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Affiliation(s)
| | - Joo Myung Lee
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Ki Hong Choi
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Bon-Kwon Koo
- Seoul National University Hospital and Institute on Aging, Seoul National University, Seoul, South Korea
| | - Hakim-Moulay Dehbi
- Cancer Research UK and University College London Cancer Trials Centre, University College London, London, England
| | - Joon-Hyung Doh
- Inje University Ilsan Paik Hospital, Daehwa-Dong, South Korea
| | - Chang-Wook Nam
- Keimyung University Dongsan Medical Center, Daegu, South Korea
| | - Eun-Seok Shin
- Ulsan Hospital, Ulsan, South Korea and Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, South Korea
| | | | - Rasha Al-Lamee
- Hammersmith Hospital, Imperial College London, London, England
| | - Ricardo Petraco
- Hammersmith Hospital, Imperial College London, London, England
| | - Sayan Sen
- Hammersmith Hospital, Imperial College London, London, England
| | - Iqbal S Malik
- Hammersmith Hospital, Imperial College London, London, England
| | | | - Hernán Mejía-Rentería
- Hospital Clínico San Carlos, IDISSC and Universidad Complutense de Madrid, Madrid, Spain
| | | | - Ali Alghamdi
- King Abdulaziz Medical City Cardiac Center, Riyadh, Saudi Arabia
| | - John Altman
- Colorado Heart and Vascular, Lakewood, Colorado
| | | | | | - Waldemar Bojara
- Gemeinschaftsklinikum Mittelrhein, Kemperhof Koblenz, Koblenz, Germany
| | - Salvatore Brugaletta
- Cardiovascular Institute, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | | | - Carlo Di Mario
- Royal Brompton Hospital, Imperial College London, London, England.,University of Florence, Florence, Italy
| | - Andrejs Erglis
- Pauls Stradins Clinical University Hospital, Riga, Latvia
| | | | - Olaf Going
- Sana Klinikum Lichtenberg, Lichtenberg, Germany
| | - Tobias Härle
- Klinikum Oldenburg, European Medical School, Carl von Ossietzky University, Oldenburg, Germany
| | | | | | | | - Allen Jeremias
- Stony Brook University Medical Center, New York, New York
| | - Rajesh K Kharbanda
- John Radcliffe Hospital, Oxford University Hospitals Foundation Trust, Oxford, England
| | | | | | | | - Mika Laine
- Helsinki University Hospital, Helsinki, Finland
| | - Sam J Lehman
- Flinders University, Adelaide, South Australia, Australia
| | | | | | | | - Jan J Piek
- AMC Heart Center, Academic Medical Center, Amsterdam, the Netherlands
| | | | | | - James Sapontis
- Monash Heart, Monash University, Melbourne, Victoria, Australia
| | - Arnold H Seto
- Veterans Affairs Long Beach Healthcare System, Long Beach, California
| | - Murat Sezer
- Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Andrew S P Sharp
- Royal Devon and Exeter Hospital, Exeter, England.,University of Exeter, Exeter, England
| | - Jasvindar Singh
- Washington University School of Medicine in St Louis, St Louis, Missouri
| | | | - Suneel Talwar
- Royal Bournemouth General Hospital, Bournemouth, England
| | | | - Kare Tang
- Essex Cardiothoracic Centre, Basildon, England.,Anglia Ruskin University, Chelmsford, England
| | - Eric Van Belle
- Institut Coeur Poumon, Lille University Hospital, Lille, France.,INSERM Unité 1011, Lille, France
| | | | | | | | - Darren Walters
- Prince Charles Hospital, Brisbane, Queensland, Australia
| | | | - Bruce Samuels
- Cedars-Sinai Heart Institute, Los Angeles, California
| | | | | | - Patrick Serruys
- Hammersmith Hospital, Imperial College London, London, England
| | - Javier Escaned
- Hospital Clínico San Carlos, IDISSC and Universidad Complutense de Madrid, Madrid, Spain
| | - Justin E Davies
- Hammersmith Hospital, Imperial College London, London, England
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7
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Fractional flow reserve and frequency of PCI in patients with coronary artery disease. Herz 2019; 45:752-758. [PMID: 31485776 DOI: 10.1007/s00059-019-04848-4] [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: 11/24/2018] [Revised: 06/22/2019] [Accepted: 08/12/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Fractional flow reserve (FFR) guided percutaneous coronary intervention (PCI) has been validated in patients with stable coronary artery disease (CAD) but has not yet been verified under specific conditions such as heart failure or microvascular dysfunction. The aim of the present study was to examine the influence of specific patient comorbidities on FFR values and thus the frequency of PCI in patients with intermediate coronary stenosis. METHODS A total of 652 patients with CAD and intermediate coronary stenosis who were assessed for FFR were included in this retrospective study. In a subgroup analysis, specific comorbidities such as heart failure with non-ST-segment-elevated acute coronary syndrome (NSTE-ACS), heart failure, diabetes mellitus, atrial fibrillation (AF), and left ventricular hypertrophy (LVH) were considered. RESULTS In all lesions with an FFR ≤ 0.80 (n = 227/808, 28.1%), PCI was performed using drug-eluting stents. Pathological FFR values (FFR ≤ 0.80) before PCI were most frequently observed in the left anterior descending artery (LAD; n = 168/418, 39.9%) followed by the right coronary artery (RCA; n = 37/178, 20.7%) and the left circumflex artery (LCX; 22/223, 9.8%). The comorbidities NSTE-ACS (p = 0.28), heart failure with reduced ejection fraction (HFrEF; p = 0.63), heart failure with preserved ejection fraction (HFpEF; p = 0.3719), diabetes mellitus (p = 0.177), or LVH (p = 0.407) had no major impact on the occurrence of pathological FFR values; there was also no association between FFR and the occurrence of lesions in the different target vessels. CONCLUSION The occurrence of pathological FFR values, most frequently documented in the LAD, was the same in patients with or without HFrEF, HFpEF, diabetes mellitus, AF, and LVH, demonstrating that these comorbidities did not influence FFR values and, thus, the indication for PCI.
