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Abo-Aly M, Lolay G, Adams C, Ahmed AE, Abdel-Latif A, Ziada KM. Comparison of intracoronary versus intravenous adenosine-induced maximal hyperemia for fractional flow reserve measurement: A systematic review and meta-analysis. Catheter Cardiovasc Interv 2019; 94:714-721. [PMID: 31074100 DOI: 10.1002/ccd.28317] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 02/05/2019] [Accepted: 04/15/2019] [Indexed: 12/29/2022]
Abstract
OBJECTIVE We sought to perform a systematic review and meta-analysis of the available literature comparing fractional flow reserve (FFR) measurements after administration of adenosine using intracoronary (IC) bolus versus standard continuous intravenous (IV) infusion. BACKGROUND FFR is considered the gold standard for invasive assessment of coronary lesions of intermediate severity. IV adenosine is recommended to induce hyperemia; however, IC adenosine is widely used for convenience. The difference between IV and IC administration in lesions assessment is not well studied. METHODS We systematically searched MEDLINE and relevant databases for studies comparing IV with IC adenosine administration for FFR measurement. We reviewed data pertaining to adenosine doses, side effects, and FFR values. RESULTS Eight studies addressing the primary question were identified. Dose of IC adenosine varied between 36 and 600 μg. Compared to IV adenosine infusion, the sensitivity of IC administration is 0.805 (95% confidence interval [95% CI]: 0.664-0.896; p < .001), specificity is 0.965 (95% CI: 0.932-0.983; p < .001), positive likelihood ratio is 24.218 (95% CI: 12,263-47.830; p < .001), negative likelihood ratio is 0.117 (95% CI: 0.033-0.411; p < .01), and diagnostic odds ratio is 274.225 [95% CI: 92.731-810.946; p < .001]. Overall, hemodynamic side effects and symptoms were reported more frequently with IV adenosine. CONCLUSIONS The available literature suggests that IC adenosine is well tolerated and may provide equivalent diagnostic accuracy compared to IV administration. However, variability in dosing regimens does not allow definitive conclusions regarding noninferiority of IC approach compared to IV administration.
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Affiliation(s)
- Mohamed Abo-Aly
- Division of Cardiovascular Medicine, Gill Heart & Vascular Institute, University of Kentucky, Lexington VA Medical Center, Lexington, Kentucky
| | - Georges Lolay
- Division of Cardiovascular Medicine, Gill Heart & Vascular Institute, University of Kentucky, Lexington VA Medical Center, Lexington, Kentucky
| | - Christopher Adams
- Division of Cardiovascular Medicine, Gill Heart & Vascular Institute, University of Kentucky, Lexington VA Medical Center, Lexington, Kentucky
| | - Ahmed Elsharawy Ahmed
- Division of Cardiovascular Medicine, Gill Heart & Vascular Institute, University of Kentucky, Lexington VA Medical Center, Lexington, Kentucky
| | - Ahmed Abdel-Latif
- Division of Cardiovascular Medicine, Gill Heart & Vascular Institute, University of Kentucky, Lexington VA Medical Center, Lexington, Kentucky
| | - Khaled M Ziada
- Division of Cardiovascular Medicine, Gill Heart & Vascular Institute, University of Kentucky, Lexington VA Medical Center, Lexington, Kentucky
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Gili S, Barbero U, Errigo D, De Luca G, Biondi-Zoccai G, Leone AM, Iannaccone M, Montefusco A, Omedé P, Moretti C, D'Amico M, Gaita F, D'Ascenzo F. Intracoronary versus intravenous adenosine to assess fractional flow reserve: a systematic review and meta-analysis. J Cardiovasc Med (Hagerstown) 2018; 19:274-283. [PMID: 29553991 DOI: 10.2459/jcm.0000000000000652] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
