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Cevik E, Tas A, Demirtakan ZG, Damman P, Alan Y, Broyd CJ, Ozcan A, Simsek DH, Sonsoz MR, Royen NV, Perera D, Davies JE, Umman S, Sezer M. Intracoronary electrocardiogram detects coronary microvascular dysfunction and ischemia in patients with no obstructive coronary arteries disease. Am Heart J 2024; 270:62-74. [PMID: 38278503 DOI: 10.1016/j.ahj.2024.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 12/18/2023] [Accepted: 01/09/2024] [Indexed: 01/28/2024]
Abstract
BACKGROUND Coronary microvascular dysfunction (CMD) is the leading cause of ischemia with no obstructive coronary arteries disease (INOCA) disease. Diagnosis of CMD relies on surrogate physiological indices without objective proof of ischemia. OBJECTIVES Intracoronary electrocardiogram (icECG) derived hyperemic indices may accurately and objectively detect CMD and reversible ischemia in related territory. METHODS INOCA patients with proven ischemia by myocardial perfusion scan (MPS) and completely normal coronary arteries underwent simultaneous intracoronary electrophysiological (icECG) and physiological (intracoronary Doppler) assessment in all 3 coronary arteries during rest and under adenosine induced hyperemia. RESULTS Sixty vessels in 21 patients were included in the final analysis. All patients had at least one vessel with abnormal CFR. 41 vessels had CMD (CFR < 2.5), of which 26 had increased microvascular resistance (structural CMD, HMR > 1.9 mmHg.cm-1.s) and 15 vessels had CMD (CFR < 2.5) with normal microvascular resistance (functional CMD, HMR <= 1.9 mmHg.cm-1.s). Only one-third of the patients (n = 7) had impaired CFR < 2.5 in all 3 epicardial arteries. Absolute ST shift between hyperemia and rest (∆ST) has shown the best diagnostic performance for ischemia (cut-off 0.10 mV, sensitivity: 95%, specificity: 72%, accuracy: 80%, AUC: 0.860) outperforming physiological indices (CFR: 0.623 and HMR: 0.653 DeLong's test P = .0002). CONCLUSIONS In INOCA patients, CMD involves coronary artery territories heterogeneously. icECG can accurately detect CMD causing perfusion abnormalities in patients with INOCA outperforming physiological CMD markers, by demonstrating actual ischemia instead of predicting the likelihood of inducible ischemia based on violated surrogate thresholds of blunted flow reserve or increased minimum microvascular resistance. CONDENSED ABSTRACT In 21 INOCA patients with coronary microvascular dysfunction (CMD) and myocardial perfusion scan proved ischemia, hyperemic indices of intracoronary electrocardiogram (icECG) have accurately detected vessel-specific CMD and resulting perfusion abnormalities & ischemia, outperforming invasive hemodynamic indices. Absolute ST shift between hyperemia and rest (∆ST) has shown the best classification performance for ischemia in no Obstructive Coronary Arteries (AUC: 0.860) outperforming Doppler derived CMD indices (CFR: 0.623 and HMR: 0.653 DeLong's test P = .0002).icECG can be used to diagnose CMD causing perfusion defects by demonstrating actual reversible ischemia at vessel-level during the initial CAG session, obviating the need for further costly ischemia tests. CLINICALTRIALS GOV: NCT05471739.
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Affiliation(s)
- Erdem Cevik
- Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey; Department of Cardiology, Istanbul University, Istanbul, Turkey
| | - Ahmet Tas
- Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Zeynep G Demirtakan
- Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey; Department of Cardiology, Istanbul University, Istanbul, Turkey
| | - Peter Damman
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Yaren Alan
- Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | | | - Alp Ozcan
- Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Duygu H Simsek
- Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Mehmet R Sonsoz
- Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey; Department of Cardiology, Istanbul University, Istanbul, Turkey
| | - Niels van Royen
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Divaka Perera
- King's College London, British Heart Foundation Centre of Research Excellence and National Institute for Health and Care Research Biomedical Research Centre at the School of Cardiovascular and Metabolic Medicine and Sciences, London, United Kingdom
| | - Justin E Davies
- Hammersmith Campus, Imperial College London, National Heart & Lung Institute, London, United Kingdom
| | - Sabahattin Umman
- Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey; Department of Cardiology, Istanbul University, Istanbul, Turkey
| | - Murat Sezer
- Acibadem International Hospital, Istanbul, Turkey.
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Ciaramella L, Di Serafino L, Mitrano L, De Rosa ML, Carbone C, Rea FS, Monaco S, Scalamogna M, Cirillo P, Esposito G. Invasive Assessment of Coronary Microcirculation: A State-of-the-Art Review. Diagnostics (Basel) 2023; 14:86. [PMID: 38201395 PMCID: PMC10795746 DOI: 10.3390/diagnostics14010086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 12/28/2023] [Accepted: 12/28/2023] [Indexed: 01/12/2024] Open
Abstract
A significant proportion of patients presenting with signs and symptoms of myocardial ischemia have no "significant" epicardial disease; thereby, the assessment of coronary microcirculation gained an important role in improving diagnosis and guiding therapy. In fact, coronary microvascular dysfunction (CMD) could be found in a large proportion of these patients, supporting both symptoms and signs of myocardial ischemia. However, CMD represents a diagnostic challenge for two main reasons: (1) the small dimension of the coronary microvasculature prevents direct angiographic visualization, and (2) despite the availability of specific diagnostic tools, they remain invasive and underused in the current clinical practice. For these reasons, CMD remains underdiagnosed, and most of the patients remain with no specific treatment and quality-of-life-limiting symptoms. Of note, recent evidence suggests that a "full physiology" approach for the assessment of the whole coronary vasculature may offer a significant benefit in terms of symptom improvement among patients presenting with ischemia and non-obstructive coronary artery disease. We analyze the pathophysiology of coronary microvascular dysfunction, providing the readers with a guide for the invasive assessment of coronary microcirculation, together with the available evidence supporting its use in clinical practice.
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Affiliation(s)
| | - Luigi Di Serafino
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Via Pansini 5, 80131 Naples, Italy; (L.C.); (L.M.); (M.L.D.R.); (C.C.); (F.S.R.); (S.M.); (M.S.); (P.C.); (G.E.)
