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Niewiara Ł, Kleczyński P, Szolc P, Guzik B, Diachyshyn M, Jelonek M, Handzlik J, Żmudka K, Legutko J. The change of angina levels in patients with chronic coronary syndromes and coronary microcirculatory dysfunction - a prospective study with 24 months follow-up. ADVANCES IN INTERVENTIONAL CARDIOLOGY 2023; 19:318-325. [PMID: 38187481 PMCID: PMC10767557 DOI: 10.5114/aic.2023.133806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 11/23/2023] [Indexed: 01/09/2024] Open
Abstract
Introduction A substantial proportion of patients with chronic coronary syndromes suffer from angina even after medical treatment and revascularization. Coronary microvascular dysfunction (CMD) is discussed as a potential mechanism. Aim To assess angina status in patients with chronic coronary syndromes undergoing functional assessment of coronary circulation regarding the presence of coronary microcirculatory dysfunction. Material and methods The study included 101 consecutive patients referred for coronary angiography requiring functional stenosis assessment, with median age of 66 years, 74% male, diagnosed or treated for dyslipidemia (91%) and diabetes type 2 (42%), 20% with a history of prior non-ST myocardial infarction. Fractional flow reserve (FFR), coronary flow reserve (CFR), resistive reserve ratio (RRR), and index of microcirculatory resistance (IMR) were measured. The diagnosis of CMD was defined by either IMR ≥ 25 units or CFR ≤ 2.0 in case of no significant stenosis. A change of one CCS class over 24 months follow-up was considered clinically significant. Results In patients without CMD diagnosis, there was a significant decrease in angina intensity (p < 0.001). Lack of angina improvement was associated with lower median RRR (2.30 (1.70, 3.30) vs. 3.05 (2.08, 4.10), p = 0.004) and lower median CFR (1.90 (1.40, 2.50) vs. 2.30 (IQR: 1.60, 3.00), p = 0.021), as compared to patients with angina improvement. Conclusions The presence of CMD is a risk factor for no angina improvement. Impaired coronary resistive reserve ratio and lower microvascular reactivity may be one of the pathomechanisms leading to the lack of angina improvement in patients with chronic coronary syndromes.
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Affiliation(s)
- Łukasz Niewiara
- Department of Interventional Cardiology, Jagiellonian University Medical College, Institute of Cardiology, St. John Paul II Hospital, Krakow, Poland
- Clinical Department of Interventional Cardiology, John Paul II Hospital, Krakow, Poland
| | - Paweł Kleczyński
- Department of Interventional Cardiology, Jagiellonian University Medical College, Institute of Cardiology, St. John Paul II Hospital, Krakow, Poland
- Clinical Department of Interventional Cardiology, John Paul II Hospital, Krakow, Poland
| | - Piotr Szolc
- Clinical Department of Interventional Cardiology, John Paul II Hospital, Krakow, Poland
- Department of Emergency Medicine, Faculty of Health Sciences, Jagiellonian University Medical College, Krakow, Poland
| | - Bartłomiej Guzik
- Department of Interventional Cardiology, Jagiellonian University Medical College, Institute of Cardiology, St. John Paul II Hospital, Krakow, Poland
- Clinical Department of Interventional Cardiology, John Paul II Hospital, Krakow, Poland
| | - Marta Diachyshyn
- Department of Interventional Cardiology, Jagiellonian University Medical College, Institute of Cardiology, St. John Paul II Hospital, Krakow, Poland
- Clinical Department of Interventional Cardiology, John Paul II Hospital, Krakow, Poland
| | - Michalina Jelonek
- Student Scientific Group of Modern Cardiac Therapy at the Department of Interventional Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Joanna Handzlik
- Student Scientific Group of Modern Cardiac Therapy at the Department of Interventional Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Krzysztof Żmudka
- Department of Interventional Cardiology, Jagiellonian University Medical College, Institute of Cardiology, St. John Paul II Hospital, Krakow, Poland
- Clinical Department of Interventional Cardiology, John Paul II Hospital, Krakow, Poland
| | - Jacek Legutko
