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Mangiacapra F, Toth GG, Paolucci L, Wyffels E, Bartunek J, Vanderheyden M, De Bruyne B, Barbato E. Gender-Based Specificities of Fractional Flow Reserve Measurement. Catheter Cardiovasc Interv 2025; 105:435-441. [PMID: 39658875 DOI: 10.1002/ccd.31313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2024] [Accepted: 11/18/2024] [Indexed: 12/12/2024]
Abstract
BACKGROUND The relationship between angiographic findings and fractional flow reserve (FFR) according to gender is currently unknown. AIMS To examine gender-based differences in the concordance between angiographic and functional assessment of coronary stenosis severity. METHODS We examined 3770 coronary stenoses of stable patients undergoing both quantitative coronary angiography and FFR measurements in at least one coronary stenosis. RESULTS Median FFR values were higher in female as compared with male patients (0.84 vs. 0.81, p < 0.001) in the overall cohort and in the first three quartiles of diameter stenosis (DS). At receiver operator characteristics (ROC) analysis, DS was effective in predicting ischemic FFR values in both men and women. A 50% DS was the optimal cut off to identify functionally significant stenoses in the entire cohort and in male patients. In females, a higher DS threshold (≥ 59%) significantly improved lesions classification (69.4% vs. 72.4%, p = 0.034), yet at the cost of an increased false negatives rate (10.5% vs. 20.8%, p < 0.001). A lower cut-off of 50% showed a superior diagnostic accuracy for ischemic FFR values (i.e., FFR values ≤ 0.80, AUC: 0.697 vs. 0.661, p = 0.006). Female gender was independently associated with a reduced risk of ischemic FFR (OR 0.51 95% CI [0.43-0.61]). CONCLUSIONS Female patients show higher FFR values across different DS thresholds compared to male patients. A DS ≥ 50% is the best threshold to identify ischemic FFR in both males and females. A higher threshold of DS (≥ 59%) is associated with a significant improvement in lesion classification, despite leading to increased false negatives rate.
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Affiliation(s)
- Fabio Mangiacapra
- Research Unit of Cardiovascular Science, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
- Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Gabor G Toth
- Divion of Cardiology, Department of Medicine, University Heart Center Graz, Medical University of Graz, Graz, Austria
| | - Luca Paolucci
- Research Unit of Cardiovascular Science, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
- Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Eric Wyffels
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium
| | | | | | | | - Emanuele Barbato
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy
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Chen Y, Gao L, Vogel B, Tian F, Jin Q, Guo J, Sun Z, Yang W, Jin Z, Yu B, Fu G, Pu J, Qu X, Zhang Q, Zhao Y, Yu L, Guan C, Tu S, Qiao S, Xu B, Mehran R, Song L. Sex Differences in Clinical Outcomes Associated With Quantitative Flow Ratio-Guided Percutaneous Coronary Intervention. JACC. ASIA 2024; 4:201-212. [PMID: 38463683 PMCID: PMC10920051 DOI: 10.1016/j.jacasi.2023.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 09/18/2023] [Accepted: 09/29/2023] [Indexed: 03/12/2024]
Abstract
Background FAVOR III China (Comparison of Quantitative Flow Ratio Guided and Angiography Guided Percutaneous Intervention in Patients with Coronary Artery Disease) reported improved clinical outcomes in quantitative flow ratio (QFR) relative to angiography-guided percutaneous coronary intervention (PCI), but the clinical impact of QFR-guided PCI according to sex remains unknown. Objectives The authors sought to compare sex differences in the 2-year clinical benefits of a QFR-guided PCI strategy and to evaluate the differences in outcomes between men and women undergoing contemporary PCI. Methods This study involved a prespecified subgroup analysis of the FAVOR III China trial, in which women and men were randomized to a QFR-guided strategy or a standard angiography-guided strategy. Sex differences in clinical benefit of the QFR guidance were analyzed for major adverse cardiac events (MACE), a composite of all-cause death, myocardial infarction, or ischemia-driven revascularization within 2 years. Results A total of 1,126 women and 2,699 men were eligible and the occurrence of 2-year MACE was similar between women and men (10.3% vs 10.5%; P = 0.96). Compared with an angiography-guided strategy, a QFR-guided strategy resulted in a 7.9% and 9.7% reduction in PCI rates in men and women, respectively. A QFR-guided strategy resulted in similar relative risk reductions for 2-year MACE in women (8.0% vs 12.7%; HR: 0.62; 95% CI: 0.42-0.90) and men (8.7% vs 12.4%; HR: 0.69; 95% CI: 0.54-0.87) (Pinteraction = 0.61). Furthermore, QFR values were not significantly different between men and women with various angiographic stenosis categories. Conclusions A QFR-guided PCI strategy resulted in improved MACE in both men and women at 2 years compared with an angiography-guided PCI strategy. The FAVOR III China Study [FAVOR III China]; (NCT03656848).
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Affiliation(s)
- Yundai Chen
- Department of Cardiology, the First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Lei Gao
- Senior Department of Cardiology, the Sixth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Birgit Vogel
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Feng Tian
- Senior Department of Cardiology, the Sixth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Qinhua Jin
- Senior Department of Cardiology, the Sixth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Jun Guo
- Senior Department of Cardiology, the Sixth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Zhijun Sun
- Senior Department of Cardiology, the Sixth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Weixian Yang
- Department of Cardiology, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zening Jin
- Department of Cardiology, Beijing Tiantan Hospital, Capital Medical University, Beijing China
| | - Bo Yu
- Department of Cardiology, the Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Guosheng Fu
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jun Pu
- Department of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xinkai Qu
- Department of Cardiology, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Qi Zhang
- Department of Cardiology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yanyan Zhao
- Medical Research and Biometrics Center, National Center for Cardiovascular Diseases, Beijing, China
| | - Lilei Yu
- Department of Cardiology, Renmin Hospital of Wuhan University, Cardiac Autonomic Nervous System Research Center of Wuhan University, Cardiovascular Research Institute, Wuhan University; Hubei Key Laboratory of Cardiology, Wuhan, China
| | - Changdong Guan
- Department of Cardiology, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shengxian Tu
- Biomedical Instrument Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Shubin Qiao
- Department of Cardiology, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bo Xu
- Department of Cardiology, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital Chinese Academy of Medical Sciences, Shenzhen, China
| | - Roxana Mehran
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Lei Song
- Department of Cardiology, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - FAVOR III China Study Group
- Department of Cardiology, the First Medical Center of Chinese PLA General Hospital, Beijing, China
- Senior Department of Cardiology, the Sixth Medical Center of Chinese PLA General Hospital, Beijing, China
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Cardiology, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Department of Cardiology, Beijing Tiantan Hospital, Capital Medical University, Beijing China
- Department of Cardiology, the Second Affiliated Hospital of Harbin Medical University, Harbin, China
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Department of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Department of Cardiology, Huadong Hospital Affiliated to Fudan University, Shanghai, China
- Department of Cardiology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
- Medical Research and Biometrics Center, National Center for Cardiovascular Diseases, Beijing, China
- Department of Cardiology, Renmin Hospital of Wuhan University, Cardiac Autonomic Nervous System Research Center of Wuhan University, Cardiovascular Research Institute, Wuhan University; Hubei Key Laboratory of Cardiology, Wuhan, China
- Biomedical Instrument Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
- National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital Chinese Academy of Medical Sciences, Shenzhen, China
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Campo Dall'Orto C, Eurípedes Vilela L, Vilella Pinto Filho G, Raphael da Silva M. Impact of Sex Differences on the Outcomes of Coronary Invasive Physiological Assessment: Long-Term Follow-Up in a Brazilian Population. WOMEN'S HEALTH REPORTS (NEW ROCHELLE, N.Y.) 2024; 5:93-103. [PMID: 38404671 PMCID: PMC10890956 DOI: 10.1089/whr.2023.0087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 01/10/2023] [Indexed: 02/27/2024]
Abstract
Objective This study aimed to evaluate the rate of major adverse cardiac events (MACEs; the sum of death, myocardial infarction, and revascularization rates) according to interventional strategies guided by invasive physiological methods in both sexes in a Brazilian population during long-term follow-up for an average of 2 years. Methods This retrospective single-center study included 151 consecutive patients (232 lesions) between January 2018 and January 2022. The participants were divided into two groups: the female group (FG), comprising 59 patients with 88 lesions, and the male group (MG), comprising 92 patients with 144 lesions. Results The FG had a greater mean age (FG: 67.96 ± 13.12 vs. MG: 62.36 ± 12.01 years, p = 0.009) and lower mean creatinine clearance (FG: 79.35 ± 38.63 vs. MG: 92.02 ± 38.62 mL/min, p = 0.02) than did the MG. The percentage of lesions in the left main coronary artery was higher in the FG than in the MG (12.5% vs. 2.78%, p = 0.006). The mean follow-up time was longer in the MG than in the FG (795.61 ± 350 vs. 619.19 ± 318 days, respectively; p = 0.001). MACE occurred in 11.86% and 13.04% of patients in the FG and MG, respectively (p = 0.850). Secondary outcomes, such as death, reinfarction, and the need for new revascularization, showed no significant between-sex differences. Conclusions Our study demonstrated the safety of invasive physiological methods to determine coronary revascularization in both male and female patients in a Brazilian population, as evidenced by the low rates of adverse cardiac events and death after a long-term follow-up.