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3
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Pintea Bentea G, Berdaoui B, Samyn S, Morissens M, van de Borne P, Castro Rodriguez J. Particularities of coronary physiology in patients with atrial fibrillation: insights from combined pressure and flow indices measurements. Front Cardiovasc Med 2023; 10:1206743. [PMID: 37645524 PMCID: PMC10461314 DOI: 10.3389/fcvm.2023.1206743] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 07/31/2023] [Indexed: 08/31/2023] Open
Abstract
Background Symptoms suggestive of myocardial ischemia are frequently encountered in patients with atrial fibrillation (AF) even in the absence of obstructive coronary artery disease. Nevertheless, an in-depth characterisation of coronary physiology in patients with AF is currently lacking. Objectives We aim to provide an insight into the characteristics of coronary physiology in AF, by performing simultaneous invasive measurements of coronary flow- and pressure- indices in a real-life population of patients with AF and indication of coronary angiography. Methods This is a prospective open label study including patients with permanent or persistent AF and indication of coronary angiography showing intermediate coronary stenosis requiring routine physiological assessment (n = 18 vessels from 14 patients). We measured FFR (fractional flow reserve), and Doppler-derived coronary flow indices, including CFR (coronary flow reserve) and HMR (hyperaemic microvascular resistance). Results From the analysed vessels, 18/18 vessels (100%) presented a pathological CFR (<2.5), indicative of coronary microvascular dysfunction (CMD), and 3/18 (17%) demonstrated obstructive epicardial coronary disease (FFR ≤ 0.8). A large proportion of vessels (15/18; 83%) showed discordant FFR/CFR with preserved FFR and low CFR. 47% of the coronary arteries in patients with AF and non-obstructive epicardial coronary disease presented structural CMD (HMR ≥ 2.5 mmHg/cm/s), and were associated with high BMR and an impaired response to adenosine. Conversely, vessels from patients with AF and non-obstructive epicardial coronary disease with functional CMD (HMR < 2.5 mmHg/cm/s) showed higher bAPV. The permanent AF subpopulation presented increased values of HMR and BMR compared to persistent AF, while structural CMD was more often associated with persistent symptoms at 3 months, taking into account the limited sample size of our study. Conclusion Our findings highlight a systematically impaired CFR in patients with AF even in the absence of obstructive epicardial coronary disease, indicative of CMD. In addition, patients with AF presented more prevalent structural CMD (HMR ≥ 2.5 mmHg/cm/s), characterized by reduced hyperaemic responses to adenosine, possibly interfering with the FFR assessment.
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Affiliation(s)
| | | | - Sophie Samyn
- Department of Cardiology, CHU Brugmann, Brussels, Belgium
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Taylor DJ, Aubiniere-Robb L, Gosling R, Newman T, Hose DR, Halliday I, Lawford PV, Narracott AJ, Gunn JP, Morris PD. Sex differences in coronary microvascular resistance measured by a computational fluid dynamics model. Front Cardiovasc Med 2023; 10:1159160. [PMID: 37485258 PMCID: PMC10357508 DOI: 10.3389/fcvm.2023.1159160] [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: 02/05/2023] [Accepted: 06/22/2023] [Indexed: 07/25/2023] Open
Abstract
Background Increased coronary microvascular resistance (CMVR) is associated with coronary microvascular dysfunction (CMD). Although CMD is more common in women, sex-specific differences in CMVR have not been demonstrated previously. Aim To compare CMVR between men and women being investigated for chest pain. Methods and results We used a computational fluid dynamics (CFD) model of human coronary physiology to calculate absolute CMVR based on invasive coronary angiographic images and pressures in 203 coronary arteries from 144 individual patients. CMVR was significantly higher in women than men (860 [650-1,205] vs. 680 [520-865] WU, Z = -2.24, p = 0.025). None of the other major subgroup comparisons yielded any differences in CMVR. Conclusion CMVR was significantly higher in women compared with men. These sex-specific differences may help to explain the increased prevalence of CMD in women.
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Affiliation(s)
- Daniel J. Taylor
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Louise Aubiniere-Robb
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Rebecca Gosling
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
- Department of Cardiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
- Insigneo Institute for in Silico Medicine, University of Sheffield, Sheffield, United Kingdom
| | - Tom Newman
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
- Department of Cardiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - D. Rodney Hose
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
- Insigneo Institute for in Silico Medicine, University of Sheffield, Sheffield, United Kingdom
| | - Ian Halliday
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
- Insigneo Institute for in Silico Medicine, University of Sheffield, Sheffield, United Kingdom
| | - Patricia V. Lawford
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
- Insigneo Institute for in Silico Medicine, University of Sheffield, Sheffield, United Kingdom
| | - Andrew J. Narracott
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
- Insigneo Institute for in Silico Medicine, University of Sheffield, Sheffield, United Kingdom
| | - Julian P. Gunn
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
- Department of Cardiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
- Insigneo Institute for in Silico Medicine, University of Sheffield, Sheffield, United Kingdom
| | - Paul D. Morris
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
- Department of Cardiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
- Insigneo Institute for in Silico Medicine, University of Sheffield, Sheffield, United Kingdom
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Ooi EL, Rajendran S, Munawar DA, Hnin K, Mahadavan G, Pati P, Tavella R, Beltrame J, Arstall M. The Association of Obstructive Sleep Apnea in Ischemia with No Obstructive Coronary Artery Disease - A Pilot Study. Curr Probl Cardiol 2023; 48:101111. [PMID: 35021111 DOI: 10.1016/j.cpcardiol.2022.101111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 01/03/2022] [Indexed: 11/03/2022]
Abstract
Obstructive sleep apnea (OSA) is increasingly recognized to be a risk factor for cardiovascular disease. This pilot study assessed the association of OSA and invasive coronary microvascular function in patients with ischemia with no obstructive coronary artery disease (INOCA). Forty-two patients with angina, were prospectively screened at a single tertiary centre covering the northern metropolitan area of South Australia, from February 2018 to December 2020 (ACTRN12618000149268). Forty patients were invited into to this observational study after coronary angiography demonstrated INOCA and functional coronary vasomotor disorder (n = 40). Twenty one participants subsequently underwent a sleep study for OSA diagnosis while 9 participants had prior formal diagnosis of OSA (ACTRN12618000227291). Of the 30 participants with OSA data, 87% (n = 26) had a diagnosis of OSA. Accordingly, 11 with mild severity, 7 with moderate severity and 8 with severe OSA. No OSA was observed in 4 participants. Participants with OSA were older [61.4±8.7 vs 49.9±9.7, P = 0.002] with similar clinical characteristics for the pattern and severity of angina and other co-morbidities. 73.3% (n = 22) had abnormal functional disorders of the epicardial coronary arteries and/or coronary microcirculation. On multivariate analysis, OSA was the only statistically significant association with functional coronary microvascular disorders [OR 53.95, 1.41 -2065.01, P = 0.032]. This study provided an observation of a significant correlation between INOCA with abnormal coronary vasomotor function and OSA in an Australian cohort. This correlation supports a possible pathophysiological interplay between these two conditions that needs to be further evaluated. The benefit of treatment of OSA in this subset remains unknown.