- Department of Interventional Cardiology, Jagiellonian University Medical College, Institute of Cardiology, St. John Paul II Hospital, Krakow, Poland
- Clinical Department of Interventional Cardiology, John Paul II Hospital, Krakow, Poland
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Niewiara Ł, Kleczyński P, Guzik B, Szolc P, Baran J, Podolec J, Diachyshyn M, Żmudka K, Legutko J. Impaired coronary flow reserve in patients with poor type 2 diabetes control: Preliminary results from prospective microvascular dysfunction registry. Cardiol J 2022; 31:185-192. [PMID: 36342032 PMCID: PMC11076028 DOI: 10.5603/cj.a2022.0100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 08/13/2022] [Accepted: 08/18/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Type 2 diabetes (DM) is a common comorbidity associated with cardiovascular disease, especially when poor glucose control is present. Extracardiac microcirculatory complications prevalence is well documented, however coronary microcirculatory dysfunction (CMD) seem to be underreported in this group. METHODS The present study analyzed coronary physiology measurements (coronary flow reserve [CFR], index of microcirculatory resistance [IMR], resistance reserve ratio [RRR]) in 47 diabetic patients (21 subjects with poor glycemia control defined as fasting glucose levels > 7.2 mmol/L and 26 with normal fasting glucose), and compared to 54 non-diabetic controls, who had undergone coronary angiography due to symptoms of chronic coronary syndrome. The median age of patients was 65.5 [59.0; 73.0] years old, 74% male, similar in terms of cardiovascular risk factors and prior myocardial infarction. Insulin was used by 19% of diabetic patients with poor glucose control and by 15% of those with DM and low fasting glucose. RESULTS Prevalence of CMD was 38% in poor glycemia control patients, 27% in DM-patients with proper glucose control and 31% of non-diabetics. Median CFR values were the lowest in poor DM control patients compared to both, normal fasting glucose (1.75 [1.37; 2.32] vs. 2.30 [1.75; 2.85], p = 0.026) and to non-diabetics (1.75 [1.37; 2.32] vs. 2.15 [1.50; 2.95], p = 0.045). Levels of IMR, RRR and MRR did not differ significantly between compared groups (p > 0.05 for all comparisons). CONCLUSIONS Poor glycemia control in type 2 DM might be associated with a higher prevalence of CMD driven by decreased coronary flow reserve, however, further research in larger groups of patients should be performed to confirm this observation.
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Affiliation(s)
- Łukasz Niewiara
- Clinical Department of Interventional Cardiology, John Paul II Hospital, Krakow, Poland
- Department of Emergency Medicine, Faculty of Health Sciences, Jagiellonian University Medical College, Krakow, Poland
| | - Paweł Kleczyński
- Clinical Department of Interventional Cardiology, John Paul II Hospital, Krakow, Poland
- Department of Interventional Cardiology, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Bartłomiej Guzik
- Clinical Department of Interventional Cardiology, John Paul II Hospital, Krakow, Poland
- Department of Interventional Cardiology, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Piotr Szolc
- Clinical Department of Interventional Cardiology, John Paul II Hospital, Krakow, Poland
- Department of Interventional Cardiology, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Jakub Baran
- Clinical Department of Interventional Cardiology, John Paul II Hospital, Krakow, Poland
- Department of Interventional Cardiology, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Jakub Podolec
- Clinical Department of Interventional Cardiology, John Paul II Hospital, Krakow, Poland
- Department of Interventional Cardiology, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Marta Diachyshyn
- Clinical Department of Interventional Cardiology, John Paul II Hospital, Krakow, Poland
| | - Krzysztof Żmudka
- Clinical Department of Interventional Cardiology, John Paul II Hospital, Krakow, Poland
- Department of Interventional Cardiology, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Jacek Legutko
- Clinical Department of Interventional Cardiology, John Paul II Hospital, Krakow, Poland.
- Department of Interventional Cardiology, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland.