AIMS Intravenous infusion of adenosine is the reference method to measure fractional flow reserve (FFR). Intracoronary boluses are often used because of time and convenience, but their effectiveness has yet to be assessed. METHODS We conducted a systematic review and meta-analysis of prospective studies directly comparing intravenous and intracoronary adenosine administration for FFR measurement. FFR values and prevalence of functionally critical lesions obtained with the different methods of adenosine administration were compared. RESULTS Twelve studies evaluating 781 lesions from 731 patients were included (63.7 years, 25.5% women, median FFR 0.82). FFR values were significantly lower with intravenous adenosine than with intracoronary adenosine [mean difference 0.01, 95% confidence interval (CI) 0.00-0.02, P = 0.005], even if no significant differences were observed when only high doses of intracoronary adenosine (≥150 μg) were considered. The prevalence of functionally critical lesions did not significantly differ between intracoronary and intravenous adenosine. Concerning the use of different doses of intracoronary adenosine, low doses (≤60 μg) were associated with higher FFR values (mean difference 0.02, 95% CI 0.01-0.03, P < 0.001) and fewer functionally critical lesions (OR 0.57, 95% CI 0.40-0.81, P = 0.002) compared with high doses. Meta-regression analysis did not show any significant interaction between the way of adenosine administration and main clinical features. Intracoronary adenosine was associated with a higher incidence of atrioventricular blocks, whereas angina and/or systemic symptoms were more frequent with intravenous adenosine. CONCLUSION Intracoronary adenosine might be as effective as intravenous adenosine to measure FFR, provided that adequate doses are used. Intracoronary adenosine represents a valuable alternative to intravenous adenosine whenever appropriately administered.
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Affiliation(s)
- Sebastiano Gili
- Department of Medical Sciences, Division of Cardiology, AOU Città della Salute e della Scienza, University of Turin
| | - Umberto Barbero
- Department of Medical Sciences, Division of Cardiology, AOU Città della Salute e della Scienza, University of Turin
| | - Daniele Errigo
- Department of Medical Sciences, Division of Cardiology, AOU Città della Salute e della Scienza, University of Turin
| | - Giuseppe De Luca
- Division of Cardiology, Azienda Ospedaliera-Universitaria 'Maggiore della Carità,' Eastern Piedmont University, Novara
| | - Giuseppe Biondi-Zoccai
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza Università di Roma, Rome.,Department of AngioCardioNeurology, IRCCS Neuromed, Pozzilli
| | - Antonio Maria Leone
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario Agostino Gemelli, Rome, Italy
| | - Mario Iannaccone
- Department of Medical Sciences, Division of Cardiology, AOU Città della Salute e della Scienza, University of Turin
| | - Antonio Montefusco
- Department of Medical Sciences, Division of Cardiology, AOU Città della Salute e della Scienza, University of Turin
| | - Pierluigi Omedé
- Department of Medical Sciences, Division of Cardiology, AOU Città della Salute e della Scienza, University of Turin
| | - Claudio Moretti
- Department of Medical Sciences, Division of Cardiology, AOU Città della Salute e della Scienza, University of Turin
| | - Maurizio D'Amico
- Department of Medical Sciences, Division of Cardiology, AOU Città della Salute e della Scienza, University of Turin
| | - Fiorenzo Gaita
- Department of Medical Sciences, Division of Cardiology, AOU Città della Salute e della Scienza, University of Turin
| | - Fabrizio D'Ascenzo
- Department of Medical Sciences, Division of Cardiology, AOU Città della Salute e della Scienza, University of Turin
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Spagnoli V, Picard F, Tadros VX, Cournoyer D, Doucet S, Tanguay JF, Gosselin G, de Guise P, Gallo R. Simplifying the assessment of coronary artery stenosis by enhancing instantaneous wave free ratio. Cardiovasc Diagn Ther 2018; 8:156-163. [PMID: 29850406 DOI: 10.21037/cdt.2017.12.04] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Background Instantaneous wave free ratio (iFR) does not require adenosine, but has a relatively wide intermediate range where functional assessment remains inconclusive. In this pilot study, we sought to enhance iFR through with the use of intracoronary (IC) saline (iFRs) and contrast media (iFRc) and determine whether these techniques correlated well with fractional flow reserve (FFR). Methods Patients with coronary artery stenosis (CAS) associated with an iFR in the intermediate zone (≥0.86 and ≤0.93) were prospectively assessed with resting distal coronary