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Sand NPR, Veien KT, Nielsen SS, Nørgaard BL, Jensen LO. The Authors’ Reply:. JACC Cardiovasc Imaging 2019; 12:940-941. [DOI: 10.1016/j.jcmg.2019.02.011] [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: 01/07/2019] [Revised: 02/12/2019] [Accepted: 02/14/2019] [Indexed: 10/26/2022]
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9
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Nous FMA, Coenen A, Boersma E, Kim YH, Kruk MBP, Tesche C, de Geer J, Yang DH, Kepka C, Schoepf UJ, Persson A, Kurata A, Budde RPJ, Nieman K. Comparison of the Diagnostic Performance of Coronary Computed Tomography Angiography-Derived Fractional Flow Reserve in Patients With Versus Without Diabetes Mellitus (from the MACHINE Consortium). Am J Cardiol 2019; 123:537-543. [PMID: 30553510 DOI: 10.1016/j.amjcard.2018.11.024] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 10/28/2018] [Accepted: 11/01/2018] [Indexed: 02/05/2023]
Abstract
Coronary computed tomography angiography-derived fractional flow reserve (CT-FFR) is a noninvasive application to evaluate the hemodynamic impact of coronary artery disease by simulating invasively measured FFR based on CT data. CT-FFR is based on the assumption of a normal coronary microvascular response. We assessed the diagnostic performance of a machine-learning based application for on-site computation of CT-FFR in patients with and without diabetes mellitus with suspected coronary artery disease. The study population included 75 diabetic and 276 nondiabetic patients who were enrolled in the MACHINE consortium. The overall diagnostic performance of coronary CT angiography alone and in combination with CT-FFR were analyzed with direct invasive FFR comparison in 110 coronary vessels of the diabetic group and in 415 coronary vessels of the nondiabetic group. Per-vessel discrimination of lesion-specific ischemia by CT-FFR was assessed by the area under the receiver operating characteristic curves. The overall diagnostic accuracy of CT-FFR in diabetic patients was 83% and in nondiabetic patients 75% (p = 0.088), showing improvement over the diagnostic accuracy of coronary CT angiography, which was 58% and 65% (p = 0.223), respectively. In addition, the diagnostic accuracy of CT-FFR was similar between diabetic and nondiabetic patients per stratified CT-FFR group (CT-FFR < 0.6, 0.6 to 0.69, 0.7 to 0.79, 0.8 to 0.89, ≥0.9). The area under the curves for diabetic and nondiabetic patients were also comparable, 0.88 and 0.82 (p = 0.113), respectively. In conclusion, on-site machine-learning CT-FFR analysis improved the diagnostic performance of coronary CT angiography and accurately discriminated lesion-specific ischemia in both diabetic and nondiabetic patients suspected of coronary artery disease.
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Affiliation(s)
- Fay M A Nous
- Department of Radiology & Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands.
| | - Adriaan Coenen
- Department of Radiology & Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Eric Boersma
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Young-Hak Kim
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Mariusz B P Kruk
- Coronary Disease and Structural Heart Diseases Department, Institute of Cardiology, Warsaw, Poland
| | - Christian Tesche
- Department of Radiology and Radiological Science, Heart & Vascular Center, Medical University of South Carolina, Charleston, South Carolina
| | - Jakob de Geer
- Department of Radiology and Department of Medical and Health Sciences, Center for Medical Image Science and Visualization, CMIV, Linköping University, Linköping, Sweden
| | - Dong Hyun Yang
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Cezary Kepka
- Coronary Disease and Structural Heart Diseases Department, Institute of Cardiology, Warsaw, Poland
| | - U Joseph Schoepf
- Department of Radiology and Radiological Science, Heart & Vascular Center, Medical University of South Carolina, Charleston, South Carolina
| | - Anders Persson
- Department of Radiology and Department of Medical and Health Sciences, Center for Medical Image Science and Visualization, CMIV, Linköping University, Linköping, Sweden
| | - Akira Kurata
- Department of Radiology & Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Radiology, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Ricardo P J Budde
- Department of Radiology & Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Koen Nieman
- Department of Radiology & Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands; Stanford University School of Medicine, Cardiovascular Institute, Stanford, California
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Benenati S, De Maria GL, Scarsini R, Porto I, Banning AP. Invasive “in the cath-lab” assessment of myocardial ischemia in patients with coronary artery disease: When does the gold standard not apply? CARDIOVASCULAR REVASCULARIZATION MEDICINE 2018; 19:362-372. [DOI: 10.1016/j.carrev.2018.01.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Accepted: 01/16/2018] [Indexed: 02/08/2023]
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11