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Affiliation(s)
- Eng Lee Ooi
- Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia.
| | - Sharmalar Rajendran
- Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia; Department of Cardiology, Northern Adelaide Local Health Network, Adelaide, SA, Australia
| | - Dian Andina Munawar
- Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia; Department of Cardiology, Northern Adelaide Local Health Network, Adelaide, SA, Australia
| | - Khin Hnin
- Norwood Specialist Clinic, Adelaide, SA Australia
| | - Gnanadevan Mahadavan
- Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia; Department of Cardiology, Northern Adelaide Local Health Network, Adelaide, SA, Australia
| | - Purendra Pati
- Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia; Department of Cardiology, Northern Adelaide Local Health Network, Adelaide, SA, Australia
| | - Rosanna Tavella
- Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia; Basil Hetzel Institute for Translational Health Research, The Queen Elizabeth Hospital, Woodville South, SA, Australia
| | - John Beltrame
- Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia; Basil Hetzel Institute for Translational Health Research, The Queen Elizabeth Hospital, Woodville South, SA, Australia
| | - Margaret Arstall
- Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia; Department of Cardiology, Northern Adelaide Local Health Network, Adelaide, SA, Australia
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Feenstra RGT, Seitz A, Boerhout CKM, de Winter RJ, Ong P, Beijk MAM, Piek JJ, Sechtem U, van de Hoef TP. Reference values for intracoronary Doppler flow velocity-derived hyperaemic microvascular resistance index. Int J Cardiol 2023; 371:16-20. [PMID: 36174827 DOI: 10.1016/j.ijcard.2022.09.054] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 09/21/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Invasive assessments of microvascular function are rapidly becoming an integral part of physiological assessment in chronic coronary syndromes. OBJECTIVE We aimed to establish a reference range for Doppler flow velocity-derived hyperaemic microvascular resistance index (HMR) in a cohort of angina with no significant epicardial coronary obstruction (ANOCA) patients with no structural pathophysiological alterations in the coronary circulation. METHODS The reference population consisted of ANOCA patients undergoing invasive coronary vasomotor function assessment who had a coronary flow reserve (CFR) >2.5, and had either (1) tested negatively for spasm provocation (n = 12) or (2) tested positively with only angina at rest (n = 29). A reference range for HMR was established using a non-parametric method and correlations with clinical characteristics were determined using a spearman rank correlation analysis. RESULTS In 41 patients median HMR amounted to 1.6 mmHg/cm/s [Q1, Q3: 1.3, 2.2 mmHg/cm/s]. The reference range for HMR that is applicable to 95% of the population was 0.8 mmHg/cm/s (90% CI: 0.8-1.0 mmHg/cm/s) to 2.7 mmHg/cm/s (90% CI: 2.6-2.7 mmHg/cm/s). No significant correlations were found between HMR and clinical characteristics. CONCLUSION In this reference population undergoing invasive coronary vasomotor function testing, the 90% confidence interval of the HMR upper limit of normal ranges from 2.6 to 2.7 mmHg/cm/s. A > 2.5 mmHg/cm/s HMR threshold can be used to identify abnormal microvascular resistance in daily clinical practice.
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Affiliation(s)
- Rutger G T Feenstra
- Amsterdam UMC, Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Andreas Seitz
- Department of Cardiology, Robert-Bosch-Krankenhaus, Stuttgart, Germany
| | - Coen K M Boerhout
- Amsterdam UMC, Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Robbert J de Winter
- Amsterdam UMC, Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Peter Ong
- Department of Cardiology, Robert-Bosch-Krankenhaus, Stuttgart, Germany
| | - Marcel A M Beijk
- Amsterdam UMC, Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Jan J Piek
- Amsterdam UMC, Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Udo Sechtem
- Department of Cardiology, Robert-Bosch-Krankenhaus, Stuttgart, Germany
| | - Tim P van de Hoef
- Amsterdam UMC, Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands; Department of Cardiology, Noordwest Ziekenhuisgroep, Alkmaar, the Netherlands.
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Morris PD, Al-Lamee RK, Berry C. Coronary physiological assessment in the catheter laboratory: haemodynamics, clinical assessment and future perspectives. Heart 2022; 108:1737-1746. [PMID: 35768192 PMCID: PMC9606498 DOI: 10.1136/heartjnl-2020-318743] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Paul D Morris
- Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, UK
| | | | - Colin Berry
- BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
- Department of Cardiology, Golden Jubilee National Hospital, Clydebank, UK
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Travieso A, Jeronimo-Baza A, Faria D, Shabbir A, Mejia-Rentería H, Escaned J. Invasive evaluation of coronary microvascular dysfunction. J Nucl Cardiol 2022; 29:2474-2486. [PMID: 35618991 PMCID: PMC9553758 DOI: 10.1007/s12350-022-02997-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 04/10/2022] [Indexed: 12/02/2022]
Abstract
Coronary microvascular dysfunction (CMD) is a prevalent cause of ischemic heart disease and is associated with poorer quality of life and worse patient outcomes. Both functional and structural abnormalities of the microcirculation can generate ischemia in the absence of epicardial stenosis or worsen concomitant obstructive coronary artery disease (CAD). The invasive assessment of CMD allows for the evaluation of the entirety of the coronary vascular tree, from the large epicardial vessels to the microcirculation, and enables the study of vasomotor function through vasoreactivity testing. The standard evaluation of CMD includes vasomotor assessment with acetylcholine, as well as flow- and resistance-derived indices calculated with either thermodilution or Doppler guidewires. Tailored treatment based upon the information gathered from the invasive evaluation of CMD has been demonstrated to reduce the burden of angina; therefore, a thorough understanding of these procedures is warranted with the aim of improving the quality of life of the patient. This review summarizes the most widespread approaches for the invasive evaluation of CMD, with a focus on patients with ischemia and non-obstructive CAD.
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Affiliation(s)
- Alejandro Travieso
- Hospital Clinico San Carlos IDISSC, Complutense University of Madrid, c/ Profesor Martin Lagos, s/n, 28040, Madrid, Spain
| | - Adrian Jeronimo-Baza
- Hospital Clinico San Carlos IDISSC, Complutense University of Madrid, c/ Profesor Martin Lagos, s/n, 28040, Madrid, Spain
| | - Daniel Faria
- Hospital Clinico San Carlos IDISSC, Complutense University of Madrid, c/ Profesor Martin Lagos, s/n, 28040, Madrid, Spain
| | - Asad Shabbir
- Hospital Clinico San Carlos IDISSC, Complutense University of Madrid, c/ Profesor Martin Lagos, s/n, 28040, Madrid, Spain
| | - Hernan Mejia-Rentería
- Hospital Clinico San Carlos IDISSC, Complutense University of Madrid, c/ Profesor Martin Lagos, s/n, 28040, Madrid, Spain
| | - Javier Escaned
- Hospital Clinico San Carlos IDISSC, Complutense University of Madrid, c/ Profesor Martin Lagos, s/n, 28040, Madrid, Spain.