pressure/aorta pressure (Pd/Pa), iFR, iFRs, iFRc and FFR. Results A total of 40 coronary lesions were studied (40 patients). Pearson correlation coefficients for FFR and iFR, FFR and iFRs, FFR and iFRc were respectively: 0.57 (P=0.0002), 0.80 (P<0.0001) and 0.77 (P<0.0001). Receiver-operating characteristic (ROC) curve analysis showed similar area under the curve (AUC) of iFRs and iFR [0.90 (95% CI: 0.76-1) vs. 0.89 (95% CI: 0.79-0.99), P=0.89]. Youden's index established cut-off values of ≤0.90 for iFR (sensitivity =91%, specificity =74%) and ≤0.78 for iFRs (sensitivity =73%, specificity =100%). In contrast, the AUC of iFRc was superior to the AUC of iFR [0.99 (95% CI: 0.98-1), P=0.049]. iFRc showed excellent accuracy and established cut-off values of ≤0.81 in predicting an FFR value of ≤0.80 (sensitivity =100%, specificity =93%). Conclusions When iFR is in the intermediate zone, functional assessment of CAS by iFR is enhanced with the use of contrast media but not saline. This pilot study could be hypothesis generating for further study to enhance iFR specificity and sensibility.
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Affiliation(s)
- Vincent Spagnoli
- Department of Cardiology, Montréal Heart Institute, Université de Montréal, Montréal, Canada
| | - Fabien Picard
- Department of Cardiology, Montréal Heart Institute, Université de Montréal, Montréal, Canada
| | - Victor-Xavier Tadros
- Department of Cardiology, Montréal Heart Institute, Université de Montréal, Montréal, Canada
| | | | - Serge Doucet
- Department of Cardiology, Montréal Heart Institute, Université de Montréal, Montréal, Canada
| | - Jean François Tanguay
- Department of Cardiology, Montréal Heart Institute, Université de Montréal, Montréal, Canada
| | - Gilbert Gosselin
- Department of Cardiology, Montréal Heart Institute, Université de Montréal, Montréal, Canada
| | - Pierre de Guise
- Department of Cardiology, Montréal Heart Institute, Université de Montréal, Montréal, Canada
| | - Richard Gallo
- Department of Cardiology, Montréal Heart Institute, Université de Montréal, Montréal, Canada
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Rigattieri S, Biondi Zoccai G, Sciahbasi A, Di Russo C, Cera M, Patrizi R, Fedele S, Berni A, Pugliese FR. Meta-Analysis of Head-to-Head Comparison of Intracoronary Versus Intravenous Adenosine for the Assessment of Fractional Flow Reserve. Am J Cardiol 2017; 120:563-568. [PMID: 28651849 DOI: 10.1016/j.amjcard.2017.05.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Revised: 05/04/2017] [Accepted: 05/04/2017] [Indexed: 02/08/2023]
Abstract
Intravenous (IV) infusion of adenosine represents the gold standard for measuring fractional flow reserve (FFR). However, IV adenosine is more expensive and time-consuming compared with intracoronary (IC) boluses of adenosine. We conducted a meta-analysis of studies comparing IC with IV adenosine for FFR assessment in the same coronary lesions. We searched for studies comparing IC with IV adenosine and reporting absolute FFR values or rate of abnormal FFR for both routes. Prespecified subgroup analysis was performed to appraise studies using low-dose (<100 μg) or high-dose IC adenosine (≥100 μg). We retrieved 11 studies amounting to 587 patients and 621 lesions. Six studies evaluated low-dose IC boluses (15 to 80 μg) and 5 studies high-dose boluses (120 to 600 μg). Absolute FFR values were slightly, yet significantly lower with IV adenosine compared with IC adenosine (mean difference 0.02, 95% confidence interval [CI] 0.00 to 0.03, p = 0.02). This difference, however, did not translate into a significant difference in the rate of abnormal FFR between IC and IV adenosine (hazard ratio 0.93, 95% CI 0.76 to 1.13, p = 0.57); moreover, no statistically significant difference was observed between low-dose and high-dose IC adenosine subgroups. Adverse events were less frequent with IC adenosine compared with IV adenosine (risk ratio 0.17, 95% CI 0.07 to 0.43, p <0.001). In conclusion, IC administration of adenosine, although inducing a slightly lower amount of hyperemia compared with IV infusion of adenosine, yields a similar diagnostic accuracy in identifying hemodynamically significant coronary stenosis and is better tolerated by the patients.