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Affiliation(s)
- Clarissa Campo Dall'Orto
- Department of Hemodynamic and Interventional Cardiology, Advanced Hemodynamic Therapy Center, Brazilian Society of Health Support Hospital, Teixeira de Freitas, Bahia, Brazil
| | - Lara Eurípedes Vilela
- Department of Hemodynamic and Interventional Cardiology, Advanced Hemodynamic Therapy Center, Brazilian Society of Health Support Hospital, Teixeira de Freitas, Bahia, Brazil
| | - Gilvan Vilella Pinto Filho
- Department of Hemodynamic and Interventional Cardiology, Advanced Hemodynamic Therapy Center, Brazilian Society of Health Support Hospital, Teixeira de Freitas, Bahia, Brazil
| | - Marcos Raphael da Silva
- Department of Hemodynamic and Interventional Cardiology, Advanced Hemodynamic Therapy Center, Brazilian Society of Health Support Hospital, Teixeira de Freitas, Bahia, Brazil
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Chantadansuwan T, Patumanond J, Charernboon T, Piyayotai D. Factors Predicting 150 and 200 Microgram Adenosine Requirement during Four Increasing Doses of Intracoronary Adenosine Bolus Fractional Flow Reserve Assessment. Diagnostics (Basel) 2022; 12:diagnostics12092076. [PMID: 36140478 PMCID: PMC9498048 DOI: 10.3390/diagnostics12092076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 08/09/2022] [Accepted: 08/24/2022] [Indexed: 01/09/2023] Open
Abstract
Direct intracoronary adenosine bolus is an excellent alternative to intravenous adenosine fractional flow reserve (FFR) measurement. This study, during four increasing adenosine boluses (50, 100, 150, and 200 mcg), aimed to explore clinical and angiographic predictors of coronary stenotic lesions for which the significant ischemic FFR (FFR ≤ 0.8) occurred at 150 and 200 mcg adenosine doses. Data from 1055 coronary lesions that underwent FFR measurement at the Central Chest Institute of Thailand from August 2011 to July 2021 were included. Baseline clinical and angiographic characteristics were analyzed. The FFR ≤ 0.8 occurred at adenosine 150 and 200 mcg boluses in 47 coronary lesions, while the FFR ≤ 0.8 occurred at adenosine 50 and 100 mcg boluses in 186 coronary lesions. After univariable and multivariable logistic regression analyses, four characteristics, including male sex, younger age, non-smoking status, and FFR procedure of RCA, were predictors of the occurrence of FFR ≤ 0.8 at adenosine 150 and 200 mcg doses. Combining all four predictors as a predictive model resulted in an AuROC of 0.72 (95% CI: 0.68–0.76), an 86% negative predictive value. Comparing these four predictors, the FFR procedure of RCA gave the most predictive power, with the AuROC of 0.60 (95% CI: 0.56–0.63).
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Affiliation(s)
- Thamarath Chantadansuwan
- Department of Cardiology, Central Chest Institute of Thailand, Nonthaburi 11000, Thailand
- Correspondence:
| | - Jayanton Patumanond
- Center for Clinical Epidemiology and Clinical Statistics, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Thammanard Charernboon
- Department of Clinical Epidemiology, Faculty of Medicine, Thammasat University, Pathum Thani 12121, Thailand
| | - Dilok Piyayotai
- Department of Internal Medicine, Faculty of Medicine, Thammasat University, Pathum Thani 12121, Thailand
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Marchese N, Barbato E, Di Gioia G, Stanislao M, Valle G, Copetti M, Pellegrini G, Vigna C. Intracoronary pressures to predict myocardial viability in patients with ischemic left ventricular dysfunction. Catheter Cardiovasc Interv 2022; 99:271-279. [DOI: 10.1002/ccd.30065] [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: 09/15/2021] [Revised: 12/07/2021] [Accepted: 12/25/2021] [Indexed: 11/12/2022]
Affiliation(s)
- Nicola Marchese
- Unit of Cardiology Fondazione IRCCS Casa Sollievo della Sofferenza San Giovanni Rotondo Foggia Italy
| | - Emanuele Barbato
- Cardiovascular Research Center OLV Hospital Aalst Belgium
- Department of Advanced Biomedical Sciences University Federico II Naples Italy
| | - Giuseppe Di Gioia
- Department of Advanced Biomedical Sciences University Federico II Naples Italy
| | - Mario Stanislao
- Unit of Nuclear Medicine Fondazione IRCCS Casa Sollievo della Sofferenza San Giovanni Rotondo Foggia Italy
| | - Guido Valle
- Unit of Nuclear Medicine Fondazione IRCCS Casa Sollievo della Sofferenza San Giovanni Rotondo Foggia Italy
| | - Massimiliano Copetti
- Unit of Biostatistics Fondazione IRCCS Casa Sollievo della Sofferenza San Giovanni Rotondo Foggia Italy
| | - Giorgia Pellegrini
- Unit of Statistical Sciences Alma Mater Studiorum University of Bologna Bologna Italy
| | - Carlo Vigna
- Unit of Cardiology Fondazione IRCCS Casa Sollievo della Sofferenza San Giovanni Rotondo Foggia Italy
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Improving PCI Outcomes Using Postprocedural Physiology and Intravascular Imaging. JACC Cardiovasc Interv 2021; 14:2415-2430. [PMID: 34794649 DOI: 10.1016/j.jcin.2021.08.069] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 07/07/2021] [Accepted: 08/03/2021] [Indexed: 11/24/2022]
Abstract
Although clinical outcomes after percutaneous coronary intervention (PCI) are improving, the long-term risk for target vessel failure remains concerning. Although the application of intravascular imaging and physiological indexes significantly improves outcomes, their routine use in practice remains limited. Nevertheless, merely using these modalities is not enough, and to truly improve patient outcomes, optimal intravascular dimensions with minimal vascular injury should be targeted. When assessing post-PCI results using either type of physiological or imaging technology, a broad spectrum of stent- and vessel-related anomalies can be expected. As not all of these issues warrant treatment, a profound knowledge of what to expect and how to recognize and when to treat these intraluminal problems is needed. Additionally, promising new modalities such as angiography-derived coronary physiology and hybrid imaging catheters are becoming available. The authors provide an overview of the currently available tools and techniques to define suboptimal PCI and when to apply these technologies to improve outcomes.
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7
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Hou H, Zhao Q, Qu C, Sun M, Liu Q, Huang X, Wang X, Zhang R, Du L, Hou J, Yu B. Sex Differences in the Non-infarct-Related Artery-Based Quantitative Flow Ratio in Patients With ST-Elevation Myocardial Infarction: A Retrospective Study. Front Cardiovasc Med 2021; 8:726307. [PMID: 34631827 PMCID: PMC8498023 DOI: 10.3389/fcvm.2021.726307] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 08/31/2021] [Indexed: 12/04/2022] Open
Abstract
Introduction: It has been reported that sex has well-established relationships with the prevalence of coronary artery disease (CAD) and the major adverse cardiovascular events. Compared with men, the difference of coronary artery and myocardial characteristics in women has effects on anatomical and functional evaluations. Quantitative flow ratio (QFR) has been shown to be effective in assessing the hemodynamic relevance of lesions in stable coronary disease. However, its suitability in acute myocardial infarction patients is unknown. This study aimed to evaluate the sex differences in the non-infarct-related artery (NIRA)-based QFR in patients with ST-elevation myocardial infarction (STEMI). Methods: In this study, 353 patients with STEMI who underwent angiographic cQFR assessment and interventional therapy were included. According to contrast-flow QFR (cQFR) standard operating procedures: reliable software was used to modeling the hyperemic flow velocity derived from coronary angiography in the absence of pharmacologically induced hyperemia. 353 patients were divided into two groups according to sex. A cQFR ≤0.80 was considered hemodynamically significant, whereas invasive coronary angiography (ICA) luminal stenosis ≥50% was considered obstructive. Demographics, clinical data, NIRA-related anatomy, and functional cQFR values were recorded. Clinical outcomes included the NIRA reclassification rate between men and women, according to the ICA and cQFR assessments. Results: Women were older and had a higher body mass index (BMI) than men. The levels of diastolic blood pressure, troponin I, peak creatine kinase-MB, low-density lipoprotein cholesterol, N terminal pro B-type natriuretic peptide, stent diameter, and current smoking rate were found to be significantly lower in the female group than in the male group. Women had a lower likelihood of a positive cQFR ≤0.80 for the same degree of stenosis and a lower rate of NIRA revascularization. Independent predictors of positive cQFR included male sex and diameter stenosis (DS) >70%. Conclusions: cQFR values differ between the sexes, as women have a higher cQFR value for the same degree of stenosis. The findings suggest that QFR variations by sex require specific interpretation, as these differences may affect therapeutic decision-making and clinical outcomes.