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9
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Eftekhari A, Westra J, Stegehuis V, Holm NR, van de Hoef TP, Kirkeeide RL, Piek JJ, Lance Gould K, Johnson NP, Christiansen EH. Prognostic value of microvascular resistance and its association to fractional flow reserve: a DEFINE-FLOW substudy. Open Heart 2022; 9:openhrt-2022-001981. [PMID: 35410913 PMCID: PMC9003618 DOI: 10.1136/openhrt-2022-001981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 03/24/2022] [Indexed: 11/29/2022] Open
Abstract
Objective This study aimed to evaluate the prognostic value of hyperemic microvascular resistance (HMR) and its relationship with hyperemic stenosis resistance (HSR) index and fractional flow reserve (FFR) in stable coronary artery disease. Methods This is a substudy of the DEFINE-FLOW cohort (NCT02328820), which evaluated the prognosis of lesions (n=456) after combined FFR and coronary flow reserve (CFR) assessment in a prospective, non-blinded, non-randomised, multicentre study in 12 centres in Europe and Japan. Participants (n=430) were evaluated by wire-based measurement of coronary pressure, flow and vascular resistance (ComboWire XT, Phillips Volcano, San Diego, California, USA). Results Mean FFR and CFR were 0.82±0.10 and 2.2±0.6, respectively. When divided according to FFR and CFR thresholds (above and below 0.80 and 2.0, respectively), HMR was highest in lesions with FFR>0.80 and CFR<2.0 (n=99) compared with lesions with FFR≤0.80 and CFR≥2.0 (n=68) (2.92±1.2 vs 1.91±0.64 mm Hg/cm/s, p<0.001). The FFR value was proportional to the ratio between HMR and the HMR+HSR (total resistance), 95% limits of agreement (−0.032; 0.019), bias (−0.003±0.02) and correlation (r2=0.98, p<0.0001). Cox regression model using HMR as continuous parameter for target vessel failure showed an HR of 1.51, 95% CI (0.9 to 2.4), p=0.10. Conclusions Increased HMR was not associated with a higher rate of adverse clinical events, in this population of mainly stable patients. FFR can be equally well expressed as HMR/HMR+HSR, thereby providing an alternative conceptual formulation linking epicardial severity with microvascular resistance. Trial registration number NCT02328820.
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Affiliation(s)
- Ashkan Eftekhari
- Department of Cardiology, Aarhus University Hospital Skejby, Aarhus, Denmark
- Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Jelmer Westra
- Department of Cardiology, Aarhus University Hospital Skejby, Aarhus, Denmark
| | - Valérie Stegehuis
- Amsterdam UMC, University of Amsterdam, Heart Center,Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Niels Ramsing Holm
- Department of Cardiology, Aarhus University Hospital Skejby, Aarhus, Denmark
| | - Tim P van de Hoef
- Amsterdam UMC, University of Amsterdam, Heart Center,Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Richard L Kirkeeide
- Weatherhead PET Center, Division of Cardiology, Department of Medicine, McGovern Medical School at UTHealth and Memorial Hermann Hospital, Houston, Texas, USA
| | - Jan J Piek
- Amsterdam UMC, University of Amsterdam, Heart Center,Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - K Lance Gould
- Weatherhead PET Center, Division of Cardiology, Department of Medicine, McGovern Medical School at UTHealth and Memorial Hermann Hospital, Houston, Texas, USA
| | - Nils P Johnson
- Weatherhead PET Center, Division of Cardiology, Department of Medicine, McGovern Medical School at UTHealth and Memorial Hermann Hospital, Houston, Texas, USA
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Park HW, Corban M, Toya T, Ahmad A, Ozcan I, Lerman L, Lerman A. Impact of invasive aortic pulse pressure on coronary microvascular endothelial-independent dysfunction and on mortality in non-obstructive coronary artery disease. Open Heart 2022; 9:openhrt-2021-001925. [PMID: 35105720 PMCID: PMC8808452 DOI: 10.1136/openhrt-2021-001925] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 01/09/2022] [Indexed: 11/04/2022] Open
Abstract
Background Pulse pressure (PP), a raw index of arterial stiffness, is inversely related to coronary microvascular function, even among patients with non-obstructive coronary artery disease (CAD), as per non-invasive studies. We aimed to determine whether invasive aortic PP is associated with coronary microvascular endothelial dysfunction (CMED) and/or coronary microvascular endothelial independent dysfunction (CMEID) in patients with non-obstructed CAD. Methods We retrospectively analysed a cohort of 1894 patients (mean age, 51.2 years; 1261 (66.6%) women) who presented with chest pain and non-obstructive CAD (angiographic stenosis <50%); coronary vasoreactivity was assessed in the mid-left anterior descending artery. The patients were classified based on whether aortic PP was high (≥50 mm Hg). CMEID was defined as abnormal coronary flow reserve (<2.5) or hyperaemic myocardial resistance (>2.0 mm Hg/cm/s), CMED was defined as abnormal acetylcholine-induced per cent change of coronary blood flow (≤50%). Results Patients with high aortic PP had a higher rate of CMEID than those with low aortic PP (40.9 vs 25.2%, p<0.001). Conversely, aortic PP was not associated with CMED. On multivariate analysis, high aortic PP was associated with CMEID occurrence (OR 1.42, 95% CI 1.13 to 1.78; p=0.003). On follow-up (median, 150 months), all-cause death was more frequent among patients with vs without high aortic PP (20.1% vs 7.3%, log-rank p<0.001) and HR was 2.08 (95% CI 1.34 to 3.32, p=0.002) on multivariate cox regression analysis. Furthermore, among patients with low aortic PP, CMEID was an independent risk factor for all-cause mortality (HR 2.04, 95% CI 1.01 to 4.16, p=0.048). Conclusion In patients with non-obstructive CAD, invasive aortic PP was significantly associated with CMEID, but not with CMED. High aortic PP was an independent predictor of all-cause mortality, but CMEID was an independent risk factor in patients with low aortic PP.