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Gargiulo G, Stabile E, Ferrone M, Barbato E, Zimmermann FM, Adjedj J, Hennigan B, Matsumura M, Johnson NP, Fearon WF, Jeremias A, Trimarco B, Esposito G. Diabetes does not impact the diagnostic performance of contrast-based fractional flow reserve: insights from the CONTRAST study. Cardiovasc Diabetol 2017; 16:7. [PMID: 28086778 PMCID: PMC5237130 DOI: 10.1186/s12933-016-0494-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2016] [Accepted: 12/30/2016] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Adenosine-free coronary pressure wire metrics have been proposed to test the functional significance of coronary artery lesions, but it is unexplored whether their diagnostic performance might be altered in patients with diabetes. METHODS We performed a post-hoc analysis of the CONTRAST study, which prospectively enrolled an international cohort of patients undergoing routine fractional flow reserve (FFR) assessment for standard indications. Paired, repeated measurements of all physiology metrics (Pd/Pa, iFR, contrast-based FFR, and FFR) were made. A central core laboratory analyzed blinded pressure tracings in a standardized fashion. RESULTS Of 763 subjects enrolled at 12 international centers, 219 (29%) had diabetes. The two groups were well-balanced for age, clinical presentation (stable or unstable), coronary vessel studied, volume and type of intracoronary contrast, and volume of intracoronary adenosine. A binary threshold of cFFR ≤ 0.83 produced an accuracy superior to both Pd/Pa and iFR when compared with FFR ≤ 0.80 in the absence of significant interaction with diabetes status; indeed, accuracy in subgroups of patients with or without diabetes was similar for cFFR (86.7 vs 85.4% respectively; p = 0.76), iFR (84.2 vs 80.0%, p = 0.29) and Pd/Pa (81.3 vs 78.9%, p = 0.55). There was no significant heterogeneity between patients with or without diabetes in terms of sensitivity and specificity of all metrics. The area under the receiver operating characteristic (ROC) curve was largest for cFFR compared with Pd/Pa and iFR which were equivalent (cFFR 0.961 and 0.928; Pd/Pa 0.916 and 0.870; iFR 0.911 and 0.861 in diabetic and non-diabetic patients respectively). CONCLUSIONS cFFR provides superior diagnostic performance compared with Pd/Pa or iFR for predicting FFR irrespective of diabetes (clinicaltrials.gov identifier NCT02184117).
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Affiliation(s)
- Giuseppe Gargiulo
- Department of Advanced Biomedical Sciences, University of Naples Frederico II, Naples, Italy
| | - Eugenio Stabile
- Department of Advanced Biomedical Sciences, University of Naples Frederico II, Naples, Italy
| | - Marco Ferrone
- Department of Advanced Biomedical Sciences, University of Naples Frederico II, Naples, Italy
| | - Emanuele Barbato
- Department of Advanced Biomedical Sciences, University of Naples Frederico II, Naples, Italy.,Cardiovascular Center, OLV Clinic, Aalst, Belgium
| | | | | | - Barry Hennigan
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, Scotland, UK.,British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland, UK
| | | | - Nils P Johnson
- Division of Cardiology, Department of Medicine, Weatherhead PET Center, McGovern Medical School at UTHealth and Memorial Hermann Hospital, Houston, TX, USA
| | - William F Fearon
- Stanford University Medical Center, Stanford, USA.,The Palo Alto VA Health Care Systems, Palo Alto, CA, USA
| | - Allen Jeremias
- Cardiovascular Research Foundation (CRF), New York, NY, USA.,Division of Cardiovascular Medicine, Stony Brook University Medical Center, Stony Brook, NY, USA
| | - Bruno Trimarco
- Department of Advanced Biomedical Sciences, University of Naples Frederico II, Naples, Italy
| | - Giovanni Esposito
- Department of Advanced Biomedical Sciences, University of Naples Frederico II, Naples, Italy. .,Division of Cardiology-Department of Advanced Biomedical Sciences, Federico II University of Naples, Via Pansini 5, 80131, Naples, Italy.
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Eftekhari A, Min J, Achenbach S, Marwan M, Budoff M, Leipsic J, Gaur S, Jensen JM, Ko BS, Christiansen EH, Kaltoft A, Bøtker HE, Jensen JF, Nørgaard BL. Fractional flow reserve derived from coronary computed tomography angiography: diagnostic performance in hypertensive and diabetic patients. Eur Heart J Cardiovasc Imaging 2016; 18:1351-1360. [DOI: 10.1093/ehjci/jew209] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 09/11/2016] [Indexed: 12/14/2022] Open
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Adiputra Y, Chen SL. Clinical Relevance of Coronary Fractional Flow Reserve: Art-of-state. Chin Med J (Engl) 2016; 128:1399-406. [PMID: 25963364 PMCID: PMC4830323 DOI: 10.4103/0366-6999.156805] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Objective: The objective was to delineate the current knowledge of fractional flow reserve (FFR) in terms of definition, features, clinical applications, and pitfalls of measurement of FFR. Data Sources: We searched database for primary studies published in English. The database of National Library of Medicine (NLM), MEDLINE, and PubMed up to July 2014 was used to conduct a search using the keyword term “FFR”. Study Selection: The articles about the definition, features, clinical application, and pitfalls of measurement of FFR were identified, retrieved, and reviewed. Results: Coronary pressure-derived FFR rapidly assesses the hemodynamic significance of individual coronary artery lesions and can readily be performed in the catheterization laboratory. The use of FFR has been shown to effectively guide coronary revascularization procedures leading to improved patient outcomes. Conclusions: FFR is a valuable tool to determine the functional significance of coronary stenosis. It combines physiological and anatomical information, and can be followed immediately by percutaneous coronary intervention (PCI) if necessary. The technique of FFR measurement can be performed easily, rapidly, and safely in the catheterization laboratory. By systematic use of FFR in dubious stenosis and multi-vessel disease, PCI can be made an even more effective and better treatment than it is currently. The current clinical evidence for FFR should encourage cardiologists to use this tool in the catheterization laboratory.