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Legutko J, Niewiara L, Guzik B, Szolc P, Podolec J, Nosal M, Diachyshyn M, Zmudka K, Kleczynski P. The impact of coronary microvascular dysfunction on the discordance between fractional flow reserve and resting full-cycle ratio in patients with chronic coronary syndromes. Front Cardiovasc Med 2022; 9:1003067. [PMID: 36277746 PMCID: PMC9581189 DOI: 10.3389/fcvm.2022.1003067] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 08/29/2022] [Indexed: 11/26/2022] Open
Abstract
Background Resting full-cycle ratio (RFR) is an alternative to fractional flow reserve (FFR) for the evaluation of borderline coronary artery lesions. Although FFR and RFR results are discordant in some cases, factors associated with the discordance remain unclear. The role of coronary microvascular dysfunction (CMD) is discussed as a potential mechanism to explain these discrepancies. Aim The study aimed to assess concordance between RFR and FFR in a real-life cohort from a high-volume center regarding the role of CMD. Methods Consecutive patients with borderline coronary lesions undergoing coronary functional testing for chronic coronary syndromes were included in the study. Measurements of RFR and FFR were performed alongside additional coronary flow reserve (CFR), resistance reserve ratio (RRR), and an index of microcirculatory resistance (IMR) measurements. CMD was defined according to the current guideline by either IMR ≥25 or CFR ≤2.0 in vessels with no significant stenosis. Results Measurements were performed in 157 coronary arteries, in 101 patients, with a median age of 66 y., 74% male, with prior history of arterial hypertension (96%), dyslipidaemia (91%), and diabetes (40%). The median value of vessel diameter stenosis was 45% according to QCA. Overall, FFR and RFR values were significantly correlated (r = 0.66, p < 0.001), where positive FFR/negative RFR and negative FFR/positive RFR were observed in 6 (3.8%) and 38 (24.2%) of 157 vessels. The RFR/FFR discrepancy was present in 44 (28%) of measurements. CMD was confirmed in 28 (64%) of vessels with discrepant RFR/FFR and in 46 (41%) of vessels with concordant results (p = 0.01). In discordant RFR/FFR vessels, as compared to concordant ones, significantly lower values of CFR [median 1.95 (IQR: 1.37, 2.30) vs. 2.10 (IQR: 1.50, 3.00), p = 0.030] and RRR [median 2.50 (IQR: 1.60, 3.10) vs. 2.90 IQR (1.90, 3.90), p = 0.048] were observed. Main predictors of RFR/FFR discrepancy in a univariate regression analysis were: higher age of patients [OR = 1.06 (1.01; 1.10), p = 0.010], presence of CMD [OR = 2.51 (1.23; 5.25), p = 0.012], lower CFR [OR = 1.64 (1.12; 2.56), p = 0.018], and lower RRR values [OR = 1.35 (95% CI: 1.03; 1.83), p = 0.038]. Conclusion In discrepant RFR/FFR vessels, CMD is more prevalent than in concordant RFR/FFR measurements, which can be driven by lower CFR or RRR values. Further research is needed to confirm this observation.
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Affiliation(s)
- Jacek Legutko
- Department of Interventional Cardiology, Institute of Cardiology, Jagiellonian University Medical College, John Paul II Hospital, Krakow, Poland,Clinical Department of Interventional Cardiology, John Paul II Hospital, Krakow, Poland
| | - Lukasz Niewiara
- Clinical Department of Interventional Cardiology, John Paul II Hospital, Krakow, Poland,Department of Emergency Medicine, Faculty of Health Sciences, Jagiellonian University Medical College, Krakow, Poland
| | - Bartlomiej Guzik
- Department of Interventional Cardiology, Institute of Cardiology, Jagiellonian University Medical College, John Paul II Hospital, Krakow, Poland,Clinical Department of Interventional Cardiology, John Paul II Hospital, Krakow, Poland
| | - Piotr Szolc
- Department of Interventional Cardiology, Institute of Cardiology, Jagiellonian University Medical College, John Paul II Hospital, Krakow, Poland,Clinical Department of Interventional Cardiology, John Paul II Hospital, Krakow, Poland
| | - Jakub Podolec
