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Hoshino M, Jukema RA, Pijls N, Hoek R, Raijmakers P, Driessen R, van Diemen P, Twisk J, van der Hoef T, Danad I, Kakuta T, Knaapen P. Microvascular resistance reserve before and after PCI: A serial FFR and [ 15O] H 2O PET study. Atherosclerosis 2024:117555. [PMID: 38702268 DOI: 10.1016/j.atherosclerosis.2024.117555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 04/03/2024] [Accepted: 04/12/2024] [Indexed: 05/06/2024]
Abstract
BACKGROUND AND AIMS Microvascular Resistance Reserve (MRR) has recently been introduced as a microvasculature-specific index and hypothesized to be independent of coronary stenosis. The aim of this study was to investigate the change of MRR after percutaneous coronary intervention (PCI). METHODS In this post-hoc analysis from the PACIFC trials, symptomatic patients underwent [15O]H2O positron emission tomography (PET) and invasive fractional flow reserve (FFR) before and after revascularization. Coronary flow reserve (CFR) from PET and invasive FFR were used to calculate MRR. RESULTS Among 52 patients (87 % male, age 59.4 ± 9.4 years), 61 vessels with a median FFR of 0.71 (95 % confidence interval: 0.55 to 0.74) and a mean MRR of 3.80 ± 1.23 were included. Following PCI, FFR, hyperemic myocardial blood flow (hMBF) and CFR increased significantly (all p-values ≤0.001). MRR remained unchanged after PCI (3.80 ± 1.23 before PCI versus 3.60 ± 0.97 after PCI; p=0.23). In vessels with a pre-PCI, FFR ≤0.70 pre- and post-PCI MRR were 3.90 ± 1.30 and 3.73 ± 1.14 (p=0.56), respectively. Similar findings were observed for vessels with a FFR between 0.71 and 0.80 (pre-PCI MRR 3.70 ± 1.17 vs. post PCI MRR 3.48 ± 0.76, p=0.19). CONCLUSIONS Our study indicates that MRR, assessed using a hybrid approach of PET and invasive FFR, is independent of the severity of epicardial stenosis. These findings suggest that MRR is a microvasculature-specific parameter.
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Affiliation(s)
- Masahiro Hoshino
- Departments of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam De Boelelaan 1117, 1081 HV Amsterdam, the Netherlands; Department of Cardiology, Tsuchiura Kyodo General Hospital, Japan
| | - Ruurt A Jukema
- Departments of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam De Boelelaan 1117, 1081 HV Amsterdam, the Netherlands
| | - Nico Pijls
- Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands
| | - Roel Hoek
- Departments of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam De Boelelaan 1117, 1081 HV Amsterdam, the Netherlands
| | - Pieter Raijmakers
- Radiology, Nuclear Medicine & PET Research, Amsterdam UMC, Vrije Universiteit Amsterdam De Boelelaan 1117, 1081 HV Amsterdam, the Netherlands
| | - Roel Driessen
- Departments of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam De Boelelaan 1117, 1081 HV Amsterdam, the Netherlands
| | - Pepijn van Diemen
- Departments of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam De Boelelaan 1117, 1081 HV Amsterdam, the Netherlands
| | - Jos Twisk
- Epidemiology & Data Science, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Tim van der Hoef
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands
| | - Ibrahim Danad
- Departments of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam De Boelelaan 1117, 1081 HV Amsterdam, the Netherlands; Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands
| | - Tsunekazu Kakuta
- Department of Cardiology, Tsuchiura Kyodo General Hospital, Japan
| | - Paul Knaapen
- Departments of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam De Boelelaan 1117, 1081 HV Amsterdam, the Netherlands.
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2
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Somsen YBO, de Winter RW, Schumacher SP, van Veelen A, van Diemen PA, Jukema RA, Hoek R, Stuijfzand WJ, Danad I, Twisk JWR, Verouden NJ, Appelman Y, Nap A, Kleijn SA, Henriques JP, Knaapen P. Impact of sex on myocardial perfusion following percutaneous coronary intervention of chronic total coronary occlusions. Cardiovasc Revasc Med 2024:S1553-8389(24)00166-0. [PMID: 38658269 DOI: 10.1016/j.carrev.2024.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Revised: 03/14/2024] [Accepted: 04/09/2024] [Indexed: 04/26/2024]
Abstract
OBJECTIVES We sought to investigate the impact of sex on myocardial perfusion changes following chronic total coronary occlusion (CTO) percutaneous coronary intervention (PCI) as measured by [15O]H2O positron-emission tomography (PET) perfusion imaging. BACKGROUND CTO PCI has been associated with an increase in myocardial perfusion, yet females are less likely to undergo revascularization. As such, data on the impact of sex on myocardial perfusion following CTO PCI is scarce. METHODS A total of 212 patients were prospectively enrolled and underwent CTO PCI combined with [15O]H2O PET perfusion imaging prior to and 3 months after PCI. Hyperemic myocardial blood flow (hMBF, mL·min-1·g-1) and coronary flow reserve (CFR) allocated to the CTO territory were quantitatively assessed. RESULTS This study comprised 34 (16 %) females and 178 (84 %) males. HMBF at baseline did not differ between sexes. Females showed a higher increase in hMBF than males (Δ1.34 ± 0.67 vs. Δ1.06 ± 0.74, p = 0.044), whereas post-PCI hMBF was comparable (2.59 ± 0.85 in females vs. 2.28 ± 0.84 in males, p = 0.052). Female sex was independently associated with a higher increase in hMBF after correction for clinical covariates. CFR increase after revascularization was similar in females and males (Δ1.47 ± 0.99 vs. Δ1.30 ± 1.14, p = 0.711). CONCLUSIONS The present study demonstrates a greater recovery of stress perfusion in females compared to males as measured by serial [15O]H2O PET imaging. In addition, a comparable increase in CFR was found in females and males. These results emphasize the benefit of performing CTO PCI in both sexes. CLINICAL PERSPECTIVE What is new? What are the clinical implications?
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Affiliation(s)
- Yvemarie B O Somsen
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.
| | - Ruben W de Winter
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.
| | - Stefan P Schumacher
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.
| | - Anna van Veelen
- Department of Cardiology Amsterdam UMC, AMC, Amsterdam, the Netherlands.
| | - Pepijn A van Diemen
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.
| | - Ruurt A Jukema
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.
| | - Roel Hoek
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.
| | - Wynand J Stuijfzand
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.
| | - Ibrahim Danad
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.
| | - Jos W R Twisk
- Department of Epidemiology & Data Science, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.
| | - Niels J Verouden
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.
| | - Yolande Appelman
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.
| | - Alexander Nap
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.
| | - Sebastiaan A Kleijn
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - José P Henriques
- Department of Cardiology Amsterdam UMC, AMC, Amsterdam, the Netherlands.
| | - Paul Knaapen
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.