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Affiliation(s)
| | - Shao-Liang Chen
- Department of Cardiology, Nanjing First Hospital of Nanjing Medical University, Nanjing, Jiangsu 210006, China
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Reith S, Battermann S, Hellmich M, Marx N, Burgmaier M. Correlation between optical coherence tomography-derived intraluminal parameters and fractional flow reserve measurements in intermediate grade coronary lesions: a comparison between diabetic and non-diabetic patients. Clin Res Cardiol 2014; 104:59-70. [DOI: 10.1007/s00392-014-0759-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Accepted: 08/11/2014] [Indexed: 10/24/2022]
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15
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Murai T, Lee T, Yonetsu T, Isobe M, Kakuta T. Influence of microvascular resistance on fractional flow reserve after successful percutaneous coronary intervention. Catheter Cardiovasc Interv 2014; 85:585-92. [DOI: 10.1002/ccd.25499] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Revised: 03/12/2014] [Accepted: 03/23/2014] [Indexed: 11/12/2022]
Affiliation(s)
- Tadashi Murai
- Department of Cardiology; Tsuchiura Kyodo General Hospital; Tsuchiura Japan
| | - Tetsumin Lee
- Department of Cardiology; Tsuchiura Kyodo General Hospital; Tsuchiura Japan
| | - Taishi Yonetsu
- Department of Cardiology; Kameda Medical Center; Kamogawa Japan
| | - Mitsuaki Isobe
- Department of Cardiovascular Medicine; Tokyo Medical and Dental University; Tokyo Japan
| | - Tsunekazu Kakuta
- Department of Cardiology; Tsuchiura Kyodo General Hospital; Tsuchiura Japan
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16
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Fineschi M, Guerrieri G, Orphal D, Palmerini E, Münzel T, Warnholtz A, Pierli C, Gori T. The impact of gender on fractional flow reserve measurements. EUROINTERVENTION 2014; 9:360-6. [PMID: 23392525 DOI: 10.4244/eijv9i3a58] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS Fractional flow reserve (FFR) allows accurate investigation of the functional significance of intermediate coronary stenoses. The present study set out to study the impact of gender on FFR measurements. METHODS AND RESULTS Three hundred and seventeen intermediate (40-70% at angiography) stenoses were assessed with FFR in 270 patients (mean age 65.8 ± 10.3 years, 84 females). Resting Pd/Pa (the ratio of mean blood pressure measured distal to the stenosis to mean aortic blood pressure in resting conditions), FFR (Pd/Pa during adenosine-induced hyperaemia) and the ΔPd/Pa (calculated as the change in Pd/Pa during hyperaemia) were measured. There was no difference in the location and degree of stenoses between genders (p>0.5). Similarly, there was no difference in age and in the prevalence of cardiovascular risk factors (all p>0.2). Resting Pd/Pa also did not differ between genders (0.92 ± 0.08 vs. 0.93 ± 0.05, p=0.23). In response to adenosine, however, a significantly larger ΔPd/Pa (0.14 ± 0.07 vs. 0.11 ± 0.07, p=0.001) and a significantly lower FFR (0.79 ± 0.12 vs. 0.82 ± 0.10, p=0.008) were observed in males. This difference was maintained in a multivariate regression analysis. CONCLUSIONS We observed gender-based differences in FFR data in daily routine. Further studies are necessary to test the mechanism of this observation and how these differences impact on the assessment of haemodynamically relevant stenoses.
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Affiliation(s)
- Massimo Fineschi
- Department of Cardiology, University Medical Hospital of Siena, Siena, Italy
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Impact of type 2 diabetes mellitus and glucose control on fractional flow reserve measurements in intermediate grade coronary lesions. Clin Res Cardiol 2013; 103:191-201. [PMID: 24264473 DOI: 10.1007/s00392-013-0633-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2013] [Accepted: 11/05/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND Hemodynamic relevance of intermediate grade coronary stenoses is accurately assessed by fractional flow reserve (FFR) measurements. However, the reliability of FFR in patients with type 2 diabetes mellitus (DM) and inadequate glucose control (IGC) is incompletely explored. This study aimed to investigate the impact of DM and IGC on the relationship between FFR measurements and quantitative coronary angiography (QCA)-derived morphological parameters. METHODS We performed FFR and QCA in 266 intermediate grade lesions of 224 patients (113 non-DM and 111 DM) with stable coronary artery disease. Diabetic patients were categorized into groups with adequate (HbA1C <7%) and inadequate (HbA1c ≥7%) glucose control. RESULTS Intermediate grade lesions from all-DM versus non-DM patients differed significantly in lesion length (LL) (10.91 ± 5.79 mm versus 9.23 ± 3.85 mm, p = 0.005) and hemodynamic relevance (FFR ≤0.8, 37.7% versus 24.2%, p = 0.018). FFR measurements in non-DM, all-DM and DM-IGC patients correlated significantly with percent diameter stenosis (%DS) [non-DM: r2 = 0.075 (p = 0.007); all-DM: r2 = 0.254 (p < 0.001), DM-IGC: r2 = 0.301 (p < 0.001)] and LL [non-DM: r2 = 0.356; all-DM: r2 = 0.580, DM-IGC: r2 = 0.513 (all p < 0.001)]. There was a better correlation between FFR and both %DS (p = 0.022) and LL (p = 0.011) among all-DM compared to non-DM patients. Receiver-operating curve analysis demonstrated that among all QCA-derived parameters LL had the best diagnostic efficacy to predict FFR ≤0.8 for non-DM (AUC 0.911, 95% CI 0.861-0.960, best cut-off value 9.22 mm), all-DM (AUC 0.967, 95% CI 0.942-0.991, best cut-off value 9.97 mm) and DM-IGC (AUC 0.960, 95% CI 0.920-0.999, best cut-off value 9.97 mm) patients. CONCLUSION Our data in intermediate grade lesions suggest that FFR is reliable in DM patients and LL is the best predictor for hemodynamic relevance in patients without and with diabetes, irrespective of the glycemic state.