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Affiliation(s)
- Hongli Hou
- Department of Cardiology, The 2nd Affiliated Hospital of Harbin Medical University, Harbin, China.,Department of Cardiology, Chenjiaqiao Hospital of Chongqing Medical and Pharmaceutical College, Chongqing, China
| | - Qi Zhao
- Department of Cardiology, The 1st Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Chao Qu
- Department of Cardiology, Heilongjiang Provincial People's Hospital, Harbin, China
| | - Meng Sun
- The Key Laboratory of Myocardial Ischemia, Harbin Medical University, Ministry of Education, Harbin, China
| | - Qi Liu
- Department of Cardiology, The 2nd Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Xingtao Huang
- Department of Cardiology, The 2nd Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Xuedong Wang
- Department of Cardiology, The 2nd Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Ruoxi Zhang
- Department of Cardiology, The 2nd Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Lifeng Du
- Department of Cardiology, Hegang People's Hospital, Hegang, China
| | - Jingbo Hou
- Department of Cardiology, The 2nd Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Bo Yu
- Department of Cardiology, The 2nd Affiliated Hospital of Harbin Medical University, Harbin, China
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Velagapudi P, Altin SE, Schneider MD, Alasnag M. Sex Differences in Intracoronary Imaging and Functional Evaluation of Coronary Arteries. CURRENT CARDIOVASCULAR IMAGING REPORTS 2021. [DOI: 10.1007/s12410-021-09557-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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9
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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: 32] [Impact Index Per Article: 6.4] [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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Hadadi L, Șerban RC, Juhász T, Țepeș O, Somkereki C, Demjén Z, Adorján I, Lupu S. Renal dysfunction is associated with lower incidence of positive fractional flow reserve values in patients with severe hypertension. Minerva Cardioangiol 2020; 68:261-267. [PMID: 32100986 DOI: 10.23736/s0026-4725.20.05103-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Renal dysfunction, an important predictor of cardiovascular mortality, is paradoxically associated with a lower incidence of positive coronary fractional flow reserve (FFR) values, possibly due to renal disease-associated myocardial microvascular dysfunction. It is unknown if this relationship is influenced by arterial hypertension, a condition strongly associated with renal- and microvascular dysfunction. METHODS The incidence of positive (<0.81) FFR values was retrospectively evaluated in consecutive patients with intermediate severity coronary artery lesions that were either associating or not associating renal dysfunction (creatinine clearance, CrCl <90 mL/min/1.73 m2), and had mild/moderate or severe arterial hypertension (treated by <3 or ≥3 different drugs). RESULTS Positive FFR values were found in 49.5% of the 109 included patients, with a significantly lower incidence in those with renal dysfunction: 23 vs. 31 cases (39.7% vs. 60.8%, P=0.03). However, uni- and multivariate subpopulation analysis evidenced that renal dysfunction was a significant independent predictor of fewer positive FFR results only in severely hypertensive patients (univariate P values for mild/moderate and severe hypertension: 0.80 and <0.01, respectively; multivariate P in severely hypertensive patients: 0.04). This categorization significantly restricted the number of borderline FFR results (0.75-0.80) where measurement interpretation could be challenging because of renal dysfunction (from 13.8% to 4.6% of the whole study population, P=0.03). CONCLUSIONS In the current study renal dysfunction was independently associated with a significantly higher incidence of negative FFR results in patients with intermediate severity coronary artery lesions only in the presence of severe arterial hypertension. This observation should be confirmed by large-scale prospective clinical trials.
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Affiliation(s)
- László Hadadi
- Department of Interventional Cardiology, Emergency Institute for Cardiovascular Diseases and Transplantation, Tîrgu Mureș, Romania -
| | - Răzvan C Șerban
- Department of Interventional Cardiology, Emergency Institute for Cardiovascular Diseases and Transplantation, Tîrgu Mureș, Romania
| | - Tamás Juhász
- Department of Internal Medicine, University of Medicine and Pharmacy of Tîrgu Mureș, Tîrgu Mureș, Romania
| | - Oana Țepeș
- Department of Adult Cardiology, Emergency Institute for Cardiovascular Diseases and Transplantation of Tîrgu Mureș, Tîrgu Mureș, Romania
| | - Cristina Somkereki
- Department of Internal Medicine, University of Medicine and Pharmacy of Tîrgu Mureș, Tîrgu Mureș, Romania.,Department of Adult Cardiology, Emergency Institute for Cardiovascular Diseases and Transplantation of Tîrgu Mureș, Tîrgu Mureș, Romania
| | - Zoltán Demjén
- Department of Adult Cardiology, Emergency Institute for Cardiovascular Diseases and Transplantation of Tîrgu Mureș, Tîrgu Mureș, Romania
| | - István Adorján
- Department of Adult Cardiology, Emergency Institute for Cardiovascular Diseases and Transplantation of Tîrgu Mureș, Tîrgu Mureș, Romania
| | - Silvia Lupu
- Department of Internal Medicine, University of Medicine and Pharmacy of Tîrgu Mureș, Tîrgu Mureș, Romania.,Department of Adult Cardiology, Emergency Institute for Cardiovascular Diseases and Transplantation of Tîrgu Mureș, Tîrgu Mureș, Romania
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11
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Murai T, van de Hoef TP, van den Boogert TP, Wijntjens GW, Stegehuis VE, Echavarria-Pinto M, Hoshino M, Yonetsu T, Planken RN, Henriques JP, Escaned J, Kakuta T, Piek JJ. Quantification of Myocardial Mass Subtended by a Coronary Stenosis Using Intracoronary Physiology. Circ Cardiovasc Interv 2019; 12:e007322. [DOI: 10.1161/circinterventions.118.007322] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Background:
In patients with stable coronary artery disease, the amount of myocardium subtended by coronary stenoses constitutes a major determinant of prognosis, as well as of the benefit of coronary revascularization. We devised a novel method to estimate partial myocardial mass (PMM; ie, the amount of myocardium subtended by a stenosis) during physiological stenosis interrogation. Subsequently, we validated the index against equivalent PMM values derived from applying the Voronoi algorithm on coronary computed tomography angiography.
Methods:
Based on the myocardial metabolic demand and blood supply, PMM was calculated as follows: PMM (g)=APV×D
2
×π/(1.24×10
−
3
×HR×sBP+1.6), where APV indicates average peak blood flow velocity; D, vessel diameter; HR, heart rate; and sBP, systolic blood pressure. We calculated PMM to 43 coronary vessels (32 patients) interrogated with pressure and Doppler guidewires, and compared it with computed tomography–based PMM.
Results:
Median PMM was 15.8 g (Q1, Q3: 11.7, 28.4 g) for physiology-based PMM, and 17.0 g (Q1, Q3: 12.5, 25.9 g) for computed tomography–based PMM (
P
=0.84). Spearman rank correlation coefficient was 0.916 (
P
<0.001), and Passing-Bablok analysis revealed absence of both constant and proportional differences (coefficient A: −0.9; 95% CI, −4.5 to 0.9; and coefficient B, 1.00; 95% CI, 0.91 to 1.25]. Bland-Altman analysis documented a mean bias of 0.5 g (limit of agreement: −9.1 to 10.2 g).
Conclusions:
Physiology-based calculation of PMM in the catheterization laboratory is feasible and can be accurately performed as part of functional stenosis assessment.
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Affiliation(s)
- Tadashi Murai
- Heart Center, Amsterdam UMC, the Netherlands (T.M., T.P.v.d.H., T.P.W.v.d.B., G.W.M.W., V.E.S., J.P.S.H., J.J.P.)
| | - Tim P. van de Hoef
- Heart Center, Amsterdam UMC, the Netherlands (T.M., T.P.v.d.H., T.P.W.v.d.B., G.W.M.W., V.E.S., J.P.S.H., J.J.P.)
| | - Thomas P.W. van den Boogert
- Heart Center, Amsterdam UMC, the Netherlands (T.M., T.P.v.d.H., T.P.W.v.d.B., G.W.M.W., V.E.S., J.P.S.H., J.J.P.)