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Huang CL, Jen HL, Huang WP, Tsao TP, Shing Young M, Yin WH. The Impact of Fractional Flow Reserve-Guided Coronary Revascularization in Patients with Coronary Stenoses of Intermediate Severity. ACTA CARDIOLOGICA SINICA 2017; 33:353-361. [PMID: 29033506 PMCID: PMC5534415 DOI: 10.6515/acs20170202b] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Accepted: 02/02/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Previous studies have shown that the use of fractional flow reserve (FFR) in addition to angiography significantly reduced the rate of all major adverse cardiovascular events (MACE). However, this practice has not been widely accepted and limited outcome data exist about FFR-guided percutaneous coronary intervention (PCI) in Taiwan. The aim of the present study was to evaluate the possible impact of FFR-guided PCI in coronary stenoses of intermediate severity. METHODS We performed a retrospective case-control study on 443 cases of intermediate coronary stenoses in 206 patients recruited from our computerized database. The study patients were divided into two groups: the FFR group (n = 101) and the angiography group (n = 105), matched with age, gender, clinical and angiographic lesion characteristics. In the angiography group, the indicated lesions had been treated with PCI by angiographic or anatomical assessment, whereas those patients in the FFR group underwent PCI of indicated lesions only if the FFR was < 0.80. The primary end point was the MACE rate regarding death, nonfatal myocardial infarction (MI), and target vessel failure at a mean follow-up of 418 days. RESULTS The MACE rate was similar in both groups (6% in the angiography group and 3% in the FFR group, p = 0.06). However, FFR-guided PCI strategy prevented unnecessary revascularization in up to 75% of patients, and markedly reduced costs of the index hospitalization. Moreover, multivariate analysis found that the use of drug-eluting stent and statin therapy, and the presence of family history of premature coronary artery disease and periprocedural MI are independent predictors of clinical outcomes. CONCLUSIONS FFR-guided intervention, compared to angiography-guided intervention for Taiwanese patients with coronary stenoses of intermediate severity, achieved similar clinical outcomes and provided cost-savings.
