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Milzi A, Dettori R, Marx N, Reith S, Burgmaier M. Quantitative flow ratio (QFR) identifies functional relevance of non-culprit lesions in coronary angiographies of patients with acute myocardial infarction. Clin Res Cardiol 2021; 110:1659-1667. [PMID: 34251507 PMCID: PMC8484103 DOI: 10.1007/s00392-021-01897-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 06/14/2021] [Indexed: 11/24/2022]
Abstract
INTRODUCTION In patients with acute myocardial infarction (AMI) and multivessel coronary disease, revascularization of non-culprit lesions guided by proof of ischemia usually requires staged ischemia testing. 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 AMI patients is unknown. In this study, we tested the diagnostic value of QFR based on acute angiograms (aQFR) during AMI to assess the hemodynamic relevance of non-culprit lesions. METHODS We retrospectively assessed the diagnostic efficiency of aQFR in 280 vessels from 220 patients, comparing it with staged ischemia testing using elective coronary angiography with FFR (n = 47), stress cardiac MRI (n = 200) or SPECT (n = 33). RESULTS aQFR showed a very good diagnostic efficiency (AUC = 0.887, 95% CI 0.832-0.943, p < 0.001) in predicting ischemia of non-culprit lesions, significantly superior to coronary lesion's geometry as assessed by quantitative coronary angiography. The optimal cut-off for aQFR to predict ischemia was 0.80 (sensitivity = 83.7%, specificity = 86.1%). Maintaining a predefined level of 95% sensitivity and specificity, we created a decision model based on aQFR: lesions with aQFR ≤ 0.75 should be treated, lesions with aQFR ≥ 0.92 do not yield any hemodynamic relevance, and lesions in the "grey zone" (aQFR 0.75-0.92) benefit from further ischemia testings. This model would allow to reduce staged ischemia tests by 46.8% without a relevant loss in diagnostic efficiency. CONCLUSION Our data demonstrate that aQFR allows an effective assessment of hemodynamic relevance of non-culprit lesions in AMI and may guide interventions of non-culprit coronary lesions.
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Affiliation(s)
- Andrea Milzi
- Department of Cardiology, University Hospital, RWTH Aachen University, Aachen, Germany.
- Department of Internal Medicine I, University Hospital of the RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Germany.
| | - Rosalia Dettori
- Department of Cardiology, University Hospital, RWTH Aachen University, Aachen, Germany
| | - Nikolaus Marx
- Department of Cardiology, University Hospital, RWTH Aachen University, Aachen, Germany
| | - Sebastian Reith
- Department of Cardiology, University Hospital, RWTH Aachen University, Aachen, Germany
| | - Mathias Burgmaier
- Department of Cardiology, University Hospital, RWTH Aachen University, Aachen, Germany
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Opincariu D, Rodean I, Rat N, Hodas R, Benedek I, Benedek T. Systemic Vulnerability, as Expressed by I-CAM and MMP-9 at Presentation, Predicts One Year Outcomes in Patients with Acute Myocardial Infarction-Insights from the VIP Clinical Study. J Clin Med 2021; 10:jcm10153435. [PMID: 34362217 PMCID: PMC8347806 DOI: 10.3390/jcm10153435] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 07/28/2021] [Accepted: 07/29/2021] [Indexed: 12/18/2022] Open
Abstract