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Affiliation(s)
- Hyun Woong Park
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.,Department of Cardiovascular Disease, Chungnam National University Sejong Hospital, Sejong, Republic of Korea
| | - Michel Corban
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Takumi Toya
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.,Division of Cardiology, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Ali Ahmad
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ilke Ozcan
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Lilach Lerman
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Amir Lerman
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
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11
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Mangiacapra F, Viscusi MM, Verolino G, Paolucci L, Nusca A, Melfi R, Ussia GP, Grigioni F. Invasive Assessment of Coronary Microvascular Function. J Clin Med 2021; 11:jcm11010228. [PMID: 35011968 PMCID: PMC8745537 DOI: 10.3390/jcm11010228] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 12/21/2021] [Accepted: 12/29/2021] [Indexed: 01/01/2023] Open
Abstract
The critical role of the coronary microvascular compartment and its invasive functional assessment has become apparent in light of the significant proportion of patients presenting signs and symptoms of myocardial ischemia, despite the absence of epicardial disease, or after the adequate treatment of it. However, coronary microvascular dysfunction (CMD) represents a diagnostic challenge because of the small dimensions of the coronary microvasculature, which prevents direct angiographic visualization. Several diagnostic tools are now available for the invasive assessment of the coronary microvascular function, which, in association with the physiological indices used to investigate the epicardial department, may provide a comprehensive evaluation of the coronary circulation as a whole. Recent evidence suggests that the physiology-guided management of CMD, although apparently costly and time-consuming, may offer a net clinical benefit in terms of symptom improvement among patients with angina and ischemic heart disease. However, despite the results of several observational studies, the prognostic effect of the physiology-driven management of CMD within this population is currently a matter of debate, and therefore represents an unmet clinical need that urgently deserves further investigation.
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12
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Abouelnour A, Gori T. Vasomotor Dysfunction in Patients with Ischemia and Non-Obstructive Coronary Artery Disease: Current Diagnostic and Therapeutic Strategies. Biomedicines 2021; 9:biomedicines9121774. [PMID: 34944590 PMCID: PMC8698648 DOI: 10.3390/biomedicines9121774] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 11/15/2021] [Accepted: 11/23/2021] [Indexed: 11/16/2022] Open
Abstract
Many patients who present with symptoms or objective evidence of ischemia have no or non-physiologically-significant disease on invasive coronary angiography. The diagnosis of ischemic heart disease is thus often dismissed, and patients receive false reassurance or other diagnoses are pursued. We now know that a significant proportion of these patients have coronary microvascular dysfunction and/or vasospastic disease as the underlying pathophysiology of their clinical presentation. Making the correct diagnosis of such abnormalities is important not only because they impact the quality of life, with recurring symptoms and unnecessary repeated testing, but also because they increase the risk for adverse cardiovascular events. The mainstay of diagnosis remains an invasive comprehensive physiologic assessment, which further allows stratifying these patients into appropriate “endotypes”. It has been shown that tailoring treatment to the patient’s assigned endotype improves symptoms and quality of life. In addition to the conventional drugs used in chronic stable angina, multiple newer agents are being investigated. Moreover, innovative non-pharmacologic and interventional therapies are emerging to provide a bail-out in refractory cases. Many of these novel therapies fail to show consistent benefits, but others show quite promising results.
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Affiliation(s)
- Amr Abouelnour
- Zentrum für Kardiologie, Kardiologie I, und Deutsches Zentrum für Herz und Kreislauf Forschung, University Medical Center Mainz, 55131 Standort Rhein-Main, Germany;
- Cardiovascular Institute, Assiut University, Assiut 71515, Egypt
| | - Tommaso Gori
- Zentrum für Kardiologie, Kardiologie I, und Deutsches Zentrum für Herz und Kreislauf Forschung, University Medical Center Mainz, 55131 Standort Rhein-Main, Germany;
- Correspondence:
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13
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van de Hoef TP, Echavarria-Pinto M, Meuwissen M, Stegehuis VE, Escaned J, Piek JJ. Contribution of Age-Related Microvascular Dysfunction to Abnormal Coronary: Hemodynamics in Patients With Ischemic Heart Disease. JACC Cardiovasc Interv 2020; 13:20-29. [PMID: 31918939 DOI: 10.1016/j.jcin.2019.08.052] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 08/23/2019] [Accepted: 08/27/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVES This study sought to investigate the contribution of age-related microcirculatory dysfunction to abnormal coronary hemodynamics in patients with coronary atherosclerosis. BACKGROUND Impairment in myocardial blood supply in patients with coronary atherosclerosis can be accentuated due to age-related changes in microcirculatory function. METHODS Intracoronary pressure and flow were measured with the Doppler technique in 299 vessels (228 patients), and the thermodilution technique in 120 vessels (99 patients). In 172 patients, Doppler measurements were also performed in unobstructed vessels. Associations of coronary hemodynamics with aging were studied in both the stenosed and unobstructed arteries. RESULTS Aging was associated with a progressive increase in minimal microvascular resistance and a progressive decrease in hyperemic flow in both obstructed and nonobstructed coronary arteries. As such, coronary flow reserve decreased with advancing age. Epicardial stenosis severity assessed by resting Pd/Pa, basal stenosis resistance index, and hyperemic stenosis resistance index was equivalent across age groups. By contrast, fractional flow reserve increased with advancing age. Consequently, the adjusted risk of a fractional flow reserve/coronary flow reserve pattern reflective of concomitant focal epicardial and diffuse or microvascular disease (relative risk: 1.6; 95% confidence interval: 1.1 to 2.3; p = 0.017) increased with advancing age, whilst the adjusted risk of a fractional flow reserve/coronary flow reserve pattern reflective of non-flow-limiting stenosis with a healthy microcirculation decreased (relative risk: 0.7; 95% CI: 0.5 to 1.0; p = 0.022). CONCLUSIONS Aging is associated with progressive pan-myocardial impairment of coronary vasodilatory capacity due to an increase in minimal microvascular resistance. Concomitant aging-related impairment in microvascular function impacts the pathophysiology of ischemic heart disease in the individual patient and is not adequately identified by hyperemic coronary pressure measurements alone.
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Affiliation(s)
- Tim P van de Hoef
- Amsterdam UMC, University of Amsterdam, Heart Center, Department of Interventional Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands; Cardiovascular Institute, Hospital Clínico San Carlos, and Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain.