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Affiliation(s)
- Chien-Lung Huang
- Division of Cardiology, Heart Center, Cheng Hsin General Hospital
| | - Hsu-Lung Jen
- Division of Cardiology, Heart Center, Cheng Hsin General Hospital
- Institute of Clinical Medicine
| | - Wen-Ping Huang
- Division of Cardiology, Heart Center, Cheng Hsin General Hospital
- Institute of Clinical Medicine
| | - Tien-Ping Tsao
- Division of Cardiology, Heart Center, Cheng Hsin General Hospital
| | | | - Wei-Hsian Yin
- Division of Cardiology, Heart Center, Cheng Hsin General Hospital
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
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Sparv D, Götberg M, Harnek J, Persson T, Madsen Hardig B, Erlinge D. Assessment of increasing intravenous adenosine dose in fractional flow reserve. BMC Cardiovasc Disord 2017; 17:60. [PMID: 28196527 PMCID: PMC5310024 DOI: 10.1186/s12872-016-0463-4] [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] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Accepted: 12/29/2016] [Indexed: 12/24/2022] Open
Abstract
Background Effects of increased adenosine dose in the assessment of fractional flow reserve (FFR) were studied in relation to FFR results, hemodynamic effects and patient discomfort. FFR require maximal hyperemia mediated by adenosine. Standard dose is 140 μg/kg/min administrated intravenously. Higher doses are commonly used in clinical practice, but an extensive comparison between standard intravenous dose and a high dose (220 μg/kg/min) has previously not been performed. Methods Seventy-five patients undergoing FFR received standard dose adenosine, followed by high dose adenosine. FFR, mean arterial pressure (MAP) and heart rate (HR) were analyzed. Patient discomfort measured by Visual Analogue Scale (VAS) was assessed. Results No significant difference was found between the doses in FFR value (0.85 [0.79–0.90] vs 0.85 [0.79–0.89], p = 0.24). The two doses correlated well irrespective of lesion severity (r = 0.86, slope = 0.89, p = <0.001). There were no differences in MAP or HR. Patient discomfort was more pronounced using high dose adenosine (8.0 [5.0–9.0]) versus standard dose (5.0 [2.0–7.0]), p = <0.001. Conclusions Increased dose adenosine does not improve hyperemia and is associated with increased patient discomfort. Our findings do not support the use of high dose adenosine. Trial registration Retrospective Trial registration: Current Controlled Trials ISRCTN14618196. Registered 15 December 2016.
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Affiliation(s)
- David Sparv
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden. .,Department of Coronary Heart Disease, Skane University Hospital, Lund, Sweden.
| | - Matthias Götberg
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden.,Department of Coronary Heart Disease, Skane University Hospital, Lund, Sweden
| | - Jan Harnek
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
| | - Tobias Persson
- Department of Coronary Heart Disease, Skane University Hospital, Lund, Sweden
| | | | - David Erlinge
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden.,Department of Coronary Heart Disease, Skane University Hospital, Lund, Sweden
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Myocardial Fractional Flow Reserve Measurement Using Contrast Media as a First-Line Assessment of Coronary Lesions in Current Practice. Can J Cardiol 2015; 32:739-46. [PMID: 26774229 DOI: 10.1016/j.cjca.2015.09.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Revised: 09/14/2015] [Accepted: 09/14/2015] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Fractional flow reserve (FFR) measurement requires adenosine injection. However, adenosine can induce conductive and rhythmic complications, or be contraindicated in some patients. Contrast-induced hyperemia could provide a simple first-line method (contrast-enhanced FFR; cFFR) to assess coronary lesions. In this study we evaluated the accuracy of cFFR to predict lesion significance. METHODS This prospective study included 104 patients with 138 coronary lesions. Each stenosis was evaluated using resting distal coronary pressure to aortic pressure ratio (Pd/Pa) measurements using intracoronary iodixanol (cFFR) and adenosine (FFR) injection. An FFR value ≤ 0.8 defined a significant lesion. RESULTS Dose-ranging analysis (n = 12 lesions) showed that 10 mL iodixanol was required to obtain the lowest cFFR value. Intermeasurement reproducibility of cFFR (n = 18 lesions) showed limited variability and small mean estimated bias (0.001 ± 0.014). Values of cFFR and FFR were highly correlated in a first series of n = 36 lesions (r = 0.9; P < 0.001). Receiver-operating characteristic curve analysis showed an excellent accuracy of cFFR cutoff value of ≤ 0.85 in predicting FFR value ≤ 0.80 (area under the curve, 0.94; 95% confidence interval, 0.90-0.98; sensitivity, 95%; specificity, 73%). This threshold was then tested prospectively in an independent cohort of n = 72 lesions. A cFFR value ≤ 0.85 correctly identified hemodynamically significant lesions with a sensitivity of 100%, specificity of 78%, positive predictive value of 78%, and negative predictive value of 100%. CONCLUSIONS cFFR is reproducible and can be achieved with usual volumes of contrast. A cFFR threshold value of 0.85 provides excellent sensitivity and negative predictive value in coronary artery stenosis.
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