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Blankenship JC, Moussa ID, Chambers CC, Brilakis ES, Haldis TA, Morrison DA, Dehmer GJ. Staging of multivessel percutaneous coronary interventions: An expert consensus statement from the Society for Cardiovascular Angiography and Interventions. Catheter Cardiovasc Interv 2011; 79:1138-52. [DOI: 10.1002/ccd.23353] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2011] [Accepted: 08/12/2011] [Indexed: 01/09/2023]
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Nakamura M. Angiography Is the Gold Standard and Objective Evidence of Myocardial Ischemia Is Mandatory If Lesion Severity Is Questionable - Indication of PCI for Angiographically Significant Coronary Artery Stenosis Without Objective Evidence of Myocardial Ischemia (Pro) -. Circ J 2011; 75:204-10; discussion 217. [DOI: 10.1253/circj.cj-10-0881] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Masato Nakamura
- Department of Cardiovascular Medicine, Toho University School of Medicine, Ohashi Medical Center
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Daniels DV, Fearon WF. Fractional Flow Reserve: A Practical Update. CURRENT CARDIOVASCULAR IMAGING REPORTS 2010. [DOI: 10.1007/s12410-010-9030-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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A flow-limiting stenosis is the major determinant of exercise-induced myocardial stunning in patients with coronary artery disease. J Cardiol 2010; 55:337-44. [DOI: 10.1016/j.jjcc.2009.12.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2009] [Revised: 12/10/2009] [Accepted: 12/21/2009] [Indexed: 11/24/2022]
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Kushner FG, Hand M, Smith SC, King SB, Anderson JL, Antman EM, Bailey SR, Bates ER, Blankenship JC, Casey DE, Green LA, Jacobs AK, Hochman JS, Krumholz HM, Morrison DA, Ornato JP, Pearle DL, Peterson ED, Sloan MA, Whitlow PL, Williams DO. 2009 focused updates: ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction (updating the 2004 guideline and 2007 focused update) and ACC/AHA/SCAI guidelines on percutaneous coronary intervention (updating the 2005 guideline and 2007 focused update): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Catheter Cardiovasc Interv 2010; 74:E25-68. [PMID: 19924773 DOI: 10.1002/ccd.22351] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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23
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Kushner FG, Hand M, Smith SC, King SB, Anderson JL, Antman EM, Bailey SR, Bates ER, Blankenship JC, Casey DE, Green LA, Hochman JS, Jacobs AK, Krumholz HM, Morrison DA, Ornato JP, Pearle DL, Peterson ED, Sloan MA, Whitlow PL, Williams DO. 2009 focused updates: ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction (updating the 2004 guideline and 2007 focused update) and ACC/AHA/SCAI guidelines on percutaneous coronary intervention (updating the 2005 guideline and 2007 focused update) a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2010; 54:2205-41. [PMID: 19942100 DOI: 10.1016/j.jacc.2009.10.015] [Citation(s) in RCA: 811] [Impact Index Per Article: 57.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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24
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Kushner FG, Hand M, Smith SC, King SB, Anderson JL, Antman EM, Bailey SR, Bates ER, Blankenship JC, Casey DE, Green LA, Hochman JS, Jacobs AK, Krumholz HM, Morrison DA, Ornato JP, Pearle DL, Peterson ED, Sloan MA, Whitlow PL, Williams DO. 2009 Focused Updates: ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction (updating the 2004 Guideline and 2007 Focused Update) and ACC/AHA/SCAI Guidelines on Percutaneous Coronary Intervention (updating the 2005 Guideline and 2007 Focused Update): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2009; 120:2271-306. [PMID: 19923169 DOI: 10.1161/circulationaha.109.192663] [Citation(s) in RCA: 725] [Impact Index Per Article: 48.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Abstract
BACKGROUND Fractional flow reserve (FFR) is an invasive method to assess the functional significance of coronary stenoses. The value of FFR in diabetic patients is controversial because of microvascular dysfunction. The aim of this study is to investigate the effect of diabetes mellitus (DM) on FFR measurements. METHODS One hundred and twenty-one patients with an intermediate lesion who had undergone FFR measurement were included in the study. Lesion severity was determined by quantitative coronary angiography. The patients were divided into groups according to the presence (group 1) or absence (group 2) of DM. The patients were further categorized according to the degree of luminal narrowing caused by the lesion (40-50, 51-60, and >60%) and reference vessel diameter (> or = 2.8 and <2.8 mm). FFR measurements were compared in each category. RESULTS There was no difference between the FFR values of diabetic and nondiabetic patients who had coronary lesions with similar degree of luminal narrowing (0.87+/-0.08 vs. 0. 0.85+/-0.07; 0.81+/-0.08 vs. 0.82+/-0.10; 0.81+/-0.10 vs. 0.83+/-0.09, P = 0.957). In the analysis comparing FFR measurements in the categories set according to reference vessel diameter, we did not find a difference either (0.82+/-0.09 vs. 0.83+/-0.09; 0.84+/-0.09 vs. 0.82+/-0.09, P = 0.878). The DeltaFFR value, which is the difference between FFR values before and after adenosine administration, was also similar in diabetic and nondiabetic patients (8.4+/-6.0 vs. 8.4+/-5.5, P = 0.997). CONCLUSION The presence of DM does not have a significant impact on FFR values in coronary stenoses of intermediate severity.