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3
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Dobrolinska MM, Jukema RA, van Velzen SGM, van Diemen PA, Greuter MJW, Prakken NHJ, van der Werf NR, Raijmakers PG, Slart RHJA, Knaapen P, Isgum I, Danad I. The prognostic value of visual and automatic coronary calcium -scoring from low dose CT-[15O]-water PET. Eur Heart J Cardiovasc Imaging 2024:jeae081. [PMID: 38525588 DOI: 10.1093/ehjci/jeae081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 02/28/2024] [Accepted: 03/06/2024] [Indexed: 03/26/2024] Open
Abstract
PURPOSE Firstly, to validate automatically and visually scored coronary artery calcium (CAC) on low dose CT (LDCT) scans with a dedicated calcium scoring CT (CSCT) scan. Secondly, to assess the added value of CAC scored from LDCT scans acquired during [15O]-water-PET myocardial perfusion imaging (MPI) on prediction of major adverse cardiac events (MACE). METHODS 572 consecutive patients with suspected coronary artery disease, who underwent [15O]-water-PET MPI with LDCT and a dedicated CSCT scan were included. In the reference CSCT scans, manual CAC scoring was performed, while LDCT scans were scored visually and automatically using deep learning approach. Subsequently, based on CAC score results from CSCT and LDCT scans, each patient's scan was assigned to one out of five cardiovascular risk groups (0; 1-100; 101-400; 401-1000; >1000) and the agreement in risk group classification between CSCT and LDCT scans was investigated. MACE was defined as a composite of all-cause death, nonfatal myocardial infarction, coronary revascularization, and unstable angina. RESULTS The agreement in risk group classification between reference CSCT manual scoring and visual/automatic LDCT scoring from LDCT was 0.66 (95% CI: 0.62-0.70) and 0.58 (95% CI: 0.53-0.62), respectively. Based on visual and automatic CAC scoring from LDCT scans, patients with CAC>100 and CAC>400, respectively, were at increased risk of MACE, independently of ischemic information from the [15O]-water-PET scan. CONCLUSIONS There is a moderate agreement in risk classification between visual and automatic CAC scoring from LDCT and reference CSCT scans. Visual and automatic CAC scoring from LDCT scans improve identification of patients at higher risk of MACE.
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Affiliation(s)
- M M Dobrolinska
- Medical Imaging Center, Departments of Radiology, Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, PO Box 30.001, 9700 RB Groningen, The Netherlands
| | - R A Jukema
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, the Netherlands
| | - S G M van Velzen
- Department of Biomedical Engineering and Physics, Amsterdam UMC location University of Amsterdam, the Netherlands
- Informatics Institute, University of Amsterdam, the Netherlands
- Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - P A van Diemen
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, the Netherlands
| | - M J W Greuter
- Medical Imaging Center, Departments of Radiology, Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, PO Box 30.001, 9700 RB Groningen, The Netherlands
- Department of Robotics and Mechatronics, Faculty of Electrical Engineering, Mathematics & Computer Science, University of Twente, P.O. Box 217, 7500 AE Enschede, Netherlands
| | - N H J Prakken
- Medical Imaging Center, Departments of Radiology, Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, PO Box 30.001, 9700 RB Groningen, The Netherlands
| | - N R van der Werf
- Department of Radiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - P G Raijmakers
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117
| | - R H J A Slart
- Medical Imaging Center, Departments of Radiology, Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, PO Box 30.001, 9700 RB Groningen, The Netherlands
- Department of Biomedical Photonic Imaging, Faculty of Science and Technology, University of Twente, Drienerlolaan 5, 7522 NB Enschede, The Netherlands
| | - P Knaapen
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, the Netherlands
| | - I Isgum
- Department of Biomedical Engineering and Physics, Amsterdam UMC location University of Amsterdam, the Netherlands
- Informatics Institute, University of Amsterdam, the Netherlands
- Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Amsterdam UMC location University of Amsterdam, the Netherlands
| | - I Danad
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
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4
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Nurmohamed NS, Danad I, Jukema RA, de Winter RW, de Groot RJ, Driessen RS, Bom MJ, van Diemen P, Pontone G, Andreini D, Chang HJ, Katz RJ, Stroes ESG, Wang H, Chan C, Crabtree T, Aquino M, Min JK, Earls JP, Bax JJ, Choi AD, Knaapen P, van Rosendael AR. Development and Validation of a Quantitative Coronary CT Angiography Model for Diagnosis of Vessel-Specific Coronary Ischemia. JACC Cardiovasc Imaging 2024:S1936-878X(24)00039-1. [PMID: 38483420 DOI: 10.1016/j.jcmg.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 11/30/2023] [Accepted: 01/11/2024] [Indexed: 03/27/2024]
Abstract
BACKGROUND Noninvasive stress testing is commonly used for detection of coronary ischemia but possesses variable accuracy and may result in excessive health care costs. OBJECTIVES This study aimed to derive and validate an artificial intelligence-guided quantitative coronary computed tomography angiography (AI-QCT) model for the diagnosis of coronary ischemia that integrates atherosclerosis and vascular morphology measures (AI-QCTISCHEMIA) and to evaluate its prognostic utility for major adverse cardiovascular events (MACE). METHODS A post hoc analysis of the CREDENCE (Computed Tomographic Evaluation of Atherosclerotic Determinants of Myocardial Ischemia) and PACIFIC-1 (Comparison of Coronary Computed Tomography Angiography, Single Photon Emission Computed Tomography [SPECT], Positron Emission Tomography [PET], and Hybrid Imaging for Diagnosis of Ischemic Heart Disease Determined by Fractional Flow Reserve) studies was performed. In both studies, symptomatic patients with suspected stable coronary artery disease had prospectively undergone coronary computed tomography angiography (CTA), myocardial perfusion imaging (MPI), SPECT, or PET, fractional flow reserve by CT (FFRCT), and invasive coronary angiography in conjunction with invasive FFR measurements. The AI-QCTISCHEMIA model was developed in the derivation cohort of the CREDENCE study, and its diagnostic performance for coronary ischemia (FFR ≤0.80) was evaluated in the CREDENCE validation cohort and PACIFIC-1. Its prognostic value was investigated in PACIFIC-1. RESULTS In CREDENCE validation (n = 305, age 64.4 ± 9.8 years, 210 [69%] male), the diagnostic performance by area under the receiver-operating characteristics curve (AUC) on per-patient level was 0.80 (95% CI: 0.75-0.85) for AI-QCTISCHEMIA, 0.69 (95% CI: 0.63-0.74; P < 0.001) for FFRCT, and 0.65 (95% CI: 0.59-0.71; P < 0.001) for MPI. In PACIFIC-1 (n = 208, age 58.1 ± 8.7 years, 132 [63%] male), the AUCs were 0.85 (95% CI: 0.79-0.91) for AI-QCTISCHEMIA, 0.78 (95% CI: 0.72-0.84; P = 0.037) for FFRCT, 0.89 (95% CI: 0.84-0.93; P = 0.262) for PET, and 0.72 (95% CI: 0.67-0.78; P < 0.001) for SPECT. Adjusted for clinical risk factors and coronary CTA-determined obstructive stenosis, a positive AI-QCTISCHEMIA test was associated with an HR of 7.6 (95% CI: 1.2-47.0; P = 0.030) for MACE. CONCLUSIONS This newly developed coronary CTA-based ischemia model using coronary atherosclerosis and vascular morphology characteristics accurately diagnoses coronary ischemia by invasive FFR and provides robust prognostic utility for MACE beyond presence of stenosis.