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, the Netherlands (T.P.W.v.d.B., R.N.P.)
| | - Gilbert W.M. Wijntjens
- Heart Center, Amsterdam UMC, the Netherlands (T.M., T.P.v.d.H., T.P.W.v.d.B., G.W.M.W., V.E.S., J.P.S.H., J.J.P.)
| | - Valérie E. Stegehuis
- Heart Center, Amsterdam UMC, the Netherlands (T.M., T.P.v.d.H., T.P.W.v.d.B., G.W.M.W., V.E.S., J.P.S.H., J.J.P.)
| | | | - Masahiro Hoshino
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan (M.H., T.Y., T.K.)
| | - Taishi Yonetsu
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan (M.H., T.Y., T.K.)
| | - R. Nils Planken
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, the Netherlands (T.P.W.v.d.B., R.N.P.)
| | - José P.S. Henriques
- Heart Center, Amsterdam UMC, the Netherlands (T.M., T.P.v.d.H., T.P.W.v.d.B., G.W.M.W., V.E.S., J.P.S.H., J.J.P.)
| | - Javier Escaned
- Department of Cardiology, Hospital Clinico San Carlos IDISSC, Universidad Complutense de Madrid, Spain (J.E.)
| | - Tsunekazu Kakuta
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan (M.H., T.Y., T.K.)
| | - Jan J. Piek
- Heart Center, Amsterdam UMC, the Netherlands (T.M., T.P.v.d.H., T.P.W.v.d.B., G.W.M.W., V.E.S., J.P.S.H., J.J.P.)
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12
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Gori T, Anadol R. Tako-Tsubo syndrome, spontaneous coronary dissection and microvascular disease: Sex-differences. Clin Hemorheol Microcirc 2018; 70:375-379. [PMID: 30320565 DOI: 10.3233/ch-189302] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Up to 50% of the patients undergoing coronary angiography present no epicardial disease. Most of these patients are women. Takotsubo cardiomyopathy, coronary microvascular dysfunction, and spontaneous coronary artery dissection are the most common syndromes that affect these patients. Their mechanisms are complex, with a interplay between neurohormonal factors and a number of other systems. The present review describes how changes in the estrogen state may lead to changes in vasomotor tone and endothelial dysfunction which result in coronary epicardial and microvascular spasm and coronary arterial wall instability in these three conditions. The sex-dependent differences in prevalence, pathogenesis, and prognosis are described.
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Affiliation(s)
- Tommaso Gori
- Kardiologie I, Zentrum für Kardiologie, University Medical Center Mainz and DZHK standort Rhein-Main, Germany
| | - Remzi Anadol
- Kardiologie I, Zentrum für Kardiologie, University Medical Center Mainz and DZHK standort Rhein-Main, Germany
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13
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Verdoia M, Erbetta R, Sagazio E, Barbieri L, Negro F, Suryapranata H, Kedhi E, De Luca G. Impact of increasing dose of intracoronary adenosine on peak hyperemia duration during fractional flow reserve assessment. Int J Cardiol 2018; 284:16-21. [PMID: 30293665 DOI: 10.1016/j.ijcard.2018.09.088] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Revised: 07/30/2018] [Accepted: 09/24/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Fractional Flow Reserve (FFR) is currently indicated as a first line strategy for the functional assessment of intermediate coronary stenoses. However, the protocol for inducing hyperemia still lacks standardization. Intracoronary adenosine boli, with a progressive increase to high-dosage, have been proposed as a sensitive and accurate strategy for the classification of coronary stenoses, although being potentially affected by the achievement of plateau of the effect and by a less prolonged and stable hyperemia as compared to intravenous administration. Therefore, the aim of the present study was to define the conditioning parameters and assess the impact of increasing-dose intracoronary adenosine on peak hyperemia duration in patients undergoing FFR for intermediate coronary stenoses. METHODS FFR was assessed in patients with intermediate (40 to 70%) lesions by pressure-recording guidewire (Prime Wire, Volcano), after induction of hyperemia with intracoronary boli of adenosine (from 60 to 1440 μg, with dose doubling at each step). Hyperemic duration was defined as the time for the variation form minimum FFR ± 0.02 and time to recovery till baseline values. RESULTS We included 87 patients, undergoing FFR evaluation of 101 lesions. Mean peak hyperemia duration and time to recovery significantly increased with adenosine doses escalation (p = 0.02 and p < 0.001). Peak hyperemia duration and time to recovery with 1440 μg adenosine were 14.5 ± 12.6 s and 45.2 ± 30.7 s, respectively. Hyperemia duration was not related to Quantitative Coronary Angiography (QCA) parameters or FFR values. In fact, a similar increase in the time of hyperemic peak was noted when comparing patients with positive or negative FFR (pbetween = 0.87) or patients with lesions < or ≥20 mm (pbetween = 0.92) and lesions involving left main coronary or proximal left anterior descending artery (LAD) (pbetween = 0.07). A linear relationship was observed between time to recovery and FFR variations, with a greater time to baseline required in patients with FFR ≤ 0.80 (p = 0.003) and in lesions ≥ 20 mm (p = 0.006), but not in LAD/LM lesions (p = 0.55). CONCLUSIONS The present study shows a progressive raise in the duration of peak hyperemia and time to recovery, after the administration of increasing doses of intracoronary adenosine for the assessment of FFR. Therefore, considering the potential advantages of a high-dose adenosine protocol, allowing a more prolonged hyperemia and a more precise and reliable measurement of FFR, further larger studies with such FFR strategy should certainly be advocated to confirm its safety and benefits, before its routinely use recommendation.
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Affiliation(s)
- Monica Verdoia
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy
| | - Riccardo Erbetta
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy
| | - Emanuele Sagazio
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy
| | - Lucia Barbieri
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy; ASST Santi Paolo e Carlo, Milano, Italy
| | - Federica Negro
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy
| | | | - Elvin Kedhi
- Division of Cardiology, ISALA Hospital, Zwolle, the Netherlands
| | - Giuseppe De Luca
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy.
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14
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Shah SV, Zimmermann FM, Johnson NP, Nishi T, Kobayashi Y, Witt N, Berry C, Jeremias A, Koo BK, Esposito G, Rioufol G, Park SJ, Oldroyd KG, Barbato E, Pijls NHJ, De Bruyne B, Fearon WF. Sex Differences in Adenosine-Free Coronary Pressure Indexes: A CONTRAST Substudy. JACC Cardiovasc Interv 2018; 11:1454-1463. [PMID: 30031722 DOI: 10.1016/j.jcin.2018.03.030] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 03/21/2018] [Accepted: 03/21/2018] [Indexed: 01/18/2023]
Abstract
OBJECTIVES The goal of this study was to investigate sex differences in adenosine-free coronary pressure indexes. BACKGROUND Several adenosine-free coronary pressure wire indexes have been proposed to assess the functional significance of coronary artery lesions; however, there is a theoretical concern that sex differences may affect diagnostic performance because of differences in resting flow and distal myocardial mass. METHODS In this CONTRAST (Can Contrast Injection Better Approximate FFR Compared to Pure Resting Physiology?) substudy, contrast fractional flow reserve (cFFR), obtained during contrast-induced submaximal hyperemia, the instantaneous wave-free ratio (iFR), and distal/proximal coronary pressure ratio (Pd/Pa) were compared with fractional flow reserve (FFR) in 547 men and 216 women. Using FFR ≤0.8 as a reference, the diagnostic performance of each index was compared. RESULTS Men and women had similar diameter stenosis (p = 0.78), but women were less likely to have FFR ≤0.80 than men (42.5% vs. 51.5%, p = 0.04). Sensitivity was similar among cFFR, iFR, and Pd/Pa when comparing women and men, respectively (cFFR, 77.5% vs. 75.3%; p = 0.69; iFR, 84.9% vs. 79.4%; p = 0.30; Pd/Pa, 78.8% vs. 77.3%; p = 0.78). cFFR was more specific than iFR or Pd/Pa regardless of sex (cFFR, 94.3% vs. 95.8%; p = 0.56; iFR, 75.6% vs. 80.1%; p = 0.38; Pd/Pa, 80.6% vs. 78.7%; p = 0.69). By receiver-operating characteristic curve analysis, cFFR provided better diagnostic accuracy than resting indexes irrespective of sex (p ≤ 0.0001). CONCLUSIONS Despite the theoretical concern, the diagnostic sensitivity and specificity of cFFR, iFR, and Pd/Pa did not differ between the sexes. Irrespective of sex, cFFR provides the best diagnostic performance.