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Sabaté M. Reserva fraccional de flujo en diabéticos. ¿Tiene fecha de caducidad? Rev Esp Cardiol 2008. [DOI: 10.1157/13117724] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Domínguez-Franco AJ, Jiménez-Navarro MF, Muñoz-García AJ, Alonso-Briales JH, Hernández-García JM, de Teresa Galván E. Pronóstico a largo plazo de diferir la intervención coronaria en diabéticos sobre la base de la reserva fraccional de flujo. Rev Esp Cardiol 2008. [DOI: 10.1157/13117735] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Costa MA, Shoemaker S, Futamatsu H, Klassen C, Angiolillo DJ, Nguyen M, Siuciak A, Gilmore P, Zenni MM, Guzman L, Bass TA, Wilke N. Quantitative magnetic resonance perfusion imaging detects anatomic and physiologic coronary artery disease as measured by coronary angiography and fractional flow reserve. J Am Coll Cardiol 2007; 50:514-22. [PMID: 17678734 DOI: 10.1016/j.jacc.2007.04.053] [Citation(s) in RCA: 107] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2006] [Revised: 02/07/2007] [Accepted: 04/03/2007] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To evaluate the ability of quantitative perfusion cardiac magnetic resonance (CMR) to assess the hemodynamic significance of coronary artery disease (CAD) compared with well-established anatomic and physiologic techniques. BACKGROUND Fractional flow reserve (FFR) is considered by many investigators to be a reliable stenosis-specific method to determine hemodynamically significant CAD. Quantitative perfusion CMR is a promising noninvasive approach to detect CAD but has yet to be validated against FFR. METHODS This is a prospective study in patients with suspected CAD who underwent coronary angiography, FFR, and CMR assessments. The quantitative myocardial perfusion reserve (MPR) was calculated in 720 myocardial sectors (8 sectors/slice). The MPR was calculated from the ratio between stress and rest myocardial flow based on signal intensity time curves using deconvolution analysis. Stress was simulated with adenosine for both FFR and MPR. The MPR assessments were compared to FFR (n = 44 coronary segments) and quantitative coronary angiography (n = 108 segments) in the corresponding coronary territories. RESULTS The MPR was 1.54 +/- 0.36 in segments with FFR < or =0.75 (n = 14) and 2.11 +/- 0.68 in those with FFR >0.75 (n = 30; p = 0.0054). An MPR cutoff of 2.04 was 92.9% (95% CI 77.9 to 100.0) sensitive and 56.7% (95% CI 32.8 to 80.6) specific in predicting a coronary segment with FFR < or =0.75. The MPR was 1.54 +/- 0.49 in coronary segments with > or =50% diameter stenosis (DS) (n = 47) and 2.13 +/- 0.80 in segments with <50% DS (n = 61; p < 0.001). An MPR cutoff of 2.04 was 85.1% (95% CI 71.1 to 99.2) sensitive and 49.2% (95% CI 33.6 to 64.8) specific in predicting CAD with > or =50% DS. CONCLUSIONS Quantitative perfusion CMR is a safe noninvasive test that represents a stenosis-specific alternative to determine the hemodynamic significance of CAD.
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Affiliation(s)
- Marco A Costa
- Division of Cardiology, University of Florida Shands Jacksonville, Jacksonville, Florida 32209, USA.