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Affiliation(s)
- Nick S Nurmohamed
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Division of Cardiology, The George Washington University School of Medicine, Washington, DC, USA.
| | - Ibrahim Danad
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Department of Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Ruurt A Jukema
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Ruben W de Winter
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Robin J de Groot
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Roel S Driessen
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Michiel J Bom
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Pepijn van Diemen
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Gianluca Pontone
- Department of Cardiovascular Imaging, Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | - Daniele Andreini
- Division of University Cardiology, IRCCS Ospedale Galeazzi Sant'Ambrogio, Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Hyuk-Jae Chang
- Division of Cardiology, Severance Cardiovascular Hospital and Severance Biomedical Science Institute, Yonsei University College of Medicine, Yonsei University Health System, Seoul, South Korea
| | - Richard J Katz
- Division of Cardiology, The George Washington University School of Medicine, Washington, DC, USA
| | - Erik S G Stroes
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Hao Wang
- Cleerly Inc, Denver, Colorado, USA
| | | | | | | | | | - James P Earls
- Division of Cardiology, The George Washington University School of Medicine, Washington, DC, USA; Cleerly Inc, Denver, Colorado, USA
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Andrew D Choi
- Division of Cardiology, The George Washington University School of Medicine, Washington, DC, USA
| | - Paul Knaapen
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
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5
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Nurmohamed NS, Bom MJ, Jukema RA, de Groot RJ, Driessen RS, van Diemen PA, de Winter RW, Gaillard EL, Sprengers RW, Stroes ESG, Min JK, Earls JP, Cardoso R, Blankstein R, Danad I, Choi AD, Knaapen P. AI-Guided Quantitative Plaque Staging Predicts Long-Term Cardiovascular Outcomes in Patients at Risk for Atherosclerotic CVD. JACC Cardiovasc Imaging 2024; 17:269-280. [PMID: 37480907 DOI: 10.1016/j.jcmg.2023.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 05/17/2023] [Accepted: 05/30/2023] [Indexed: 07/24/2023]
Abstract
BACKGROUND The recent development of artificial intelligence-guided quantitative coronary computed tomography angiography analysis (AI-QCT) has enabled rapid analysis of atherosclerotic plaque burden and characteristics. OBJECTIVES This study set out to investigate the 10-year prognostic value of atherosclerotic burden derived from AI-QCT and to compare the spectrum of plaque to manually assessed coronary computed tomography angiography (CCTA), coronary artery calcium scoring (CACS), and clinical risk characteristics. METHODS This was a long-term follow-up study of 536 patients referred for suspected coronary artery disease. CCTA scans were analyzed with AI-QCT and plaque burden was classified with a plaque staging system (stage 0: 0% percentage atheroma volume [PAV]; stage 1: >0%-5% PAV; stage 2: >5%-15% PAV; stage 3: >15% PAV). The primary major adverse cardiac event (MACE) outcome was a composite of nonfatal myocardial infarction, nonfatal stroke, coronary revascularization, and all-cause mortality. RESULTS The mean age at baseline was 58.6 years and 297 patients (55%) were male. During a median follow-up of 10.3 years (IQR: 8.6-11.5 years), 114 patients (21%) experienced the primary outcome. Compared to stages 0 and 1, patients with stage 3 PAV and percentage of noncalcified plaque volume of >7.5% had a more than 3-fold (adjusted HR: 3.57; 95% CI 2.12-6.00; P < 0.001) and 4-fold (adjusted HR: 4.37; 95% CI: 2.51-7.62; P < 0.001) increased risk of MACE, respectively. Addition of AI-QCT improved a model with clinical risk factors and CACS at different time points during follow-up (10-year AUC: 0.82 [95% CI: 0.78-0.87] vs 0.73 [95% CI: 0.68-0.79]; P < 0.001; net reclassification improvement: 0.21 [95% CI: 0.09-0.38]). Furthermore, AI-QCT achieved an improved area under the curve compared to Coronary Artery Disease Reporting and Data System 2.0 (10-year AUC: 0.78; 95% CI: 0.73-0.83; P = 0.023) and manual QCT (10-year AUC: 0.78; 95% CI: 0.73-0.83; P = 0.040), although net reclassification improvement was modest (0.09 [95% CI: -0.02 to 0.29] and 0.04 [95% CI: -0.05 to 0.27], respectively). CONCLUSIONS Through 10-year follow-up, AI-QCT plaque staging showed important prognostic value for MACE and showed additional discriminatory value over clinical risk factors, CACS, and manual guideline-recommended CCTA assessment.
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Affiliation(s)
- Nick S Nurmohamed
- Department of Cardiology, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Department of Vascular Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands; Division of Cardiology, The George Washington University School of Medicine, Washington, DC, USA. https://twitter.com/NickNurmohamed
| | - Michiel J Bom
- Department of Cardiology, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Ruurt A Jukema
- Department of Cardiology, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Robin J de Groot
- Department of Cardiology, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Roel S Driessen
- Department of Cardiology, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Pepijn A van Diemen
- Department of Cardiology, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Ruben W de Winter
- Department of Cardiology, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Emilie L Gaillard
- Department of Cardiology, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Department of Vascular Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Ralf W Sprengers
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Erik S G Stroes
- Department of Vascular Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | | | - James P Earls
- Division of Cardiology, The George Washington University School of Medicine, Washington, DC, USA; Cleerly Inc, Denver, Colorado, USA
| | - Rhanderson Cardoso
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ron Blankstein
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ibrahim Danad
- Department of Cardiology, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Department of Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Andrew D Choi
- Division of Cardiology, The George Washington University School of Medicine, Washington, DC, USA.
| | - Paul Knaapen
- Department of Cardiology, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
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6
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de Winter RW, van Diemen PA, Schumacher SP, Jukema RA, Somsen YBO, Hoek R, van Rossum AC, Twisk JWR, de Waard GA, Nap A, Raijmakers PG, Driessen RS, Knaapen P, Danad I. Hemodynamic Insights into Combined Fractional Flow Reserve and Instantaneous Wave-Free Ratio Assessment Through Quantitative [ 15O]H 2O PET Myocardial Perfusion Imaging. J Nucl Med 2024; 65:279-286. [PMID: 38176722 DOI: 10.2967/jnumed.123.265973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 11/01/2023] [Indexed: 01/06/2024] Open
Abstract
In patients evaluated for obstructive coronary artery disease (CAD), guidelines recommend using either fractional flow reserve (FFR) or instantaneous wave-free ratio (iFR) to guide coronary revascularization decision-making. The hemodynamic significance of lesions with discordant FFR and iFR measurements is debated. This study compared [15O]H2O PET-derived absolute myocardial perfusion between vessels with concordant and discordant FFR and iFR measurements. Methods: We included 197 patients suspected of obstructive CAD who had undergone [15O]H2O PET perfusion imaging and combined FFR/iFR interrogation in 468 vessels. Resting myocardial blood flow (MBF), hyperemic MBF, and coronary flow reserve (CFR) were compared among 4 groups: FFR low/iFR low (n = 79), FFR high/iFR low (n = 22), FFR low/iFR high (n = 22), and FFR high/iFR high (n = 345). Predefined [15O]H2O PET thresholds for ischemia were 2.3 mL·min-1·g-1 or less for hyperemic MBF and 2.5 or less for CFR. Results: Hyperemic MBF was lower in the concordant low (2.09 ± 0.67 mL·min-1·g-1), FFR high/iFR low (2.41 ± 0.80 mL·min-1·g-1), and FFR low/iFR high (2.40 ± 0.69 mL·min-1·g-1) groups compared with the concordant high group (2.91 ± 0.84 mL·min-1·g-1) (P < 0.001, P = 0.004, and P < 0.001, respectively). A lower CFR was observed in the concordant low (2.37 ± 0.76) and FFR high/iFR low (2.64 ± 0.84) groups compared with the concordant high group (3.35 ± 1.07, P < 0.01 for both). However, for vessels with either low FFR or low iFR, quantitative hyperemic MBF and CFR values exceeded the ischemic threshold in 38% and 49%, respectively. In addition, resting MBF exhibited a negative correlation with iFR (P < 0.001) and was associated with FFR low/iFR high discordance compared with concordant low FFR/low iFR measurements, independent of clinical and angiographic characteristics, as well as hyperemic MBF (odds ratio [OR], 0.41; 95% CI, 0.26-0.65; P < 0.001). Conclusion: We found reduced myocardial perfusion in vessels with concordant low and discordant FFR/iFR measurements. However, FFR/iFR combinations often inaccurately classified vessels as either ischemic or nonischemic when compared with hyperemic MBF and CFR. Furthermore, a lower resting MBF was associated with a higher iFR and the occurrence of FFR low/iFR high discordance. Our study showed that although combined FFR/iFR assessment can be useful to estimate the hemodynamic significance of coronary lesions, these pressure-derived indices provide a limited approximation of [15O]H2O PET-derived quantitative myocardial perfusion as the physiologic standard of CAD severity.