(1) Background: The prediction of recurrent events after acute myocardial infarction (AMI) does not sufficiently integrate systemic inflammation, coronary morphology or ventricular function in prediction algorithms. We aimed to evaluate the accuracy of inflammatory biomarkers, in association with angiographical and echocardiographic parameters, in predicting 1-year MACE after revascularized AMI. (2) Methods: This is an extension of a biomarker sub-study of the VIP trial (NCT03606330), in which 225 AMI patients underwent analysis of systemic vulnerability and were followed for 1 year. Hs-CRP, MMP-9, IL-6, I-CAM, V-CAM and E-selectin were determined at 1 h after revascularization. The primary end-point was the 1-year MACE rate. (3) Results: The MACE rate was 24.8% (n = 56). There were no significant differences between groups in regard to IL-6, V-CAM and E-selectin. The following inflammatory markers were significantly higher in MACE patients: hs-CRP (11.1 ± 13.8 vs. 5.1 ± 4.4 mg/L, p = 0.03), I-CAM (452 ± 283 vs. 220.5 ± 104.6, p = 0.0003) and MMP-9 (2255 ± 1226 vs. 1099 ± 706.1 ng/mL p = 0.0001). The most powerful predictor for MACE was MMP-9 of >1155 ng/mL (AUC-0.786, p < 0.001) even after adjustments for diabetes, LVEF, acute phase complications and other inflammatory biomarkers. For STEMI, the most powerful predictors for MACE included I-CAM > 239.7 ng/mL, V-CAM > 877.9 ng/mL and MMP-9 > 1393 ng/mL. (4) Conclusions: High levels of I-CAM and MMP-9 were the most powerful predictors for recurrent events after AMI for the overall study population. For STEMI subjects, the most important predictors included increased levels of I-CAM, V-CAM and MMP-9, while none of the analyzed parameters had proven to be predictive. Inflammatory biomarkers assayed during the acute phase of AMI presented a more powerful predictive capacity for MACE than the LVEF.
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Affiliation(s)
- Diana Opincariu
- Department of Cardiology, University of Medicine, Pharmacy, Sciences and Technology “George Emil Palade”, 540142 Târgu Mureș, Romania; (I.R.); (N.R.); (I.B.); (T.B.)
- Cardiomed Medical Center, 22 December 1989 Street, No. 76, 540124 Târgu Mureș, Romania
- Correspondence: or (D.O.); or (R.H.); Tel.: +40-756-787-587 (D.O.); +40-742-385-600 (R.H.)
| | - Ioana Rodean
- Department of Cardiology, University of Medicine, Pharmacy, Sciences and Technology “George Emil Palade”, 540142 Târgu Mureș, Romania; (I.R.); (N.R.); (I.B.); (T.B.)
| | - Nora Rat
- Department of Cardiology, University of Medicine, Pharmacy, Sciences and Technology “George Emil Palade”, 540142 Târgu Mureș, Romania; (I.R.); (N.R.); (I.B.); (T.B.)
- Cardiomed Medical Center, 22 December 1989 Street, No. 76, 540124 Târgu Mureș, Romania
| | - Roxana Hodas
- Department of Cardiology, University of Medicine, Pharmacy, Sciences and Technology “George Emil Palade”, 540142 Târgu Mureș, Romania; (I.R.); (N.R.); (I.B.); (T.B.)
- Correspondence: or (D.O.); or (R.H.); Tel.: +40-756-787-587 (D.O.); +40-742-385-600 (R.H.)
| | - Imre Benedek
- Department of Cardiology, University of Medicine, Pharmacy, Sciences and Technology “George Emil Palade”, 540142 Târgu Mureș, Romania; (I.R.); (N.R.); (I.B.); (T.B.)
- Cardiomed Medical Center, 22 December 1989 Street, No. 76, 540124 Târgu Mureș, Romania
| | - Theodora Benedek
- Department of Cardiology, University of Medicine, Pharmacy, Sciences and Technology “George Emil Palade”, 540142 Târgu Mureș, Romania; (I.R.); (N.R.); (I.B.); (T.B.)