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Affiliation(s)
- Sonia V Shah
- Stanford University School of Medicine, Stanford, California; Stanford Cardiovascular Institute, Stanford, California
| | | | - Nils P Johnson
- McGovern Medical School at UTHealth and Memorial Hermann Hospital, Houston, Texas
| | - Takeshi Nishi
- Stanford University School of Medicine, Stanford, California; Stanford Cardiovascular Institute, Stanford, California
| | - Yuhei Kobayashi
- Stanford University School of Medicine, Stanford, California; Stanford Cardiovascular Institute, Stanford, California
| | - Nils Witt
- Karolinska Institutet, Södersjukhuset, Stockholm, Sweden
| | - Colin Berry
- West of Scotland Heart and Lung Center, Golden Jubilee National Hospital, Clydebank, United Kingdom; British Heart Foundation Glasgow Cardiovascular Research Center, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Allen Jeremias
- Division of Cardiovascular Medicine, Stony Brook University Medical Center, Stony Brook, New York; Cardiovascular Research Foundation, New York, New York
| | - Bon-Kwon Koo
- Seoul National University Hospital, Seoul, South Korea
| | | | | | - Seung-Jung Park
- University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Keith G Oldroyd
- West of Scotland Heart and Lung Center, Golden Jubilee National Hospital, Clydebank, United Kingdom
| | - Emanuele Barbato
- University of Naples Federico II, Naples, Italy; Cardiovascular Center Aalst, Aalst, Belgium
| | - Nico H J Pijls
- Catharina Hospital, Eindhoven, the Netherlands; Eindhoven University of Technology, Eindhoven, the Netherlands
| | | | - William F Fearon
- Stanford University School of Medicine, Stanford, California; Stanford Cardiovascular Institute, Stanford, California.
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15
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Abstract
PURPOSE OF THE REVIEW Paradoxically, although women have a lower burden of coronary atherosclerosis, they experience more symptoms, more frequent hospitalizations, and a worse prognosis compared to men. This is in part due to biological variations in pathophysiology between the two sexes, and in part related to inadequate understanding of these differences, subconscious referral bias, and suboptimal application of existing women-specific guidelines. We sought to review the contemporary literature and provide an update on risk assessment, diagnosis, and management of IHD in women. RECENT FINDINGS IHD in women is often secondary to diffuse non-obstructive atherosclerosis, coronary spasm, inflammation, and endothelial and microvascular dysfunction, and less commonly due to the male pattern of flow-limiting epicardial stenosis. Both IHD patterns likely represent sex-specific manifestations of the same disease process. Additionally, there is a differential expression of risk factors and symptoms between men and women. Application of male-pattern IHD risk factors and presentation to women contributes to under-recognition, under-testing, and under-treatment of IHD in women compared to men. Traditional diagnostic evaluation has focused on detection of epicardial disease, amenable to revascularization. Our improved understanding of sex-specific pathophysiology of IHD has enabled us to also develop tools for detection of microvascular disease. Advances in stress MRI, flow quantification on stress PET, and provocative invasive angiography have filled this void and offer important diagnostic and prognostic information. Despite our improved understanding of sex-specific differences in presentation, risk factors, pathophysiology, diagnostic testing, and management strategies of IHD, women with IHD continue to experience worse outcomes than men. This disparity underscores the need for improved research and understanding of biological sex differences, elimination of subconscious gender bias in referral patterns, and improved application of existing research into clinical practice.
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16
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Wilson WM, Shah ASV, Birse D, Harley E, Northridge DB, Uren NG. The relationship between the basal coronary translesional pressure ratio and fractional flow reserve. Catheter Cardiovasc Interv 2017; 90:745-753. [PMID: 28766832 DOI: 10.1002/ccd.27027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 01/25/2017] [Accepted: 02/15/2017] [Indexed: 01/10/2023]
Abstract
AIM Fractional flow reserve (FFR) allows for physiological definition of coronary lesion severity but requires induction of maximal coronary circulation hyperemia with administration of adenosine leading to coronary resistive vessel vasodilatation. However, the hyperemic response to adenosine, and therefore the calculation of FFR, may be affected by dysfunction of the coronary microvasculature. The aim was to define the relationship between basal Pd /Pa and FFR and identify lesion-independent predictors of the change in Pd /Pa with hyperemia. METHODS AND RESULTS One hundred and sixty-six consecutive patients undergoing FFR measurement were prospectively enrolled (mean age 62.6 ± 10.3 years, 27% females). Basal Pd /Pa , FFR, and delta Pd /Pa (difference between basal Pd /Pa and FFR) were recorded. Independent predictors of delta Pd /Pa included angiographic lesion severity, lesion length, gender, body mass index, and total cholesterol:HDL cholesterol ratio. The best basal Pd /Pa cutoff value to predict lesion physiological significance was 0.87 (positive predictive value of 100% for an FFR value ≤0.80) and the best cutoff for nonsignificance was 0.93 (negative predictive value of 98% for an FFR value >0.80). CONCLUSION The delta Pd /Pa may be affected by patient gender, body mass index, and cholesterol profile. A basal Pd /Pa value of ≥0.93 is highly predictive of an FFR >0.80. Conversely, a basal Pd /Pa value of ≤0.87 is highly predictive of an FFR ≤0.80. © 2017 Wiley Periodicals, Inc.
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Affiliation(s)
| | - Anoop S V Shah
- Edinburgh Heart Centre, Royal Infirmary of Edinburgh, United Kingdom
| | - Duncan Birse
- Edinburgh Heart Centre, Royal Infirmary of Edinburgh, United Kingdom
| | - Emma Harley
- Edinburgh Heart Centre, Royal Infirmary of Edinburgh, United Kingdom
| | | | - Neal G Uren
- Edinburgh Heart Centre, Royal Infirmary of Edinburgh, United Kingdom
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17
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Picard F, Pighi M, Ly HQ. Fractional flow reserve and resting indices for coronary physiologic assessment: Practical guide, tips, and tricks. Catheter Cardiovasc Interv 2017; 90:598-611. [PMID: 28160376 DOI: 10.1002/ccd.26933] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Revised: 11/19/2016] [Accepted: 12/22/2016] [Indexed: 01/10/2023]
Abstract
Physiologic assessment using fractional flow reserve (FFR) to guide percutaneous coronary interventions (PCI) has been demonstrated to improve clinical outcomes, compared to angiography-guided PCI. Recently, resting indices such as resting Pd/Pa, "instantaneous wave-free ratio", and contrast medium induced FFR have been evaluated for the assessment of the functional consequences of coronary lesions. Herein, we review and discuss the use of FFR and other indices for the functional assessment of coronary lesions. This review will cover theoretical aspects, as well as practical points and common pitfalls related to coronary physiological assessment. © 2017 Wiley Periodicals, Inc.
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Affiliation(s)
- Fabien Picard
- Interventional Cardiology Division, Department of Medicine, Montreal Heart Institute, Université de Montréal, Montréal, Qubec, Canada
| | - Michele Pighi
- Interventional Cardiology Division, Department of Medicine, Montreal Heart Institute, Université de Montréal, Montréal, Qubec, Canada
| | - Hung Q Ly
- Interventional Cardiology Division, Department of Medicine, Montreal Heart Institute, Université de Montréal, Montréal, Qubec, Canada
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18
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Abstract
A number of studies consistently report higher rates of all clinical outcomes including postinfarction mortality, need for repeat revascularization, and reinfarction in women with cardiovascular diseases than in men. As well, the gender gap in the prevalence of cardiovascular diseases decreases progressively with increasing age. Yet, the diagnosis and treatment of these diseases differ between genders and women remain underdiagnosed for coronary heart disease. In a recent retrospective analysis we showed that, along with vessel under study and age, gender is a determinant of adenosine responses during studies of fractional flow reserve, an effect that was probably due to differences in microvascular function and that influenced the interpretation of fractional flow reserve data. These data demonstrate that not only the clinical presentation is different, but also the diagnostic approach to coronary artery disease might differ between sexes.A gap still exists in the understanding of the mechanisms, awareness, and treatment of coronary artery disease in women, but also, as we show, in the application of diagnostic modalities that are well established in men.
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19
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Lakhter V, Alkhouli M, Zack CJ, Zhao H, Cohen HA, O'Neill BP, O'Murchu B, Bove AA, Bashir R. Sex Differences in Fractional Flow Reserve-Guided Revascularization: A Nationwide Analysis. J Womens Health (Larchmt) 2016; 26:109-115. [PMID: 27754754 DOI: 10.1089/jwh.2016.5806] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Women with coronary artery disease are less likely to be revascularized than men based on angiography alone. Recent studies have shown that female patients have higher fractional flow reserve (FFR) values for a given severity of coronary stenosis. However, gender differences in coronary revascularization rates following FFR assessment are unknown. METHODS The nationwide inpatient sample database was used to identify all patients who underwent FFR in the United States between January 2009 and December 2010. We used propensity score matching to compare revascularization rates and in-hospital outcomes among men and women undergoing FFR measurements. RESULTS Among 3712 patients who underwent FFR during the study period, 1235 matched pairs of men and women were identified. The overall revascularization rates were lower in women than men (40.1% vs. 52.8%, p < 0.01). Women were less likely to undergo either percutaneous (35.2% vs. 45.6%, p < 0.01) or surgical revascularization following FFR than men (5.2% vs. 7.4%, p = 0.03). Women had a nonsignificant trend toward higher in-hospital mortality (0.8% vs. 0.5%, p = 0.32) and significantly higher rates of access site hematoma formation (2.7% vs. 0.8%, p < 0.01) compared to men. CONCLUSION In conclusion, this large nationwide study reveals that coronary revascularization rates are significantly lower in women than in men even after functional assessment with FFR.