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Affiliation(s)
- Ruben W de Winter
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Pepijn A van Diemen
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Stefan P Schumacher
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Ruurt A Jukema
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Yvemarie B O Somsen
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Roel Hoek
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Albert C van Rossum
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Jos W R Twisk
- Department of Epidemiology and Data Science, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands; and
| | - Guus A de Waard
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Alexander Nap
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Pieter G Raijmakers
- Department of Radiology, Nuclear Medicine, and PET Research, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Roel S Driessen
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Paul Knaapen
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands;
| | - Ibrahim Danad
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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7
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van Diemen PA, de Winter RW, Schumacher SP, Everaars H, Bom MJ, Jukema RA, Somsen YB, Raijmakers PG, Kooistra RA, Timmer J, Maaniitty T, Robbers LF, von Bartheld MB, Demirkiran A, van Rossum AC, Reiber JH, Knuuti J, Underwood SR, Nagel E, Knaapen P, Driessen RS, Danad I. The diagnostic performance of quantitative flow ratio and perfusion imaging in patients with prior coronary artery disease. Eur Heart J Cardiovasc Imaging 2023; 25:116-126. [PMID: 37578007 PMCID: PMC10735295 DOI: 10.1093/ehjci/jead197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 07/07/2023] [Accepted: 07/20/2023] [Indexed: 08/15/2023] Open
Abstract
AIMS In chronic coronary syndrome (CCS) patients with documented coronary artery disease (CAD), ischaemia detection by myocardial perfusion imaging (MPI) and an invasive approach are viable diagnostic strategies. We compared the diagnostic performance of quantitative flow ratio (QFR) with single-photon emission computed tomography (SPECT), positron emission tomography (PET), and cardiac magnetic resonance imaging (CMR) in patients with prior CAD [previous percutaneous coronary intervention (PCI) and/or myocardial infarction (MI)]. METHODS AND RESULTS This PACIFIC-2 sub-study evaluated 189 CCS patients with prior CAD for inclusion. Patients underwent SPECT, PET, and CMR followed by invasive coronary angiography with fractional flow reserve (FFR) measurements of all major coronary arteries (N = 567), except for vessels with a sub-total or chronic total occlusion. Quantitative flow ratio computation was attempted in 488 (86%) vessels with measured FFR available (FFR ≤0.80 defined haemodynamically significant CAD). Quantitative flow ratio analysis was successful in 334 (68%) vessels among 166 patients and demonstrated a higher accuracy (84%) and sensitivity (72%) compared with SPECT (66%, P < 0.001 and 46%, P = 0.001), PET (65%, P < 0.001 and 58%, P = 0.032), and CMR (72%, P < 0.001 and 33%, P < 0.001). The specificity of QFR (87%) was similar to that of CMR (83%, P = 0.123) but higher than that of SPECT (71%, P < 0.001) and PET (67%, P < 0.001). Lastly, QFR exhibited a higher area under the receiver operating characteristic curve (0.89) than SPECT (0.57, P < 0.001), PET (0.66, P < 0.001), and CMR (0.60, P < 0.001). CONCLUSION QFR correlated better with FFR in patients with prior CAD than MPI, as reflected in the higher diagnostic performance measures for detecting FFR-defined, vessel-specific, significant CAD.
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Affiliation(s)
- Pepijn A van Diemen
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam 1081 HV, The Netherlands
| | - Ruben W de Winter
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam 1081 HV, The Netherlands
| | - Stefan P Schumacher
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam 1081 HV, The Netherlands
| | - Henk Everaars
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam 1081 HV, The Netherlands
| | - Michiel J Bom
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam 1081 HV, The Netherlands
| | - Ruurt A Jukema
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam 1081 HV, The Netherlands
| | - Yvemarie B Somsen
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam 1081 HV, The Netherlands
| | - Pieter G Raijmakers
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | | | | | - Teemu Maaniitty
- Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland
| | - Lourens F Robbers
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam 1081 HV, The Netherlands
| | - Martin B von Bartheld
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam 1081 HV, The Netherlands
| | - Ahmet Demirkiran
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam 1081 HV, The Netherlands
| | - Albert C van Rossum
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam 1081 HV, The Netherlands
| | | | - Juhani Knuuti
- Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland
| | | | - Eike Nagel
- Institute of Experimental and Translational Cardiovascular Imaging, DZHK Centre for Cardiovascular Imaging, University Hospital Frankfurt am Main, Frankfurt am Main, Germany
| | - Paul Knaapen
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam 1081 HV, The Netherlands
| | - Roel S Driessen
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam 1081 HV, The Netherlands
| | - Ibrahim Danad
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam 1081 HV, The Netherlands
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8
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Somsen YBO, de Winter RW, Giunta R, Schumacher SP, van Diemen PA, Jukema RA, Stuijfzand WJ, Danad I, Lissenberg-Witte BI, Verouden NJ, Nap A, Kleijn SA, Galassi AR, Henriques JP, Knaapen P. Collateral grading systems in retrograde percutaneous coronary intervention of chronic total occlusions. Catheter Cardiovasc Interv 2023; 102:844-856. [PMID: 37671770 DOI: 10.1002/ccd.30812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 07/08/2023] [Accepted: 08/15/2023] [Indexed: 09/07/2023]
Abstract
BACKGROUND The Japanese Channel (J-Channel) score was introduced to aid in retrograde percutaneous coronary intervention (PCI) of chronic total coronary occlusions (CTOs). The predictive value of the J-Channel score has not been compared with established collateral grading systems such as the Rentrop classification and Werner grade. AIMS To investigate the predictive value of the J-Channel score, Rentrop classification and Werner grade for successful collateral channel (CC) guidewire crossing and technical CTO PCI success. METHODS A total of 600 prospectively recruited patients underwent CTO PCI. All grading systems were assessed under dual catheter injection. CC guidewire crossing was considered successful if the guidewire reached the distal segment of the CTO vessel through a retrograde approach. Technical CTO PCI success was defined as thrombolysis in myocardial infarction flow grade 3 and residual stenosis <30%. RESULTS Of 600 patients, 257 (43%) underwent CTO PCI through a retrograde approach. Successful CC guidewire crossing was achieved in 208 (81%) patients. The predictive value of the J-Channel score for CC guidewire crossing (area under curve 0.743) was comparable with the Rentrop classification (0.699, p = 0.094) and superior to the Werner grade (0.663, p = 0.002). Technical CTO PCI success was reported in 232 (90%) patients. The Rentrop classification exhibited a numerically higher discriminatory ability (0.676) compared to the J-Channel score (0.664) and Werner grade (0.589). CONCLUSIONS The J-channel score might aid in strategic collateral channel selection during retrograde CTO PCI. However, the J-Channel score, Rentrop classification, and Werner grade have limited value in predicting technical CTO PCI success.