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Hatano T, Chikamori T, Usui Y, Morishima T, Hida S, Yamashina A. Diagnostic significance of positive I-123 BMIPP despite negative stress Tl-201 myocardial imaging in patients with suspected coronary artery disease. Circ J 2006; 70:184-9. [PMID: 16434813 DOI: 10.1253/circj.70.184] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND There is frequently discordance in the interpretation of myocardial single-photon emission computed tomography images using both rest iodine-123 15-(p-iodophenyl)-3-(R,S) methylpentadecanoic acid (BMIPP) and stress thallium-201 ((201)Tl); that is, negative BMIPP vs positive (201)Tl studies. However, little attention has been paid to reverse discordance (ie, positive BMIPP despite negative stress (201)Tl). METHODS AND RESULTS In the present study 105 consecutive patients with suspected coronary artery disease (CAD) who underwent both rest BMIPP and stress (201)Tl imaging were evaluated. No patient with previous myocardial infarction was included. Scintigraphic studies revealed that BMIPP was in concordance with (201)Tl in 71 patients: both were positive in 38 and negative in 33, whereas both were discordant in 20 and reverse discordant in 14. In patients with reverse discordance, the pattern of BMIPP abnormality was segmental in 8 and spotty in 6; the former was related to coronary territory. Based on the BMIPP findings and clinical symptoms, 7 patients with positive BMIPP despite negative (201)Tl underwent coronary angiography: 3-vessel CAD was found in 3 patients, 2-vessel CAD in 1, coronary spasm in 2, and insignificant lesions in 1. In the remaining 7 patients, no cardiac event was observed during 2-year follow-up. CONCLUSIONS In patients showing positive BMIPP despite negative (201)Tl, a segmental BMIPP perfusion abnormality indicates a high likelihood for CAD, despite normal stress (201)Tl imaging. Thus, adding BMIPP to (201)Tl imaging may help to better identify patients with significant CAD, including multivessel disease.
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Affiliation(s)
- Tsuguhisa Hatano
- Department of Internal Medicine II, Tokyo Medical University, 6-7-1 Nishi-shinjuku, Shinjuku-ku, Tokyo 160-0023, Japan.
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Tanaka H, Chikamori T, Hida S, Usui Y, Harafuji K, Igarashi Y, Yamashina A. Comparison of post-exercise and post-vasodilator stress myocardial stunning as assessed by electrocardiogram-gated single-photon emission computed tomography. Circ J 2006; 69:1338-45. [PMID: 16247208 DOI: 10.1253/circj.69.1338] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Exercise gated single-photon emission computed tomography (SPECT) using technetium-99m (99mTc)-sestamibi evaluates both myocardial perfusion during stress and wall motion >30 min after the stress, which has the potential to assess not only exercise-induced myocardial ischemia but also the development of myocardial stunning. METHODS AND RESULTS To evaluate the incidence of post-stress myocardial stunning, as well as comparing the effects of different stress methods on the development of stunning, 179 consecutive patients with known or suspected coronary artery disease (CAD) underwent (99m)Tc-sestamibi SPECT with either exercise (n=135) or adenosine triphosphate disodium (ATP) (n=44). Electrocardiogram-gated SPECT images were acquired >30 min after the stress and again 4 h later, and perfusion and wall motion were evaluated. Post-stress myocardial stunning occurred in 24 patients (13%): 22 after exercise and 2 after ATP stress. The magnitude of the transient wall motion abnormality after exercise was greater in patients with severe ischemia, compared with those with mild-to-moderate ischemia (p<0.0001). By contrast, with ATP stress, the magnitude of the transient wall motion abnormality was similar, regardless of the severity of perfusion abnormality. Furthermore, a significant correlation between summed difference score and transient wall motion abnormality was found after exercise (r=0.68, p<0.0001). With ATP, however, no such correlation was observed (r=0.28, p=NS). CONCLUSIONS Using 99mTc-sestamibi gated SPECT, myocardial stunning is frequently observed after exercise and correlates with the severity of myocardial ischemia, but this does not occur with ATP, which is regarded as a specific marker for severe CAD.
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Affiliation(s)
- Hirokazu Tanaka
- Department of Internal Medicine II/Cardiology, Tokyo Medical University, Tokyo, Japan.
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Ikeda N, Nishimura S, Kyo S, Komiyama N, Matsumoto K, Inoue T, Suzuki H. Valsartan Cardio-Renal Protection in Patients Undergoing Coronary Angiography Complicated With Chronic Renal Insufficiency (VAL-CARP) Trial Rationale and Design. Circ J 2006; 70:548-52. [PMID: 16636488 DOI: 10.1253/circj.70.548] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Despite an increase in the frequency of coronary angiography (CAG) in Japan, the exact incidence of contrast-induced nephropathy (CIN) remains unknown in the Japanese population, especially in patients with chronic renal insufficiency. In addition, the nature of pharmacological interventions that would benefit the patients before or after procedures such as coronary bypass graft (CABG) and percutaneous coronary intervention (PCI) has not been fully investigated. METHODS In the trial 500 patients with renal insufficiency (defined as a glomerular filtration rate (GFR) of between 89 and 30 ml . min(-1) . (1.73 m(-2)) following CAG will be randomly assigned to receive either valsartan, an angiotensin receptor blocker or angiotensin converting enzyme (ACE) inhibitor plus valsartan.1 The primary end-point is a change in the GFR of patients, which will be followed up for 3 years, including following CABG surgery or PCI. The incidence of cardiac events as well as the adverse effects of pharmacological intervention will be evaluated. In addition, the incidence of renal artery stenosis at the time of CAG will be reported also; however, the patients with renal artery stenosis will be excluded from the present study. CONCLUSION The present study will provide data on: 1) the exact incidence and course of renal function of CIN after CAG; and 2) the comparative therapeutic benefit of pharmacological intervention with valsartan alone or with valsartan and an ACE inhibitor in combination in patients with coexisting coronary artery diseases and chronic renal insufficiency, regardless of whether they receive CABG or PCI. In addition to these studies, an estimate of the incidence of renal artery stenosis in these patients will be demonstrated.