| | - Mauro Echavarria-Pinto
- Cardiovascular Institute, Hospital Clínico San Carlos, and Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain; Hospital General ISSSTE - Facultad de Medicina, Universidad Autónoma de Querétaro, Querétaro, México
| | | | - Valerie E Stegehuis
- Amsterdam UMC, University of Amsterdam, Heart Center, Department of Interventional Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Javier Escaned
- Cardiovascular Institute, Hospital Clínico San Carlos, and Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain; Faculty of Medicine, Complutense University, Madrid, Spain
| | - Jan J Piek
- Amsterdam UMC, University of Amsterdam, Heart Center, Department of Interventional Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
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14
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Knuuti J, Wijns W, Saraste A, Capodanno D, Barbato E, Funck-Brentano C, Prescott E, Storey RF, Deaton C, Cuisset T, Agewall S, Dickstein K, Edvardsen T, Escaned J, Gersh BJ, Svitil P, Gilard M, Hasdai D, Hatala R, Mahfoud F, Masip J, Muneretto C, Valgimigli M, Achenbach S, Bax JJ. 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes. Eur Heart J 2020; 41:407-477. [PMID: 31504439 DOI: 10.1093/eurheartj/ehz425] [Citation(s) in RCA: 3654] [Impact Index Per Article: 913.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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15
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16
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Sheikh AR, Zeitz CJ, Rajendran S, Di Fiore DP, Tavella R, Beltrame JF. Clinical and coronary haemodynamic determinants of recurrent chest pain in patients without obstructive coronary artery disease - A pilot study. Int J Cardiol 2019; 267:16-21. [PMID: 29957255 DOI: 10.1016/j.ijcard.2018.04.077] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Revised: 04/15/2018] [Accepted: 04/18/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Coronary haemodynamic testing frequently identifies abnormal pathophysiological parameters in patients with angina and non-obstructed coronaries on angiography (NoCAD) but the clinical utility of these measures has received limited attention. OBJECTIVE This study aims to identify the clinical and coronary haemodynamic determinants of recurrent chest pain at one month in patients with NoCAD. METHODS Patients with angina, NoCAD (<50% stenosis) and normal LV systolic function underwent invasive coronary haemodynamic testing involving: (1) angiographic TIMI frame and opacification rate, (2) microvascular functional measures including coronary flow reserve (CFR) and hyperaemic microvascular resistance (HMR), (3) coronary endothelial function assessment with low dose intracoronary acetylcholine (IC-ACh) infusions (0.18 μg/min & 1.8 μg/min over 2 min), and (4) Provocative spasm testing with high dose IC-ACh boluses (25, 50 and 100 μg). Clinical and health status were assessed at baseline and one month. RESULTS In the 49 NoCAD patients (78% female, mean age of 54 ± 11) undergoing comprehensive coronary haemodynamic testing, 33 (67%) continued to experience chest pain at one month. Determinants of recurrent chest pain on univariate analysis included baseline chest pain status or a HMR > 1.9. Multivariate logistic regression analysis identified frequent angina at baseline (OR: 68.9 [4.1, 1165.0], p = 0.003), previous unstable angina admission (OR: 43.9 [3.5, 547.9], p = 0.003) and a HMR > 1.9 (OR: 15.6 [2.1, 114.0], p = 0.007) as independent predictors of recurrent chest pain. CONCLUSION In this small pilot study, an abnormal HMR was the only coronary haemodynamic parameter that was a determinant of ongoing angina at short-term follow-up.
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Affiliation(s)
- Abdul R Sheikh
- Discipline of Medicine, University of Adelaide, Adelaide, South Australia 5005, Australia; Cardiology Department, The Queen Elizabeth & Royal Adelaide Hospitals, Central Adelaide Local Health Network, Adelaide, South Australia, Australia; Basil Hetzel Institute for Translational Health Research, 37 Woodville Road, Woodville South, South Australia 5011, Australia
| | - Christopher J Zeitz
- Discipline of Medicine, University of Adelaide, Adelaide, South Australia 5005, Australia; Cardiology Department, The Queen Elizabeth & Royal Adelaide Hospitals, Central Adelaide Local Health Network, Adelaide, South Australia, Australia; Cardiology Unit, Lyell McEwin Hospital, Northern Adelaide Local Health Network, Haydown Road, Elizabeth Vale, South Australia 5112, Australia
| | - Sharmalar Rajendran
- Discipline of Medicine, University of Adelaide, Adelaide, South Australia 5005, Australia; Cardiology Department, The Queen Elizabeth & Royal Adelaide Hospitals, Central Adelaide Local Health Network, Adelaide, South Australia, Australia; Cardiology Unit, Lyell McEwin Hospital, Northern Adelaide Local Health Network, Haydown Road, Elizabeth Vale, South Australia 5112, Australia
| | - David P Di Fiore
- Discipline of Medicine, University of Adelaide, Adelaide, South Australia 5005, Australia; Cardiology Department, The Queen Elizabeth & Royal Adelaide Hospitals, Central Adelaide Local Health Network, Adelaide, South Australia, Australia; Basil Hetzel Institute for Translational Health Research, 37 Woodville Road, Woodville South, South Australia 5011, Australia
| | - Rosanna Tavella
- Discipline of Medicine, University of Adelaide, Adelaide, South Australia 5005, Australia; Basil Hetzel Institute for Translational Health Research, 37 Woodville Road, Woodville South, South Australia 5011, Australia
| | - John F Beltrame
- Discipline of Medicine, University of Adelaide, Adelaide, South Australia 5005, Australia; Cardiology Department, The Queen Elizabeth & Royal Adelaide Hospitals, Central Adelaide Local Health Network, Adelaide, South Australia, Australia; Basil Hetzel Institute for Translational Health Research, 37 Woodville Road, Woodville South, South Australia 5011, Australia.
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17
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Ikeoka K, Hoshida S, Watanabe T, Shinoda Y, Minamisaka T, Fukuoka H, Inui H, Ueno K, Sakata Y. Pathophysiological Significance of Velocity-Based Microvascular Resistance at Maximal Hyperemia in Peripheral Artery Disease. J Atheroscler Thromb 2018; 25:1128-1136. [PMID: 29491227 PMCID: PMC6224199 DOI: 10.5551/jat.43117] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
AIM Maximal hyperemic response, leading to examination of microvascular resistance in lower-limb lesions is not well understood. This study aimed to investigate the infrainguinal arterial physiological response through a hyperemic condition and the pathophysiological significance of microvascular resistance in peripheral artery disease. METHODS Sixteen limbs with focal stenosis of the superficial femoral artery (SFA) and 16 control limbs were analyzed. We assessed the fractional flow reserve (FFR), vascular flow reserve (VFR), and hyperemic microvascular resistance (h-MR) of the SFA with a pressure/Doppler flow sensor-tipped combination guidewire before and after endovascular therapy (EVT). Skin perfusion pressure (SPP) on both the dorsal and the plantar sides of the foot was measured at baseline before and after the endovascular procedures. RESULTS FFR (p<0.05) and VFR (p<0.05), but not h-MR, improved after EVT. There was no association between h-MR and FFR or VFR before EVT. h-MR was negatively correlated with the dorsal SPP before EVT (r=-0.589, p<0.05). h-MR in patients with high h-MR before EVT significantly decreased after EVT (p<0.05). Patients with high, but not those with low, h-MR before EVT exhibited a significant increase in dorsal and plantar SPP after EVT (p<0.05, each). CONCLUSION EVT for SFA stenosis improved FFR and VFR comprehensively, with no apparent change in h-MR. However, high h-MR before EVT may play a predictive role for limb perfusion improvement associated with h-MR reduction after EVT.