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Affiliation(s)
- Yvemarie B O Somsen
- Departments of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Ruben W de Winter
- Departments of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Rocco Giunta
- Department of Cardiology, University of Palermo, Palermo, Italy
| | - Stefan P Schumacher
- Departments of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Pepijn A van Diemen
- Departments of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Ruurt A Jukema
- Departments of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Wijnand J Stuijfzand
- Departments of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Ibrahim Danad
- Departments of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Cardiology, University of Utrecht, Utrecht, The Netherlands
| | - Birgit I Lissenberg-Witte
- Department of Epidemiology and Data Science, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Niels J Verouden
- Departments of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Alexander Nap
- Departments of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Sebastiaan A Kleijn
- Departments of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | | | - José P Henriques
- Department of Cardiology, Amsterdam UMC, AMC, Amsterdam, The Netherlands
| | - Paul Knaapen
- Departments of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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9
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Jukema RA, de Winter RW, Hopman LHGA, Driessen RS, van Diemen PA, Appelman Y, Twisk JWR, Planken RN, Raijmakers PG, Knaapen P, Danad I. Impact of cardiac history and myocardial scar on increase of myocardial perfusion after revascularization. Eur J Nucl Med Mol Imaging 2023; 50:3897-3909. [PMID: 37561140 PMCID: PMC10611874 DOI: 10.1007/s00259-023-06356-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Accepted: 07/22/2023] [Indexed: 08/11/2023]
Abstract
PURPOSE We sought to assess the impact of coronary revascularization on myocardial perfusion and fractional flow reserve (FFR) in patients without a cardiac history, with prior myocardial infarction (MI) or non-MI percutaneous coronary intervention (PCI). Furthermore, we studied the impact of scar tissue. METHODS Symptomatic patients underwent [15O]H2O positron emission tomography (PET) and FFR before and after revascularization. Patients with prior CAD, defined as prior MI or PCI, underwent scar quantification by magnetic resonance imaging late gadolinium enhancement. RESULTS Among 137 patients (87% male, age 62.2 ± 9.5 years) 84 (61%) had a prior MI or PCI. The increase in FFR and hyperemic myocardial blood flow (hMBF) was less in patients with prior MI or non-MI PCI compared to those without a cardiac history (FFR: 0.23 ± 0.14 vs. 0.20 ± 0.12 vs. 0.31 ± 0.18, p = 0.02; hMBF: 0.54 ± 0.75 vs. 0.62 ± 0.97 vs. 0.91 ± 0.96 ml/min/g, p = 0.04). Post-revascularization FFR and hMBF were similar across patients without a cardiac history or with prior MI or non-MI PCI. An increase in FFR was strongly associated to hMBF increase in patients without a cardiac history or with prior MI/non-MI PCI (r = 0.60 and r = 0.60, p < 0.01 for both). Similar results were found for coronary flow reserve. In patients with prior MI scar was negatively correlated to hMBF increase and independently predictive of an attenuated CFR increase. CONCLUSIONS Post revascularization FFR and perfusion were similar among patients without a cardiac history, with prior MI or non-MI PCI. In patients with prior MI scar burden was associated to an attenuated perfusion increase.
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Affiliation(s)
- Ruurt A Jukema
- Departments of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Ruben W de Winter
- Departments of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Luuk H G A Hopman
- Departments of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Roel S Driessen
- Departments of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Pepijn A van Diemen
- Departments of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Yolande Appelman
- Departments of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Jos W R Twisk
- Epidemiology & Data Science, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - R Nils Planken
- Radiology, Nuclear Medicine & PET Research, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Pieter G Raijmakers
- Radiology, Nuclear Medicine & PET Research, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Paul Knaapen
- Departments of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Ibrahim Danad
- Departments of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
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10
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de Winter RW, Jukema RA, van Diemen PA, Schumacher SP, Somsen YB, van de Hoef TP, van Rossum AC, Twisk JW, Maaniitty T, Knuuti J, Saraste A, Nap A, Raijmakers PG, Danad I, Knaapen P. Prognostic Value of Modified Coronary Flow Capacity Derived From [ 15O]H 2O Positron Emission Tomography Perfusion Imaging. Circ Cardiovasc Imaging 2023; 16:e014845. [PMID: 37725672 PMCID: PMC10510823 DOI: 10.1161/circimaging.122.014845] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 07/26/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND Coronary flow capacity (CFC) is a measure that integrates hyperemic myocardial blood flow and coronary flow reserve to quantify the pathophysiological impact of coronary artery disease on vasodilator capacity. This study explores the prognostic value of modified CFC derived from [15O]H2O positron emission tomography perfusion imaging. METHODS Quantitative rest/stress perfusion measurements were obtained from 1300 patients with known or suspected coronary artery disease. Patients were classified as having myocardial steal (n=38), severely reduced CFC (n=141), moderately reduced CFC (n=394), minimally reduced CFC (n=245), or normal flow (n=482) using previously defined thresholds. The end point was a composite of death and nonfatal myocardial infarction. RESULTS During a median follow-up of 5.5 (interquartile range, 3.7-7.8) years, the end point occurred in 153 (12%) patients. Myocardial steal (hazard ratio [HR], 6.70 [95% CI, 3.21-13.99]; P<0.001), severely reduced CFC (HR, 2.35 [95% CI, 1.16-4.78]; P=0.018), and moderately reduced CFC (HR, 1.95 [95% CI, 1.11-3.41]; P=0.020) were associated with worse prognosis compared with normal flow, after adjusting for clinical characteristics. Similarly, in the overall population, increased resting myocardial blood flow (HR, 3.05 [95% CI, 1.68-5.54]; P<0.001), decreased hyperemic myocardial blood flow (HR, 0.68 [95% CI, 0.52-0.90]; P=0.007) and decreased coronary flow reserve (HR, 0.55 [95% CI, 0.42-0.71]; P<0.001) were independently associated with adverse outcome. In a model adjusted for the combined use of perfusion metrics, modified CFC demonstrated independent prognostic value (overall P=0.017). CONCLUSIONS [15O]H2O positron emission tomography-derived resting myocardial blood flow, hyperemic myocardial blood flow, coronary flow reserve, and CFC are prognostic factors for death and nonfatal myocardial infarction in patients with known or suspected coronary artery disease. Importantly, after adjustment for clinical characteristics and the combined use of [15O]H2O positron emission tomography perfusion metrics, modified CFC remained independently associated with adverse outcome.