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Affiliation(s)
- Naofumi Ikeda
- Department of Nephrology, Saitama Medical School, Saitama, Japan.
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Nishino M, Hoshida S, Egami Y, Kondo I, Shutta R, Yamaguchi H, Tanaka K, Tanouchi J, Hori M, Yamada Y. Coronary Flow Reserve by Contrast Enhanced Transesophageal Coronary Sinus Doppler Measurements Can Evaluate Diabetic Microvascular Dysfunction. Circ J 2006; 70:1415-20. [PMID: 17062963 DOI: 10.1253/circj.70.1415] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND This study was undertaken to investigate whether coronary flow reserve (CFR) using coronary sinus flow (CSF), which can be measured by transesophageal Doppler echocardiography (TEDE), especially when contrast enhanced, is useful in evaluating microvascular dysfunction in patients with diabetes mellitus (DM). METHODS AND RESULTS CSF recordings using contrast enhanced TEDE were performed before and after adenosine triphosphate infusion (0.15 mg x kg(-1) x min(-1)) in 16 patients with type 2 DM and diabetic retinopathy and in 13 non-DM patients (control). Coronary angiography revealed normal epicardial coronary arteries. CFR was defined as the ratio of the antegrade flow velocity time integral in hyperemic conditions and basal levels. Clear envelopes of CSF were obtained in all DM patients using contrast-enhanced TEDE. CFR using CSF in the DM group was significantly decreased compared with the control group (1.4+/-0.4 vs 2.1+/-0.5, p<0.01), but there were no significant differences of age, ejection fraction, rate of hypertension and hypercholesterolemia between the 2 groups. Using 1.7 of CFR as the cut-off value, diabetic microvascular dysfunction could be detected with 82% sensitivity and 83% specificity. CONCLUSIONS CFR calculated by CSF using contrast-enhanced TEDE may be useful for evaluating diabetic microvascular dysfunction.
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Affiliation(s)
- Masami Nishino
- Division of Cardiology, Osaka Rosai Hospital, Sakai 591-8025, Japan.
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Koo BK, Kim CH, Na SH, Youn TJ, Chae IH, Choi DJ, Kim HS, Lee MM, Oh BH, Park YB, Choi YS, Tahk SJ. Intracoronary Continuous Adenosine Infusion A Novel and Effective Way of Inducing Maximal Hyperemia for Fractional Flow Reserve Measurement. Circ J 2005; 69:908-12. [PMID: 16041158 DOI: 10.1253/circj.69.908] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Various methods are used to induce maximal hyperemia for physiologic studies, but the feasibility and efficacy of continuous intracoronary (IC) infusion of adenosine for measurement of fractional flow reserve (FFR) has not been well-defined. METHODS AND RESULTS Patients with intermediate coronary artery stenosis were consecutively enrolled. In the phase I study, FFR was measured after 3 dosages of IC adenosine infusion (180, 240 and 300 microg/min) in 30 patients. The phase II study was performed to compare the hyperemic efficacy of IC infusion (240 microg/min) with IC bolus injection (40, 80 microg) and intravenous (IV) infusion (140 microg x kg (-1) x min(-1)) of adenosine in 20 patients. In the phase I study, no significant differences in FFR were observed with the 3 different doses of IC infusion (p = 0.06). In the phase II study, FFR after an IC bolus injection (0.83+/-0.06) was significantly higher than with IV (0.79+/-0.07) or IC (0.78+/-0.09) infusion (p < 0.01). However, no difference in FFR was observed for IC and IV infusions. CONCLUSION IC infusion of adenosine seems to be a safe and effective method of inducing maximal hyperemia for FFR measurement.
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Affiliation(s)
- Bon-Kwon Koo
- Division of Cardiology, Department of Internal Medicine, Seoul National University College of Medicine, Cardiovascular Center, Seoul
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Harafuji K, Chikamori T, Kawaguchi S, Obitsu Y, Ito S, Igarashi Y, Tanaka H, Usui Y, Hida S, Ishimaru S, Yamashina A. Value of Pharmacologic Stress Myocardial Perfusion Imaging for Preoperative Risk Stratification for Aortic Surgery. Circ J 2005; 69:558-63. [PMID: 15849442 DOI: 10.1253/circj.69.558] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Aortic surgery is an invasive, high-risk noncardiac procedure and the patients who require it have a high prevalence of coronary artery disease. Therefore, preoperative risk stratification for this subset is essential. METHODS AND RESULTS To assess the perioperative risk for aortic surgery, pharmacologic stress single-photon emission computed tomography (SPECT) was performed in 302 patients: aortic dissection in 56, thoracic aortic aneurysm in 124, and abdominal aortic aneurysm in 122. Not only was the presence or absence of perfusion defects analyzed, but also the 20-segment model. Pharmacologic thallium SPECT revealed negative findings in 210 patients and positives in 92. Perioperative cardiac events occurred in 9 patients: 7 occurred in patients with positive SPECT, and in only 2 of those with negative SPECT (2/210 vs 7/92; p<0.05). Multivariate analysis using logistic regression model revealed that a summed stress score>or=14 was the most important factor to identify patients who subsequently had perioperative cardiac events. CONCLUSIONS Pharmacologic stress SPECT has significant value in the risk stratification of patients before aortic surgery. In patients with positive SPECT, an aggressive approach to reduce the preoperative risk is necessary, whereas aortic surgery can be performed safely in patients with negative SPECT.
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