- Department of Interventional Cardiology, Institute of Cardiology, Jagiellonian University Medical College, John Paul II Hospital, Krakow, Poland,Clinical Department of Interventional Cardiology, John Paul II Hospital, Krakow, Poland
| | - Marcin Nosal
- Center of Invasive Cardiology, Angiology and Electrotherapy, Krosno, Poland
| | - Marta Diachyshyn
- Clinical Department of Interventional Cardiology, John Paul II Hospital, Krakow, Poland
| | - Krzysztof Zmudka
- Department of Interventional Cardiology, Institute of Cardiology, Jagiellonian University Medical College, John Paul II Hospital, Krakow, Poland,Clinical Department of Interventional Cardiology, John Paul II Hospital, Krakow, Poland
| | - Paweł Kleczynski
- Department of Interventional Cardiology, Institute of Cardiology, Jagiellonian University Medical College, John Paul II Hospital, Krakow, Poland,Clinical Department of Interventional Cardiology, John Paul II Hospital, Krakow, Poland,*Correspondence: Paweł Kleczynski
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Contrast medium Pd/Pa ratio in comparison to fractional flow reserve, quantitative flow ratio and instantaneous wave-free ratio for evaluation of intermediate coronary lesions. ADVANCES IN INTERVENTIONAL CARDIOLOGY 2021; 16:384-390. [PMID: 33598010 PMCID: PMC7863821 DOI: 10.5114/aic.2020.101762] [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: 08/30/2020] [Accepted: 10/01/2020] [Indexed: 01/10/2023] Open
Abstract
Introduction Contrast medium Pd/Pa ratio (cFFR) was introduced as an alternative to fractional flow reserve (FFR). Aim To assess the accuracy of cFFR in predicting of FFR, quantitative flow ratio (QFR) and instantaneous wave-free ratio (iFR). Material and methods Resting Pd/Pa, cFFR, FFR, QFR, and iFR were measured in 110 intermediate coronary lesions. cFFR was obtained after intracoronary injection of contrast medium. FFR was measured after the intravenous administration of adenosine. QFR was derived from fixed empiric hyperemic flow velocity based on coronary angiography. iFR was calculated by measuring the resting pressure gradient across a coronary lesion during diastole. Results Forty-four patients with 110 intermediate coronary lesions were enrolled. Mean baseline Pd/Pa was 0.93 ±0.05. Mean cFFR value was similar to FFR value (0.83 ±0.09 vs. 0.81 ±0.09; p = 0.13) and QFR (0.81 ±0.1; p = 0.69) and iFR (0.90 ±0.07; p = 0.1). A total of 46 vessels (41.8%) had FFR ≤ 0.80, 50 (45.5%) vessels had cFFR ≤ 0.83, 44 (40.0%) vessels had QFR ≤ 0.80, and 38 (34.5%) vessels had iFR ≤ 0.89. An excellent agreement between cFFR and resting Pd/Pa, FFR, QFR, and iFR was confirmed (intraclass correlation coefficients of 0.83, 0.99, 0.98, and 0.88, respectively). The optimal cutoff value of cFFR was 0.83 for prediction of FFR ≤ 0.80 with sensitivity, specificity, and accuracy of 96.9%, 97.8%, and 97.3%, respectively. 100% sensitivity was observed for a cutoff value of 0.82 and 100% specificity for a cutoff value of 0.84; AUC = 0.998 (0.995–1.00); p < 0.001. Conclusions Contrast medium Pd/Pa ratio seems to be accurate in predicting the functional significance of borderline coronary lesions assessed with FFR, iFR, and QFR.
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Kleczyński P, Dziewierz A, Rzeszutko L, Dudek D, Legutko J. Is quantitative flow ratio enough to accurately assess intermediate coronary stenosis? A comparison study with fractional flow reserve. Cardiol J 2020; 26:793-795. [PMID: 31970737 DOI: 10.5603/cj.2019.0116] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 11/14/2019] [Accepted: 11/14/2019] [Indexed: 11/25/2022] Open
Affiliation(s)
| | - Artur Dziewierz
- 2nd Department of Cardiology, Institute of Cardiology, Jagiellonian University Medical College, 17 Kopernika St., 31-501, Krakow, Poland
| | - Lukasz Rzeszutko
- 2nd Department of Cardiology, Institute of Cardiology, Jagiellonian University Medical College, 17 Kopernika St., 31-501, Krakow, Poland
| | - Dariusz Dudek
- 2nd Department of Cardiology, Institute of Cardiology, Jagiellonian University Medical College, 17 Kopernika St., 31-501, Krakow, Poland
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