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Affiliation(s)
- Vladimir Lakhter
- 1 Division of Cardiovascular Diseases, Department of Medicine, Temple University Hospital , Philadelphia, Pennsylvania
| | - Mohamad Alkhouli
- 2 Division of Cardiology, WVU Heart & Vascular Institute, West Virginia University , Morgantown, West Virginia
| | - Chad J Zack
- 3 Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic , Rochester, Minnesota
| | - Huaqing Zhao
- 4 Department of Clinical Sciences, Temple University School of Medicine , Philadelphia, Pennsylvania
| | - Howard A Cohen
- 1 Division of Cardiovascular Diseases, Department of Medicine, Temple University Hospital , Philadelphia, Pennsylvania
| | - Brian P O'Neill
- 1 Division of Cardiovascular Diseases, Department of Medicine, Temple University Hospital , Philadelphia, Pennsylvania
| | - Brian O'Murchu
- 1 Division of Cardiovascular Diseases, Department of Medicine, Temple University Hospital , Philadelphia, Pennsylvania
| | - Alfred A Bove
- 1 Division of Cardiovascular Diseases, Department of Medicine, Temple University Hospital , Philadelphia, Pennsylvania
| | - Riyaz Bashir
- 1 Division of Cardiovascular Diseases, Department of Medicine, Temple University Hospital , Philadelphia, Pennsylvania
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20
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Wolfrum M, Fahrni G, de Maria GL, Knapp G, Curzen N, Kharbanda RK, Fröhlich GM, Banning AP. Impact of impaired fractional flow reserve after coronary interventions on outcomes: a systematic review and meta-analysis. BMC Cardiovasc Disord 2016; 16:177. [PMID: 27608682 PMCID: PMC5017064 DOI: 10.1186/s12872-016-0355-7] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Accepted: 08/26/2016] [Indexed: 12/26/2022] Open
Abstract
Background FFR is routinely used to guide percutaneous coronary interventions (PCI). Visual assessment of the angiographic result after PCI has limited efficacy. Even when the angiographic result seems satisfactory FFR after a PCI might be useful for identifying patients with a suboptimal interventional result and higher risk for poor clinical outcome who might benefit from additional procedures. The aim of this meta-analysis was to investigate available data of studies that examined clinical outcomes of patients with impaired vs. satisfactory fractional flow reserve (FFR) after percutaneous coronary interventions (PCI). Methods This meta-analysis was carried out according to the Cochrane Handbook for Systematic Reviews. The Mantel-Haenszel method using the fixed-effect meta-analysis model was used for combining the results. Studies were identified by searching the literature through mid-January, 2016, using the following search terms: fractional flow reserve, coronary circulation, after, percutaneous coronary intervention, balloon angioplasty, stent implantation, and stenting. Primary endpoint was the rate of major adverse cardiac events (MACE). Secondary endpoints included rates of death, myocardial infarction (MI), repeated revascularisation. Results Eight relevant studies were found including a total of 1337 patients. Of those, 492 (36.8 %) had an impaired FFR after PCI, and 853 (63.2 %) had a satisfactory FFR after PCI. Odds ratios indicated that a low FFR following PCI was associated with an impaired outcome: major adverse cardiac events (MACE, OR: 4.95, 95 % confidence interval [CI]: 3.39–7.22, p <0.001); death (OR: 3.23, 95 % CI: 1.19–8.76, p = 0.022); myocardial infarction (OR: 13.83, 95 % CI: 4.75–40.24, p <0.0001) and repeated revascularisation (OR: 4.42, 95 % CI: 2.73–7.15, p <0.0001). Conclusions Compared to a satisfactory FFR, a persistently low FFR following PCI is associated with a worse clinical outcome. Prospective studies are needed to identify underlying causes, determine an optimal threshold for post-PCI FFR, and clarify whether simple additional procedures can influence the post-PCI FFR and clinical outcome. Electronic supplementary material The online version of this article (doi:10.1186/s12872-016-0355-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Mathias Wolfrum
- Oxford Heart Centre, Oxford University Hospitals, Headley Way, Oxford, OX39DU, UK
| | - Gregor Fahrni
- Oxford Heart Centre, Oxford University Hospitals, Headley Way, Oxford, OX39DU, UK
| | | | - Guido Knapp
- Department of Statistics, TU University Dortmund, Dortmund, Germany
| | - Nick Curzen
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Rajesh K Kharbanda
- Oxford Heart Centre, Oxford University Hospitals, Headley Way, Oxford, OX39DU, UK
| | - Georg M Fröhlich
- Department of Cardiology, Charité Universitätsmedizin Berlin (Campus Benjamin Franklin), Berlin, Germany
| | - Adrian P Banning
- Oxford Heart Centre, Oxford University Hospitals, Headley Way, Oxford, OX39DU, UK.
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21
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Matar FA, Falasiri S, Glover CB, Khaliq A, Leung CC, Mroue J, Ebra G. When should fractional flow reserve be performed to assess the significance of borderline coronary artery lesions: Derivation of a simplified scoring system. Int J Cardiol 2016; 222:606-610. [PMID: 27517648 DOI: 10.1016/j.ijcard.2016.07.171] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2016] [Accepted: 07/27/2016] [Indexed: 12/31/2022]
Abstract
OBJECTIVES To derive a simplified scoring system (SSS) that can assist in selecting patients who would benefit from the application of fractional flow reserve (FFR). BACKGROUND Angiographers base decisions to perform FFR on their interpretation of % diameter stenosis (DS), which is subject to variability. Recent studies have shown that the amount of myocardium at jeopardy is an important factor in determining the degree of hemodynamic compromise. METHODS We conducted a retrospective multivariable analysis to identify independent predictors of hemodynamic compromise in 289 patients with 317 coronary vessels undergoing FFR. A SSS was derived using the odds ratios as a weighted factor. The receiver operator characteristics curve was used to identify the optimal cutoff (≥3) to discern a functionally significant lesion (FFR≤0.8). RESULTS Male gender, left anterior descending artery apical wrap, disease proximal to lesion, minimal lumen diameter and % DS predicted abnormal FFR (≤0.8) and lesion location in the left circumflex predicted a normal FFR. Using a cutoff score of ≥3 on the SSS, a specificity of 90.4% (95% CI: 83.0-95.3) and a sensitivity of 38.0% (95% CI: 31.5-44.9) was generated with a positive predictive value of 89.0% (95% CI: 80.7%-94.6%) and negative predictive value of 41.6% (95% CI: 35.1%-48.3%). CONCLUSIONS The decision to use FFR should be based not only on the % DS but also the size of the myocardial mass jeopardized. A score of ≥3 on the SSS should prompt further investigation with a pressure wire.
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Affiliation(s)
- Fadi A Matar
- Department of Cardiovascular Sciences, The University of South Florida, Morsani College of Medicine, Tampa, FL, USA.
| | - Shayan Falasiri
- Department of Cardiovascular Sciences, The University of South Florida, Morsani College of Medicine, Tampa, FL, USA
| | - Charles B Glover
- Department of Cardiovascular Sciences, The University of South Florida, Morsani College of Medicine, Tampa, FL, USA
| | - Asma Khaliq
- Department of Cardiovascular Sciences, The University of South Florida, Morsani College of Medicine, Tampa, FL, USA
| | - Calvin C Leung
- Department of Cardiovascular Sciences, The University of South Florida, Morsani College of Medicine, Tampa, FL, USA
| | - Jad Mroue
- Department of Cardiovascular Sciences, The University of South Florida, Morsani College of Medicine, Tampa, FL, USA
| | - George Ebra
- Department of Cardiovascular Sciences, The University of South Florida, Morsani College of Medicine, Tampa, FL, USA
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22
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López-Palop R, Carrillo P, Agudo P, Cordero A, Frutos A, Mashlab S, Martínez R, El Amrani A, Ramos D. Factors Associated With Errors in Visual Estimation of the Functional Significance of Coronary Lesions. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2016; 69:657-663. [PMID: 27068021 DOI: 10.1016/j.rec.2015.12.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Accepted: 12/03/2015] [Indexed: 06/05/2023]
Abstract
UNLABELLED INTRODUCTION AND OBJECTIVES Visual angiographic assessment continues to be used when decisions are made on whether to revascularize ambiguous coronary lesions. Multiple factors, other than the degree of stenosis, have been associated with the functional significance of a coronary lesion. The aim of this study was to investigate the ability of interventionists to visually predict the functional significance of a coronary lesion and the clinical and angiographic characteristics associated with errors in prediction. METHODS We conducted a concordance study of the functional significance of coronary lesions predicted by experienced interventionists and fractional flow reserve values measured by intracoronary pressure wire in 665 intermediate lesions (40%-70% diameter stenosis) in 587 patients. We determined which factors were independently associated with errors in prediction. RESULTS There was disagreement between the predicted fractional flow reserve value of ≤ 0.80 and the observed value in 30.1% of the lesions (overestimation: 11.3%; underestimation, 18.8%). Stent location in an artery other than the anterior descending artery or in a bifurcation was associated with overestimation. Male sex, severe calcification, and a greater myocardial territory distal to the lesion were significantly associated with the functional significance of the underestimated lesion. CONCLUSIONS Even when taking into account angiographic and clinical characteristics, there is a high rate of disagreement between visual estimation and direct measurement of intermediate coronary stenosis in relation to its functional significance. Specific angiographic and clinical characteristics are associated with an increased tendency to overestimate or underestimate the significance of lesions.