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Affiliation(s)
- Ruben W. de Winter
- Departments of Cardiology (R.W.d.W., R.A.J., P.A.v.D., S.P.S., Y.B.O.S., T.P.v.d.H., A.C.v.R., A.N., I.D., P.K.), Amsterdam University Medical Centers, Location Vrije Universiteit Amsterdam, the Netherlands
| | - Ruurt A. Jukema
- Departments of Cardiology (R.W.d.W., R.A.J., P.A.v.D., S.P.S., Y.B.O.S., T.P.v.d.H., A.C.v.R., A.N., I.D., P.K.), Amsterdam University Medical Centers, Location Vrije Universiteit Amsterdam, the Netherlands
| | - Pepijn A. van Diemen
- Departments of Cardiology (R.W.d.W., R.A.J., P.A.v.D., S.P.S., Y.B.O.S., T.P.v.d.H., A.C.v.R., A.N., I.D., P.K.), Amsterdam University Medical Centers, Location Vrije Universiteit Amsterdam, the Netherlands
| | - Stefan P. Schumacher
- Departments of Cardiology (R.W.d.W., R.A.J., P.A.v.D., S.P.S., Y.B.O.S., T.P.v.d.H., A.C.v.R., A.N., I.D., P.K.), Amsterdam University Medical Centers, Location Vrije Universiteit Amsterdam, the Netherlands
| | - Yvemarie B.O. Somsen
- Departments of Cardiology (R.W.d.W., R.A.J., P.A.v.D., S.P.S., Y.B.O.S., T.P.v.d.H., A.C.v.R., A.N., I.D., P.K.), Amsterdam University Medical Centers, Location Vrije Universiteit Amsterdam, the Netherlands
| | - Tim P. van de Hoef
- Departments of Cardiology (R.W.d.W., R.A.J., P.A.v.D., S.P.S., Y.B.O.S., T.P.v.d.H., A.C.v.R., A.N., I.D., P.K.), Amsterdam University Medical Centers, Location Vrije Universiteit Amsterdam, the Netherlands
| | - Albert C. van Rossum
- Departments of Cardiology (R.W.d.W., R.A.J., P.A.v.D., S.P.S., Y.B.O.S., T.P.v.d.H., A.C.v.R., A.N., I.D., P.K.), Amsterdam University Medical Centers, Location Vrije Universiteit Amsterdam, the Netherlands
| | - Jos W.R. Twisk
- Epidemiology & Data Science (J.W.R.T.), Amsterdam University Medical Centers, Location Vrije Universiteit Amsterdam, the Netherlands
| | - Teemu Maaniitty
- Turku PET Centre, Turku University Hospital and University of Turku, Finland (T.M., J.K., A.S.)
| | - Juhani Knuuti
- Turku PET Centre, Turku University Hospital and University of Turku, Finland (T.M., J.K., A.S.)
| | - Antti Saraste
- Turku PET Centre, Turku University Hospital and University of Turku, Finland (T.M., J.K., A.S.)
| | - Alexander Nap
- Departments of Cardiology (R.W.d.W., R.A.J., P.A.v.D., S.P.S., Y.B.O.S., T.P.v.d.H., A.C.v.R., A.N., I.D., P.K.), Amsterdam University Medical Centers, Location Vrije Universiteit Amsterdam, the Netherlands
| | - Pieter G. Raijmakers
- Radiology, Nuclear Medicine & PET Research (P.G.R.), Amsterdam University Medical Centers, Location Vrije Universiteit Amsterdam, the Netherlands
| | - Ibrahim Danad
- Departments of Cardiology (R.W.d.W., R.A.J., P.A.v.D., S.P.S., Y.B.O.S., T.P.v.d.H., A.C.v.R., A.N., I.D., P.K.), Amsterdam University Medical Centers, Location Vrije Universiteit Amsterdam, the Netherlands
| | - Paul Knaapen
- Departments of Cardiology (R.W.d.W., R.A.J., P.A.v.D., S.P.S., Y.B.O.S., T.P.v.d.H., A.C.v.R., A.N., I.D., P.K.), Amsterdam University Medical Centers, Location Vrije Universiteit Amsterdam, the Netherlands
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11
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De Winter RW, Van Diemen PA, Schumacher SP, Jukema RA, Somsen YBO, Bom MJ, Everaars H, Van Rossum AC, Verouden NJ, Raijmakers PG, Nap A, Driessen RS, Danad I, Knaapen P. Concordant low and discordant fractional flow reserve and instantaneous wave-free ratio measurements are associated with reduced myocardial perfusion. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
In patients undergoing invasive coronary angiography with functional lesion assessment, both fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) measurements can be used to guide coronary revascularization decision-making. The hemodynamic significance of lesions with discordant FFR and iFR measurements is debated.
Purpose
This study compared quantitative myocardial perfusion indices as assessed by [15O]H2O positron emission tomography (PET) perfusion imaging in vessels with concordant high, discordant and concordant low FFR/iFR measurements
Methods
This post-hoc analysis of the PACIFIC I and II studies included 198 patients suspected of obstructive coronary artery disease who had undergone [15O]H2O PET imaging and subsequent FFR/iFR interrogation in 468 vessels. Resting myocardial blood flow (MBF), hyperemic MBF and coronary flow reserve (CFR) were compared between 4 vessel subgroups: FFR+/iFR+ (n=79), FFR−/iFR+ (n=22), FFR+/iFR− (n=22) and FFR−/iFR− (n=345).
Results
Discordant FFR/iFR indices were found in 44 (9%) vessels. Hyperemic MBF was significantly lower for vessels with FFR+/iFR+ (2.09±0.67 mL min–1 g–1), FFR−/iFR+ (2.41±0.80 mL min–1 g–1) and FFR+/iFR− (2.40±0.69 mL min–1 g–1) compared to FFR−/iFR− vessels (2.91±0.84 mL min–1 g–1) (p<0.01, p=0.03 and p<0.01, respectively). Hyperemic MBF did not differ between vessels with FFR+/iFR+ compared to FFR−/iFR+ (p=0.38) and FFR+/iFR− (p=0.35) vessels. In addition, resting MBF was lower and CFR did not differ in the FFR+/iFR− versus the FFR−/iFR− group (resting MBF: 0.80±0.16 mL min–1 g–1 vs. 0.90±0.24 mL min–1 g–1, p=0.03 and CFR: 3.05±0.84 vs. 3.35±1.07, p=0.56). Finally, CFR was similar in FFR+/iFR+ and FFR−/iFR+ vessels (2.37±0.76 vs. 2.64±0.84, p=0.92).