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Affiliation(s)
- Kuniyasu Ikeoka
- Department of Cardiovascular Medicine, Yao Municipal Hospital
| | - Shiro Hoshida
- Department of Cardiovascular Medicine, Yao Municipal Hospital
| | | | | | | | | | - Hirooki Inui
- Department of Cardiovascular Medicine, Yao Municipal Hospital
| | - Keisuke Ueno
- Department of Cardiovascular Medicine, Yao Municipal Hospital
| | - Yasushi Sakata
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
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18
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Vijayan S, Barmby DS, Pearson IR, Davies AG, Wheatcroft SB, Sivananthan M. Assessing Coronary Blood Flow Physiology in the Cardiac Catheterisation Laboratory. Curr Cardiol Rev 2017; 13:232-243. [PMID: 28545351 PMCID: PMC5633718 DOI: 10.2174/1573403x13666170525102618] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2017] [Revised: 05/09/2017] [Accepted: 05/17/2017] [Indexed: 01/10/2023] Open
Abstract
Background: Contemporary management of coronary disease focuses on the treatment of stenoses in the major epicardial vessels. However, myocardial blood flow is known to be contingent on a range of factors in addition to the patency of the epicardial vessels. These include anatomical and physiological factors such as the extent of myocardium supplied by the vessel, systemic blood pres-sure, the natural variation in vascular tone in response to physiological needs which allows for coro-nary autoregulation and pathological factors such as the presence of downstream obstruction to flow due to disease of the small coronary vessels or myocardium. The assessment of clinical effectiveness and adequacy of coronary revascularisation requires the ability to comprehensively and accurately as-sess and measure myocardial perfusion. Conclusion: In this article, we review the current methods of evaluating coronary blood flow and my-ocardial perfusion in the cardiac catheterisation laboratory.
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Affiliation(s)
- Sethumadhavan Vijayan
- Interventional Fellow, Department of Cardiology, Leeds General Infirmary, Great George Street, Leeds, LS1 3EX, United Kingdom
| | - David S Barmby
- Department of Cardiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Ian R Pearson
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Andrew G Davies
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - Stephen B Wheatcroft
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - Mohan Sivananthan
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
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19
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Niccoli G, Indolfi C, Davies JE. Evaluation of intermediate coronary stenoses in acute coronary syndromes using pressure guidewire. Open Heart 2017; 4:e000431. [PMID: 28761673 PMCID: PMC5515130 DOI: 10.1136/openhrt-2016-000431] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 08/15/2016] [Accepted: 08/30/2016] [Indexed: 01/10/2023] Open
Abstract
Fractional flow reserve (FFR) is increasingly used to guide myocardial revascularisation. However, supporting evidence regarding its use originates from studies that have enrolled mainly patients with stable angina, while patients with acute coronary syndromes (ACS) have not been included. Notably, multifactorial microvascular dysfunction and an increased sympathetic tone in patients with ACS may lead to blunted response to adenosine and false-negative results of FFR due to submaximal hyperaemia. This may raise the possibility of deferring treatment of stenosis that instead would have needed dilatation, thus leaving a residual risk of preventable cardiac events. In this literature review, we aim at summarising laboratory and clinical investigations concerning the use of FFR in culprit and non-culprit lesions in ACS. Furthermore, we will report recent data on instantaneous wave-free ratio, an adenosine-free index of functional stenosis severity, in stable coronary artery disease and in patients with ACS.
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Affiliation(s)
- Giampaolo Niccoli
- Department of Cardiovascular Medicine, Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy
| | - Ciro Indolfi
- Division of Cardiology, Department of Medical and Surgical Sciences & URT CNR, Magna Graecia University, Catanzaro, Italy
| | - Justin E Davies
- National Heart and Lung Institute, International Centre for Circulatory Health, Imperial College London and Imperial College Healthcare NHS Trust, London, UK
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20
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Wijntjens GWM, van Lavieren MA, van de Hoef TP, Piek JJ. Physiological assessment of coronary stenosis: a view from the coronary microcirculation. Interv Cardiol 2015. [DOI: 10.2217/ica.15.24] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
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21
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Stuijfzand WJ, Uusitalo V, Kero T, Danad I, Rijnierse MT, Saraste A, Raijmakers PG, Lammertsma AA, Harms HJ, Heymans MW, Huisman MC, Marques KM, Kajander SA, Pietilä M, Sörensen J, Royen NV, Knuuti J, Knaapen P. Relative Flow Reserve Derived From Quantitative Perfusion Imaging May Not Outperform Stress Myocardial Blood Flow for Identification of Hemodynamically Significant Coronary Artery Disease. Circ Cardiovasc Imaging 2015; 8:CIRCIMAGING.114.002400. [DOI: 10.1161/circimaging.114.002400] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Wijnand J. Stuijfzand
- From the Departments of Cardiology (W.J.S., I.D., M.T.R., K.M.M., N.v.R., P.K.), Radiology and Nuclear Medicine (P.G.R., A.A.L, H.J.H., M.C.H.), Department of Epidemiology and Biostatistics (M.W.H.), VU University Medical Center, Amsterdam, The Netherlands; Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland (V.U., A.S., S.A.K, M.P., J.K.); and Department of Nuclear Medicine and PET, Institution of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala
| | - Valtteri Uusitalo
- From the Departments of Cardiology (W.J.S., I.D., M.T.R., K.M.M., N.v.R., P.K.), Radiology and Nuclear Medicine (P.G.R., A.A.L, H.J.H., M.C.H.), Department of Epidemiology and Biostatistics (M.W.H.), VU University Medical Center, Amsterdam, The Netherlands; Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland (V.U., A.S., S.A.K, M.P., J.K.); and Department of Nuclear Medicine and PET, Institution of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala
| | - Tanja Kero
- From the Departments of Cardiology (W.J.S., I.D., M.T.R., K.M.M., N.v.R., P.K.), Radiology and Nuclear Medicine (P.G.R., A.A.L, H.J.H., M.C.H.), Department of Epidemiology and Biostatistics (M.W.H.), VU University Medical Center, Amsterdam, The Netherlands; Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland (V.U., A.S., S.A.K, M.P., J.K.); and Department of Nuclear Medicine and PET, Institution of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala
| | - Ibrahim Danad
- From the Departments of Cardiology (W.J.S., I.D., M.T.R., K.M.M., N.v.R., P.K.), Radiology and Nuclear Medicine (P.G.R., A.A.L, H.J.H., M.C.H.), Department of Epidemiology and Biostatistics (M.W.H.), VU University Medical Center, Amsterdam, The Netherlands; Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland (V.U., A.S., S.A.K, M.P., J.K.); and Department of Nuclear Medicine and PET, Institution of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala