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Affiliation(s)
- Ramón López-Palop
- Unidad de Hemodinámica, Sección de Cardiología, Hospital Universitario San Juan de Alicante, San Juan de Alicante, Alicante, Spain.
| | - Pilar Carrillo
- Unidad de Hemodinámica, Sección de Cardiología, Hospital Universitario San Juan de Alicante, San Juan de Alicante, Alicante, Spain
| | - Pilar Agudo
- Unidad de Hemodinámica, Sección de Cardiología, Hospital Universitario San Juan de Alicante, San Juan de Alicante, Alicante, Spain
| | - Alberto Cordero
- Unidad de Hemodinámica, Sección de Cardiología, Hospital Universitario San Juan de Alicante, San Juan de Alicante, Alicante, Spain
| | - Araceli Frutos
- Unidad de Hemodinámica, Sección de Cardiología, Hospital Universitario San Juan de Alicante, San Juan de Alicante, Alicante, Spain
| | - Samer Mashlab
- Unidad de Hemodinámica, Sección de Cardiología, Hospital Universitario San Juan de Alicante, San Juan de Alicante, Alicante, Spain
| | - Rubén Martínez
- Unidad de Hemodinámica, Sección de Cardiología, Hospital Universitario San Juan de Alicante, San Juan de Alicante, Alicante, Spain
| | - Amin El Amrani
- Unidad de Hemodinámica, Sección de Cardiología, Hospital Universitario San Juan de Alicante, San Juan de Alicante, Alicante, Spain
| | - David Ramos
- Unidad de Hemodinámica, Sección de Cardiología, Hospital Universitario San Juan de Alicante, San Juan de Alicante, Alicante, Spain
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23
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López-Palop R, Carrillo P, Agudo P, Cordero A, Frutos A, Mashlab S, Martínez R, El Amrani A, Ramos D. Factores asociados al error en la estimación visual de la importancia funcional de lesiones coronarias. Rev Esp Cardiol (Engl Ed) 2016. [DOI: 10.1016/j.recesp.2015.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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24
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Picard F, Tadros VX, Pighi M, Spagnoli V, De Hemptinne Q, Ly HQ. [Fractional flow reserve and instantaneous wave-free ratio for the physiological assessment of coronary artery stenosis in the catheterization laboratory: Practical tips]. Ann Cardiol Angeiol (Paris) 2016; 66:32-41. [PMID: 27211352 DOI: 10.1016/j.ancard.2016.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Accepted: 03/15/2016] [Indexed: 01/14/2023]
Abstract
In recent years, a large body of evidence has revealed the limitations of angiographic evaluation in determining the physiological significance of coronary stenosis, particularly when these are intermediate lesions. Percutaneous coronary interventions (PCI) guided by physiological assessment using fractional flow reserve (FFR) have been shown to reduce cardiovascular events when compared to angiography alone. Recently, another coronary physiologic parameter has been introduced: the "instantaneous wave-free ratio" (iFR). In this review, we will discuss the FFR, the iFR, and their use in the functional assessment of coronary stenosis in the cardiac catheterization laboratory. This review will cover theoretical aspects for non-interventional cardiologists, as well as practice points and common pitfalls related to coronary physiological assessment for interventional cardiologists.
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Affiliation(s)
- F Picard
- Interventional Cardiology Division, Department of Medicine, Montreal Heart Institute, université de Montréal, Montréal, QC, Canada
| | - V X Tadros
- Interventional Cardiology Division, Department of Medicine, Montreal Heart Institute, université de Montréal, Montréal, QC, Canada
| | - M Pighi
- Interventional Cardiology Division, Department of Medicine, Montreal Heart Institute, université de Montréal, Montréal, QC, Canada
| | - V Spagnoli
- Interventional Cardiology Division, Department of Medicine, Montreal Heart Institute, université de Montréal, Montréal, QC, Canada
| | - Q De Hemptinne
- Interventional Cardiology Division, Department of Medicine, Montreal Heart Institute, université de Montréal, Montréal, QC, Canada
| | - H Q Ly
- Interventional Cardiology Division, Department of Medicine, Montreal Heart Institute, université de Montréal, Montréal, QC, Canada.
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25
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Açıkgöz SK, Açar B, Aydın S, Açıkgöz E, Er O, Şensoy B, Balci MM, Yayla Ç, Şen F, Topal S, Aydoğdu S. Red Cell Distribution Width Can Predict the Significance of Angiographically Intermediate Coronary Lesions. Med Princ Pract 2016; 25:31-5. [PMID: 26468646 PMCID: PMC5588303 DOI: 10.1159/000441001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Accepted: 09/10/2015] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVE In the present study, the association between red cell distribution width (RDW) with functional significance of intermediate coronary artery lesions was investigated. MATERIALS AND METHODS Two hundred and forty-six consecutive patients, 168 males and 78 females, who underwent fractional flow reserve (FFR) measurement for angiographically intermediate coronary stenosis (40-70% in quantitative coronary analysis) in the left anterior descending coronary artery were enrolled into the study. The functional significance of intermediate coronary artery lesions was determined by FFR measurement. An FFR value <0.75 was defined as functionally significant. Venous blood samples were taken within 48 h before the FFR measurement, and RDW levels were determined by a Coulter LH Series hematology analyzer. Logistic regression analysis was used to examine the association between functional significance in FFR measurement and other variables. RESULTS Of the 246 patients, 62 (25.2%) exhibited significant functional stenosis (FFR <0.75) in the FFR measurement. The mean RDW level was significantly higher in patients with significant stenosis (14.19 ± 0.73 vs. 13.69 ± 0.77, p < 0.001). In stepwise multivariate logistic regression analysis, RDW (OR = 2.489, 95% CI = 1.631-3.799, p < 0.001) and male gender (OR = 2.826, 95% CI = 1.347-5.928, p = 0.006) were independent predictors of significant functional stenosis. CONCLUSION Increased RDW levels were associated with functional significance of angiographically intermediate coronary artery stenoses.
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Affiliation(s)
- Sadık Kadri Açıkgöz
- Cardiology Clinic, Turkiye Yuksek Ihtisas Education and Research Hospital, Ankara, Turkey
- *Sadýk Kadri Açýkgöz, Turkiye Yuksek Ihtisas Hastanesi, TR–06100 Sihhiye, Ankara (Turkey), E-Mail
| | - Burak Açar
- Cardiology Clinic, Turkiye Yuksek Ihtisas Education and Research Hospital, Ankara, Turkey
| | - Selahattin Aydın
- Cardiology Clinic, Turkiye Yuksek Ihtisas Education and Research Hospital, Ankara, Turkey
| | - Eser Açıkgöz
- Cardiology Department, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Okan Er
- Cardiology Clinic, Turkiye Yuksek Ihtisas Education and Research Hospital, Ankara, Turkey
| | - Barış Şensoy
- Cardiology Clinic, Turkiye Yuksek Ihtisas Education and Research Hospital, Ankara, Turkey
| | - Mustafa Mücahit Balci
- Cardiology Clinic, Turkiye Yuksek Ihtisas Education and Research Hospital, Ankara, Turkey
| | - Çağrı Yayla
- Cardiology Clinic, Turkiye Yuksek Ihtisas Education and Research Hospital, Ankara, Turkey
| | - Fatih Şen
- Cardiology Clinic, Turkiye Yuksek Ihtisas Education and Research Hospital, Ankara, Turkey
| | - Salih Topal
- Cardiology Department, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Sinan Aydoğdu
- Cardiology Clinic, Turkiye Yuksek Ihtisas Education and Research Hospital, Ankara, Turkey
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26
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Tebaldi M, Biscaglia S, Fineschi M, Manari A, Menozzi M, Secco GG, Di Lorenzo E, D'Ascenzo F, Fabbian F, Tumscitz C, Ferrari R, Campo G. Fractional Flow Reserve Evaluation and Chronic Kidney Disease: Analysis From a Multicenter Italian Registry (the FREAK Study). Catheter Cardiovasc Interv 2015; 88:555-562. [PMID: 26717890 DOI: 10.1002/ccd.26364] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Revised: 11/03/2015] [Accepted: 11/22/2015] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To establish if the presence of chronic kidney disease (CKD) influences fractional flow reserve (FFR) value in patients with intermediate coronary stenosis. BACKGROUND FFR-guided coronary revascularization reduces cardiac adverse events in patients with coronary artery disease. CKD impairs microcirculation and increases cardiovascular risk. Whether CKD presence may limit FFR accuracy is unknown. METHODS We used data from a multicenter prospective registry enrolling 1.004 patients undergoing FFR evaluation for intermediate stenosis. We assessed the relationship between clinical and angiographic variables and FFR measurement. CKD was defined as CrCl value ≤45 ml/min. FFR value was considered potentially flow-limiting, and therefore positive, if ≤0.80. The index of microcirculatory resistance (IMR) was calculated in 20 patients stratified according CrCl value (single-center substudy). RESULTS FFR measurement was positive in 395 (39%) patients. Overall, 131 (13%) patients had CKD. Patients with CrCl ≤45 ml/min showed significantly higher FFR values as compared to the others (0.84 ± 0.07 vs. 0.81 ± 0.08, p < 0.001). Positive FFR occurrence was lower in patients with CrCl ≤45 ml/min (27% vs. 41%, p < 0.01). After multivariable analysis, diabetes (HR 1.07, 95%CI 1.008-1.13, p = 0.03), left anterior descending (HR 1.35, 95%CI 1.27-1.43, p < 0.001) and CrCl ≤45 ml/min (HR 0.92, 95%CI 0.87-0.97, p = 0.005) emerged as independent predictors of FFR measurement. Accordingly, IMR values were higher in patients with CrCl ≤45 ml/min (32 U [28245] vs. 16 U [11220], p < 0.01). CONCLUSIONS FFR and IMR measurements differ between CKD patients and those with normal renal function. Flow-limiting FFR is less frequent in patients with CrCl ≤45 ml/min. © 2015 Wiley Periodicals, Inc.