- Cardiomed Medical Center, 22 December 1989 Street, No. 76, 540124 Târgu Mureș, Romania
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Baumann AAW, Mishra A, Worthley MI, Nelson AJ, Psaltis PJ. Management of multivessel coronary artery disease in patients with non-ST-elevation myocardial infarction: a complex path to precision medicine. Ther Adv Chronic Dis 2020; 11:2040622320938527. [PMID: 32655848 PMCID: PMC7331770 DOI: 10.1177/2040622320938527] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 05/26/2020] [Indexed: 12/15/2022] Open
Abstract
Recent analyses suggest the incidence of acute coronary syndrome is declining in high- and middle-income countries. Despite this, overall rates of non-ST-elevation myocardial infarction (NSTEMI) continue to rise. Furthermore, NSTEMI is a greater contributor to mortality after hospital discharge than ST-elevation myocardial infarction (STEMI). Patients with NSTEMI are often older, comorbid and have a high likelihood of multivessel coronary artery disease (MVD), which is associated with worse clinical outcomes. Currently, optimal treatment strategies for MVD in NSTEMI are less well established than for STEMI or stable coronary artery disease. Specifically, in relation to percutaneous coronary intervention (PCI) there is a paucity of randomized, prospective data comparing multivessel and culprit lesion-only PCI. Given the heterogeneous pathological basis for NSTEMI with MVD, an approach of complete revascularization may not be appropriate or necessary in all patients. Recognizing this, this review summarizes the limited evidence base for the interventional management of non-culprit disease in NSTEMI by comparing culprit-only and multivessel PCI strategies. We then explore how a personalized, precise approach to investigation, therapy and follow up may be achieved based on patient-, disease- and lesion-specific factors.
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Affiliation(s)
- Angus A. W. Baumann
- Department of Cardiology, Central Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Aashka Mishra
- Flinders Medical School, Flinders University, Adelaide, South Australia, Australia
| | - Matthew I. Worthley
- Department of Cardiology, Central Adelaide Local Health Network, Adelaide, South Australia, Australia
- Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - Adam J. Nelson
- Duke Clinical Research Institute, Durham, NC, USA
- Vascular Research Centre, Lifelong Health Theme, South Australian Health & Medical Research Institute, Adelaide, South Australia, Australia
- Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
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Safety and Efficacy of Embolic Protection Devices in Saphenous Vein Graft Interventions: A Propensity Score Analysis-Multicenter SVG PCI PROTECTA Study. J Clin Med 2020; 9:jcm9041198. [PMID: 32331299 PMCID: PMC7230434 DOI: 10.3390/jcm9041198] [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: 03/14/2020] [Revised: 04/06/2020] [Accepted: 04/20/2020] [Indexed: 11/23/2022] Open
Abstract
Background: Evidence concerning the efficacy of the embolic protection devices (EPDs) in saphenous vein graft (SVG) percutaneous coronary intervention (PCI) is sparse. The study was designed to compare major cardiovascular events of all-comer population of SVG PCI with and without EPDs at one year of follow-up. Methods and results: A multi-center registry comparing PCI with and without EPDs in consecutive patients undergoing PCI of SVG. The group comprised 792 patients, among which 266 (33.6%) had myocardial infarction (MI). The primary composite endpoint was major adverse cardiac and cerebrovascular event (MACCE) defined as death, MI, target vessel revascularization (TVR), and stroke assessed at one year. After propensity score analysis, there were no differences in MACCE (21.9% vs. 23.9%; HR 0.91, 95% CI 0.57–1.45, p = 0.681, respectively) nor in secondary endpoints of death, MI, TVR, target lesion revascularization (TLR) and stroke at one year in EPDs PCI group vs. no-EPDs PCI group. Similarly, there were no differences between groups in the study endpoints at 30 days follow-up. Conclusions: There were no clinical benefit for routine use of EPDs during SVG PCI in short and long-term follow-up. Further studies are warranted to explore the effect of individual types of EPDs on clinical outcomes.
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Revascularization strategies for patients with myocardial infarction and multi-vessel disease: A critical appraisal of the current evidence. J Geriatr Cardiol 2019; 16:717-723. [PMID: 31645859 PMCID: PMC6790959 DOI: 10.11909/j.issn.1671-5411.2019.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Approximately half of patients presenting with myocardial infarction are found to have non-infarct related multi-vessel severe coronary artery disease. Various observational studies and randomized controlled trials have been conducted to assess if revascularization of non-infarct related artery is associated with better clinical outcomes. In this review, the authors discuss the various revascularization strategies in patients with multi-vessel disease who present with myocardial infarction.
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