| | - Mischa T. Rijnierse
- From the Departments of Cardiology (W.J.S., I.D., M.T.R., K.M.M., N.v.R., P.K.), Radiology and Nuclear Medicine (P.G.R., A.A.L, H.J.H., M.C.H.), Department of Epidemiology and Biostatistics (M.W.H.), VU University Medical Center, Amsterdam, The Netherlands; Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland (V.U., A.S., S.A.K, M.P., J.K.); and Department of Nuclear Medicine and PET, Institution of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala
| | - Antti Saraste
- From the Departments of Cardiology (W.J.S., I.D., M.T.R., K.M.M., N.v.R., P.K.), Radiology and Nuclear Medicine (P.G.R., A.A.L, H.J.H., M.C.H.), Department of Epidemiology and Biostatistics (M.W.H.), VU University Medical Center, Amsterdam, The Netherlands; Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland (V.U., A.S., S.A.K, M.P., J.K.); and Department of Nuclear Medicine and PET, Institution of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala
| | - Pieter G. Raijmakers
- From the Departments of Cardiology (W.J.S., I.D., M.T.R., K.M.M., N.v.R., P.K.), Radiology and Nuclear Medicine (P.G.R., A.A.L, H.J.H., M.C.H.), Department of Epidemiology and Biostatistics (M.W.H.), VU University Medical Center, Amsterdam, The Netherlands; Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland (V.U., A.S., S.A.K, M.P., J.K.); and Department of Nuclear Medicine and PET, Institution of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala
| | - Adriaan A. Lammertsma
- From the Departments of Cardiology (W.J.S., I.D., M.T.R., K.M.M., N.v.R., P.K.), Radiology and Nuclear Medicine (P.G.R., A.A.L, H.J.H., M.C.H.), Department of Epidemiology and Biostatistics (M.W.H.), VU University Medical Center, Amsterdam, The Netherlands; Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland (V.U., A.S., S.A.K, M.P., J.K.); and Department of Nuclear Medicine and PET, Institution of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala
| | - Hans J. Harms
- From the Departments of Cardiology (W.J.S., I.D., M.T.R., K.M.M., N.v.R., P.K.), Radiology and Nuclear Medicine (P.G.R., A.A.L, H.J.H., M.C.H.), Department of Epidemiology and Biostatistics (M.W.H.), VU University Medical Center, Amsterdam, The Netherlands; Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland (V.U., A.S., S.A.K, M.P., J.K.); and Department of Nuclear Medicine and PET, Institution of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala
| | - Martijn W. Heymans
- From the Departments of Cardiology (W.J.S., I.D., M.T.R., K.M.M., N.v.R., P.K.), Radiology and Nuclear Medicine (P.G.R., A.A.L, H.J.H., M.C.H.), Department of Epidemiology and Biostatistics (M.W.H.), VU University Medical Center, Amsterdam, The Netherlands; Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland (V.U., A.S., S.A.K, M.P., J.K.); and Department of Nuclear Medicine and PET, Institution of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala
| | - Marc C. Huisman
- From the Departments of Cardiology (W.J.S., I.D., M.T.R., K.M.M., N.v.R., P.K.), Radiology and Nuclear Medicine (P.G.R., A.A.L, H.J.H., M.C.H.), Department of Epidemiology and Biostatistics (M.W.H.), VU University Medical Center, Amsterdam, The Netherlands; Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland (V.U., A.S., S.A.K, M.P., J.K.); and Department of Nuclear Medicine and PET, Institution of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala
| | - Koen M. Marques
- From the Departments of Cardiology (W.J.S., I.D., M.T.R., K.M.M., N.v.R., P.K.), Radiology and Nuclear Medicine (P.G.R., A.A.L, H.J.H., M.C.H.), Department of Epidemiology and Biostatistics (M.W.H.), VU University Medical Center, Amsterdam, The Netherlands; Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland (V.U., A.S., S.A.K, M.P., J.K.); and Department of Nuclear Medicine and PET, Institution of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala
| | - Sami A. Kajander
- From the Departments of Cardiology (W.J.S., I.D., M.T.R., K.M.M., N.v.R., P.K.), Radiology and Nuclear Medicine (P.G.R., A.A.L, H.J.H., M.C.H.), Department of Epidemiology and Biostatistics (M.W.H.), VU University Medical Center, Amsterdam, The Netherlands; Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland (V.U., A.S., S.A.K, M.P., J.K.); and Department of Nuclear Medicine and PET, Institution of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala
| | - Mikko Pietilä
- From the Departments of Cardiology (W.J.S., I.D., M.T.R., K.M.M., N.v.R., P.K.), Radiology and Nuclear Medicine (P.G.R., A.A.L, H.J.H., M.C.H.), Department of Epidemiology and Biostatistics (M.W.H.), VU University Medical Center, Amsterdam, The Netherlands; Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland (V.U., A.S., S.A.K, M.P., J.K.); and Department of Nuclear Medicine and PET, Institution of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala
| | - Jens Sörensen
- From the Departments of Cardiology (W.J.S., I.D., M.T.R., K.M.M., N.v.R., P.K.), Radiology and Nuclear Medicine (P.G.R., A.A.L, H.J.H., M.C.H.), Department of Epidemiology and Biostatistics (M.W.H.), VU University Medical Center, Amsterdam, The Netherlands; Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland (V.U., A.S., S.A.K, M.P., J.K.); and Department of Nuclear Medicine and PET, Institution of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala
| | - Niels van Royen
- From the Departments of Cardiology (W.J.S., I.D., M.T.R., K.M.M., N.v.R., P.K.), Radiology and Nuclear Medicine (P.G.R., A.A.L, H.J.H., M.C.H.), Department of Epidemiology and Biostatistics (M.W.H.), VU University Medical Center, Amsterdam, The Netherlands; Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland (V.U., A.S., S.A.K, M.P., J.K.); and Department of Nuclear Medicine and PET, Institution of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala
| | - Juhani Knuuti
- From the Departments of Cardiology (W.J.S., I.D., M.T.R., K.M.M., N.v.R., P.K.), Radiology and Nuclear Medicine (P.G.R., A.A.L, H.J.H., M.C.H.), Department of Epidemiology and Biostatistics (M.W.H.), VU University Medical Center, Amsterdam, The Netherlands; Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland (V.U., A.S., S.A.K, M.P., J.K.); and Department of Nuclear Medicine and PET, Institution of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala
| | - Paul Knaapen
- From the Departments of Cardiology (W.J.S., I.D., M.T.R., K.M.M., N.v.R., P.K.), Radiology and Nuclear Medicine (P.G.R., A.A.L, H.J.H., M.C.H.), Department of Epidemiology and Biostatistics (M.W.H.), VU University Medical Center, Amsterdam, The Netherlands; Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland (V.U., A.S., S.A.K, M.P., J.K.); and Department of Nuclear Medicine and PET, Institution of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala
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22
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van Lavieren MA, van de Hoef TP, Piek JJ. Coronary wedge pressure and collateral flow contribution: not a dichotomy! EUROINTERVENTION 2014; 9:1485-8. [PMID: 24755391 DOI: 10.4244/eijv9i12a250] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Martijn A van Lavieren
- AMC Heart Center, Academic Medical Center - University of Amsterdam, Amsterdam, The Netherlands
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