Conclusions
We found lower baseline flow and similar flow reserve in FFR+/iFR− compared to FFR−/iFR− vessels. Importantly, [15O]H2O PET imaging demonstrated reduced hyperemic MBF in vessels with concordant low and discordant FFR and iFR measurements.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- R W De Winter
- Amsterdam UMC - Location VUmc, Department of Cardiology , Amsterdam , The Netherlands
| | - P A Van Diemen
- Amsterdam UMC - Location VUmc, Department of Cardiology , Amsterdam , The Netherlands
| | - S P Schumacher
- Amsterdam UMC - Location VUmc, Department of Cardiology , Amsterdam , The Netherlands
| | - R A Jukema
- Amsterdam UMC - Location VUmc, Department of Cardiology , Amsterdam , The Netherlands
| | - Y B O Somsen
- Amsterdam UMC - Location VUmc, Department of Cardiology , Amsterdam , The Netherlands
| | - M J Bom
- Amsterdam UMC - Location VUmc, Department of Cardiology , Amsterdam , The Netherlands
| | - H Everaars
- Amsterdam UMC - Location VUmc, Department of Cardiology , Amsterdam , The Netherlands
| | - A C Van Rossum
- Amsterdam UMC - Location VUmc, Department of Cardiology , Amsterdam , The Netherlands
| | - N J Verouden
- Amsterdam UMC - Location VUmc, Department of Cardiology , Amsterdam , The Netherlands
| | - P G Raijmakers
- Amsterdam UMC - Location VUmc, Department of Radiology, Nuclear Medicine and PET Research , Amsterdam , The Netherlands
| | - A Nap
- Amsterdam UMC - Location VUmc, Department of Cardiology , Amsterdam , The Netherlands
| | - R S Driessen
- Amsterdam UMC - Location VUmc, Department of Cardiology , Amsterdam , The Netherlands
| | - I Danad
- Amsterdam UMC - Location VUmc, Department of Cardiology , Amsterdam , The Netherlands
| | - P Knaapen
- Amsterdam UMC - Location VUmc, Department of Cardiology , Amsterdam , The Netherlands
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12
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De Winter RW, Jukema RA, Van Diemen PA, Schumacher SP, Somsen YBO, Van De Hoef TP, Van Rossum AC, Twisk JW, Maaniitty T, Knuuti J, Saraste A, Nap A, Raijmakers PG, Danad I, Knaapen P. Prognostic value of coronary flow capacity derived from [15O]H2O positron emission tomography perfusion imaging. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Coronary flow capacity (CFC) is a cross-modality framework integrating hyperemic myocardial blood flow (hMBF) and coronary flow reserve (CFR) to quantify the physiological impact of coronary atherosclerotic disease on vasodilator capacity.
Purpose
This study explores the prognostic value of CFC derived from [15O]H2O positron emission tomography (PET) perfusion imaging in addition to traditional perfusion metrics.
Methods
Quantitative perfusion measurements were obtained from 1300 patients with suspected or known coronary artery disease who underwent [15O]H2O PET imaging. Patients were classified as having myocardial steal, severely reduced CFC, moderately reduced CFC, minimally reduced CFC or normal flow using previously defined perfusion thresholds. The endpoint was a composite of death and non-fatal myocardial infarction (MI).
Results
The composite endpoint occurred in 153 (12%) patients during a median follow-up of 5.5 (interquartile range 3.7–7.8) years. Myocardial steal (HR 10.65, 95% CI 4.45–25.49, p<0.001), severely reduced CFC (HR 3.77, 95% CI 1.88–7.58, p<0.001), moderately reduced CFC (HR 2.03, 95% CI 1.25–3.29, p=0.004) and minimally reduced CFC (HR 1.72, 95% CI 1.05–2.81, p=0.030) were independently associated with worse outcome after adjusting for clinical risk factors. Similarly, increased resting MBF (HR 3.19, 95% CI 1.74–5.83, p<0.001), decreased hMBF (HR 0.72, 95% CI 0.57–0.90, p=0.004) and decreased CFR (HR 0.59, 95% CI 0.47–0.73, p<0.001) were significant prognostic factors for events. In a combined perfusion model, only resting MBF (p=0.018) and CFC (overall p=0.012) demonstrated independent prognostic value.
Conclusions
[15O]H2O PET-derived resting MBF, hMBF, CFR and CFC were prognostic factors for death and non-fatal MI. Notably, in a combined model including all perfusion metrics, only resting MBF and CFC were independently associated with adverse outcome.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- R W De Winter
- Amsterdam UMC - Location VUmc, Department of Cardiology , Amsterdam , The Netherlands
| | - R A Jukema
- Amsterdam UMC - Location VUmc, Department of Cardiology , Amsterdam , The Netherlands
| | - P A Van Diemen
- Amsterdam UMC - Location VUmc, Department of Cardiology , Amsterdam , The Netherlands
| | - S P Schumacher
- Amsterdam UMC - Location VUmc, Department of Cardiology , Amsterdam , The Netherlands
| | - Y B O Somsen
- Amsterdam UMC - Location VUmc, Department of Cardiology , Amsterdam , The Netherlands
| | - T P Van De Hoef
- Amsterdam UMC - Location VUmc, Department of Cardiology , Amsterdam , The Netherlands
| | - A C Van Rossum
- Amsterdam UMC - Location VUmc, Department of Cardiology , Amsterdam , The Netherlands
| | - J W Twisk
- Amsterdam UMC - Location VUmc, Department of Epidemiology and Data Science , Amsterdam , The Netherlands
| | - T Maaniitty
- Turku University Hospital, Turku PET Centre, University of Turku , Turku , Finland
| | - J Knuuti
- Turku University Hospital, Turku PET Centre, University of Turku , Turku , Finland
| | - A Saraste
- Turku University Hospital, Turku PET Centre, University of Turku , Turku , Finland
| | - A Nap
- Amsterdam UMC - Location VUmc, Department of Cardiology , Amsterdam , The Netherlands
| | - P G Raijmakers
- Amsterdam UMC - Location VUmc, Department of Radiology, Nuclear Medicine and PET Research , Amsterdam , The Netherlands
| | - I Danad
- Amsterdam UMC - Location VUmc, Department of Cardiology , Amsterdam , The Netherlands
| | - P Knaapen
- Amsterdam UMC - Location VUmc, Department of Cardiology , Amsterdam , The Netherlands
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13
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Somsen YBO, De Winter RW, Giunta R, Schumacher SP, Van Diemen PA, Jukema RA, Stuijfzand WJA, Danad I, Lissenberg-Witte B, Verouden NJ, Nap A, Galassi AR, Henriques JP, Knaapen P. Predicting success of the retrograde approach in percutaneous coronary intervention of chronic total coronary occlusions as guided by collateral grading systems. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Retrograde chronic total coronary occlusion (CTO) percutaneous coronary intervention (PCI) requires selection of appropriate interventional collaterals. At present, utilization of the Rentrop and Werner grading systems are encouraged to assess the collateral channels (CCs) prior to attempted guidewire (GW) crossing [1]. The J-Channel score was recently introduced to predict CC GW crossing difficulty, yet data on its applicability is lacking [2].
Purpose
To investigate the predictive ability of the J-Channel score for CC GW crossing success and technical CTO-PCI success compared to the Rentrop and Werner grading systems.
Methods
A total of 262 patients who underwent single-vessel retrograde CTO-PCI were prospectively recruited in a single-center registry. The J-Channel score, Rentrop and Werner grade were assessed by invasive coronary angiography. Crossing of CCs was considered successful if the GW reached the distal cap of the CTO body. Technical CTO-PCI success was defined as Thrombolysis in Myocardial Infarction flow grade 3 and residual stenosis <30%.
Results
Mean J-Channel score was found at 1.9±1.2. Median Rentrop and Werner grade were 3 [IQR 2–3] and 1 [IQR 1–2]. Technical CTO-PCI success was 90%. In 211 (81%) cases, CC GW crossing was successful. Receiver operating characteristics analysis showed comparable discriminatory capacity for Rentrop and Werner grade (AUC 0.67 and 0.65, p=0.611), whereas the predictive ability of the J-Channel score (AUC 0.74) was superior to the Werner grade (p<0.001). A high J-Channel score was inversely associated with CC GW crossing success (p<0.001). For technical CTO-PCI success, overall performance of all grading systems weakened, wherein Rentrop grade was numerically highest, followed by the J-Channel score and Werner grade (AUC 0.69, 0.67, and 0.58, respectively). Notably, a high Rentrop grade was associated with increased CC GW crossing and technical CTO-PCI success (p<0.001).