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Affiliation(s)
- Matteo Tebaldi
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria Di Ferrara, Cona, Ferrara, Italy.
| | - Simone Biscaglia
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria Di Ferrara, Cona, Ferrara, Italy
| | - Massimo Fineschi
- Department of Cardiology, University Medical Hospital of Siena, Siena, Italy
| | - Antonio Manari
- Department of Cardiology, Santa Maria Nuova Hospital, Reggio-Emilia, Italy
| | - Mila Menozzi
- Department of Cardiology, Ospedale Degli Infermi, Rimini
| | - Gioel Gabrio Secco
- Division of Cardiology, "Santi Antonio E Biagio E Cesare Arrigo" Hospital, Alessandria, Italy
| | - Emilio Di Lorenzo
- Department of Heart and Vessels, S.G. Moscati Hospital, Avellino, Italy
| | - Fabrizio D'Ascenzo
- Division of Cardiology Città Della Salute E Della Scienza, Hospital University of Turin, Turin, Italy
| | - Fabio Fabbian
- Clinica Medica, Departement of Medical Science, University of Ferrara, Cona, Ferrara, Italy
| | - Carlo Tumscitz
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria Di Ferrara, Cona, Ferrara, Italy
| | - Roberto Ferrari
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria Di Ferrara, Cona, Ferrara, Italy.,Maria Cecilia Hospital, GVM Care & Research, E.S. Health Science Foundation, Cotignola, Italy
| | - Gianluca Campo
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria Di Ferrara, Cona, Ferrara, Italy.,Laboratorio per Le Tecnologie Delle Terapie Avanzate (LTTA) Center, Ferrara, Italy
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27
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Crystal GJ, Klein LW. Fractional flow reserve: physiological basis, advantages and limitations, and potential gender differences. Curr Cardiol Rev 2015; 11:209-19. [PMID: 25329922 PMCID: PMC4558352 DOI: 10.2174/1573403x10666141020113318] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Revised: 10/04/2014] [Accepted: 10/15/2014] [Indexed: 01/31/2023] Open
Abstract
Fractional flow reserve (FFR) is a physiological index of the severity of a stenosis in an epicardial coronary artery, based on the pressure differential across the stenosis. Clinicians are increasingly relying on this method because it is independent of baseline flow, relatively simple, and cost effective. The accurate measurement of FFR is predicated on maximal hyperemia being achieved by pharmacological dilation of the downstream resistance vessels (arterioles). When the stenosis causes FFR to be impaired by > 20%, it is considered to be significant and to justify revascularization. A diminished hyperemic response due to microvascular dysfunction can lead to a false normal FFR value, and a misguided clinical decision. The blunted vasodilation could be the result of defects in the signaling pathways modulated (activated or inhibited) by the drug. This might involve a downregulation or reduced number of vascular receptors, endothelial impairment, or an increased activity of an opposing vasoconstricting mechanism, such as the coronary sympathetic nerves or endothelin. There are data to suggest that microvascular dysfunction is more prevalent in post-menopausal women, perhaps due to reduced estrogen levels. The current review discusses the historical background and physiological basis for FFR, its advantages and limitations, and the phenomenon of microvascular dysfunction and its impact on FFR measurements. The question of whether it is warranted to apply gender-specific guidelines in interpreting FFR measurements is addressed.
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Affiliation(s)
- George J Crystal
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, 836 West Wellington Avenue, Chicago, IL 60657, USA.
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28
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Thompson AG, Raju R, Blanke P, Yang TH, Mancini GBJ, Budoff MJ, Norgaard BL, Min JK, Leipsic JA. Diagnostic accuracy and discrimination of ischemia by fractional flow reserve CT using a clinical use rule: results from the Determination of Fractional Flow Reserve by Anatomic Computed Tomographic Angiography study. J Cardiovasc Comput Tomogr 2015; 9:120-8. [PMID: 25819194 DOI: 10.1016/j.jcct.2015.01.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Revised: 11/09/2014] [Accepted: 01/09/2015] [Indexed: 12/23/2022]
Abstract
BACKGROUND Fractional flow reserve (FFR) is the gold standard for determining lesion-specific ischemia. Computed FFRCT derived from coronary CT angiography (coronary CTA) correlates well with invasive FFR and accurately differentiates between ischemia-producing and nonischemic lesions. The diagnostic performance of FFRCT when applied in a clinically relevant way to all vessels ≥ 2 mm in diameter stratified by sex and age has not been previously examined. METHODS Two hundred fifty-two patients and 407 vessels underwent coronary CTA, FFRCT, invasive coronary angiography, and invasive FFR. FFRCT and FFR ≤ 0.80 were considered ischemic, whereas CT stenosis ≥ 50% was considered obstructive. The diagnostic performance of FFRCT was assessed following a prespecified clinical use rule which included all vessels ≥ 2 mm in diameter, not just those assessed by invasive FFR measurements. Stenoses <30% were assigned an FFR of 0.90, and stenoses >90% were assigned an FFR of 0.50. Diagnostic performance of FFRCT was stratified by vessel diameter, sex, and age. RESULTS By FFR, ischemia was identified in 129 of 252 patients (51%) and in 151 of 407 vessels (31%). Mean age (± standard deviation) was 62.9 ± 9 years, and women were older (65.5 vs 61.9 years; P = .003). Per-patient diagnostic accuracy (83% vs 72%; P < .005) and specificity (54% vs 82%, P < .001) improved significantly after application of the clinical use tool. These were significantly improved over standard coronary CTA values before application of the clinical use rule. Discriminatory power of FFRCT also increased compared with baseline (area under the receiver operating characteristics curve [AUC]: 0.93 vs 0.81, P < .001). Diagnostic performance improved in both sexes with no significant differences between the sexes (AUC: 0.93 vs 0.90, P = .43). There were no differences in the discrimination of FFRCT after application of the clinical use rule when stratified by age ≥ 65 or <65 years (AUC: 0.95 vs 0.90, P = .10). CONCLUSIONS The diagnostic accuracy and discriminatory power of FFRCT improve significantly after the application of a clinical use rule which includes all clinically relevant vessels >2 mm in diameter. FFRCT has similar diagnostic accuracy and discriminatory power for ischemia detection in men and women irrespective of age using a cut point of 65 years.
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Affiliation(s)
- Angus G Thompson
- Department of Radiology, St Paul's Hospital, University of British Columbia, 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
| | - Rekha Raju
- Department of Radiology, St Paul's Hospital, University of British Columbia, 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Philipp Blanke
- Department of Radiology, St Paul's Hospital, University of British Columbia, 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Tae-Hyun Yang
- Department of Radiology, St Paul's Hospital, University of British Columbia, 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | | | - Matthew J Budoff
- Department of Medicine, Harbor UCLA Medical Center, Los Angeles, California
| | - Bjarne L Norgaard
- Department of Cardiology B, Aarhus University Hospital Skejby, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - James K Min
- Department of Radiology, New York-Presbyterian Hospital and the Weill Cornell Medical College, New York, NY, USA
| | - Jonathon A Leipsic
- Department of Radiology, St Paul's Hospital, University of British Columbia, 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
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