Conclusions
In retrograde CTO-PCI, there is limited incremental value of the J-Channel score, Rentrop classification and Werner grade in predicting technical CTO-PCI success. However, their application might aid in strategic collateral channel selection prior to attempted guidewire crossing.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- Y B O Somsen
- Vrije Universiteit Medical Centre (VUMC) , Amsterdam , The Netherlands
| | - R W De Winter
- Vrije Universiteit Medical Centre (VUMC) , Amsterdam , The Netherlands
| | - R Giunta
- University of Palermo, Cardiology , Palermo , Italy
| | - S P Schumacher
- Vrije Universiteit Medical Centre (VUMC) , Amsterdam , The Netherlands
| | - P A Van Diemen
- Vrije Universiteit Medical Centre (VUMC) , Amsterdam , The Netherlands
| | - R A Jukema
- Vrije Universiteit Medical Centre (VUMC) , Amsterdam , The Netherlands
| | - W J A Stuijfzand
- Vrije Universiteit Medical Centre (VUMC) , Amsterdam , The Netherlands
| | - I Danad
- Vrije Universiteit Medical Centre (VUMC) , Amsterdam , The Netherlands
| | | | - N J Verouden
- Vrije Universiteit Medical Centre (VUMC) , Amsterdam , The Netherlands
| | - A Nap
- Vrije Universiteit Medical Centre (VUMC) , Amsterdam , The Netherlands
| | - A R Galassi
- University of Palermo, Cardiology , Palermo , Italy
| | - J P Henriques
- Academic Medical Center, Cardiology , Amsterdam , The Netherlands
| | - P Knaapen
- Vrije Universiteit Medical Centre (VUMC) , Amsterdam , The Netherlands
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14
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de Winter RW, Schumacher SP, van Diemen PA, Jukema RA, Somsen YB, Stuijfzand WJ, Driessen RS, Bom MJ, Everaars H, van Rossum AC, van de Ven PM, Opolski MP, Verouden NJ, Danad I, Raijmakers PG, Nap A, Knaapen P. Impact of percutaneous coronary intervention of chronic total occlusions on absolute perfusion in remote myocardium. EUROINTERVENTION 2022; 18:e314-e323. [PMID: 34866043 PMCID: PMC9912974 DOI: 10.4244/eij-d-21-00702] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Revascularisation of a chronic total coronary occlusion (CTO) impacts the coronary physiology of the remote myocardial territory. AIMS This study aimed to evaluate the intrinsic effect of CTO percutaneous coronary intervention (PCI) on changes in absolute perfusion in remote myocardium. METHODS A total of 164 patients who underwent serial [15O]H2O positron emission tomography (PET) perfusion imaging at baseline and three months after successful single-vessel CTO PCI were included to evaluate changes in hyperaemic myocardial blood flow (hMBF) and coronary flow reserve (CFR) in the remote myocardium supplied by both non-target coronary arteries. RESULTS Perfusion indices in CTO and remote myocardium showed a positive correlation before (resting MBF: r=0.84, hMBF: r=0.75, and CFR: r=0.77, p<0.01 for all) and after (resting MBF: r=0.87, hMBF: r=0.87, and CFR: r=0.81, p<0.01 for all) CTO PCI. Absolute increases in hMBF and CFR were observed in remote myocardium following CTO revascularisation (from 2.29±0.67 to 2.48±0.75 mL·min-1·g-1 and from 2.48±0.76 to 2.74±0.85, respectively, p<0.01 for both). Improvements in remote myocardial perfusion were largest in patients with a higher increase in hMBF (β 0.58, 95% CI: 0.48-0.67, p<0.01) and CFR (β 0.54, 95% CI: 0.44-0.64, p<0.01) in the CTO territory, independent of clinical, angiographic and procedural characteristics. CONCLUSIONS CTO revascularisation resulted in an increase in remote myocardial perfusion. Furthermore, the quantitative improvement in hMBF and CFR in the CTO territory was independently associated with the absolute perfusion increase in remote myocardial regions. As such, CTO PCI may have a favourable physiologic impact beyond the intended treated myocardium.
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Affiliation(s)
- Ruben W. de Winter
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Stefan P. Schumacher
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Pepijn A. van Diemen
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Ruurt A. Jukema
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Yvemarie B.O. Somsen
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Wynand J. Stuijfzand
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Roel S. Driessen
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Michiel J. Bom
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Henk Everaars
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Albert C. van Rossum
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Peter M. van de Ven
- Department of Epidemiology & Data Science, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Maksymilian P. Opolski
- Department of Interventional Cardiology and Angiology, National Institute of Cardiology, Warsaw, Poland
| | - Niels J. Verouden
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Ibrahim Danad
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Pieter G. Raijmakers
- Radiology, Nuclear Medicine & PET Research, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Alex Nap
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Paul Knaapen
- Department of Cardiology Heart Center, Amsterdam UMC, location Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, the Netherlands
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15
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de Winter RW, Jukema RA, van Diemen PA, Schumacher SP, Driessen RS, Stuijfzand WJ, Everaars H, Bom MJ, van Rossum AC, van de Ven PM, Verouden NJ, Nap A, Raijmakers PG, Danad I, Knaapen P. The impact of coronary revascularization on vessel-specific coronary flow capacity and long-term outcomes: a serial [15O]H2O positron emission tomography perfusion imaging study. Eur Heart J Cardiovasc Imaging 2022; 23:743-752. [PMID: 34878102 PMCID: PMC9159743 DOI: 10.1093/ehjci/jeab263] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 11/25/2021] [Indexed: 11/12/2022] Open
Abstract
AIMS Coronary flow capacity (CFC) integrates quantitative hyperaemic myocardial blood flow (hMBF) and coronary flow reserve (CFR) to comprehensively assess physiological severity of coronary artery disease (CAD). This study evaluated the effects of revascularization on CFC as assessed by serial [15O]H2O positron emission tomography (PET) perfusion imaging. METHODS AND RESULTS A total of 314 patients with stable CAD underwent [15O]H2O PET imaging at baseline and after myocardial revascularization to assess changes in hMBF, CFR, and CFC in 415 revascularized vessels. Using thresholds for ischaemia and normal perfusion, vessels were stratified in five CFC categories: myocardial steal, severely reduced CFC, moderately reduced CFC, minimally reduced CFC, and normal flow. Additionally, the association between CFC increase and the composite endpoint of death and non-fatal myocardial infarction (MI) was studied. Vessel-specific CFC improved after revascularization (P < 0.01). Furthermore, baseline CFC was an independent predictor of CFC increase (P < 0.01). The largest changes in ΔhMBF (0.90 ± 0.74, 0.93 ± 0.65, 0.79 ± 0.74, 0.48 ± 0.61, and 0.29 ± 0.66 mL/min/g) and ΔCFR (1.01 ± 0.88, 0.99 ± 0.69, 0.87 ± 0.88, 0.66 ± 0.91, and -0.01 ± 1.06) were observed in vessels with lower baseline CFC (P < 0.01 for both). During a median follow-up of 3.5 (95% CI 3.1-3.9) years, an increase in CFC was independently associated with lower rates of death and non-fatal MI (HR 0.43, 95% CI 0.19-0.98, P = 0.04). CONCLUSION Successful revascularization results in an increase in CFC. Furthermore, baseline CFC was an independent predictor of change in hMBF, CFR, and subsequently CFC. In addition, an increase in CFC was associated with a favourable outcome in terms of death and non-fatal MI.
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Affiliation(s)
- Ruben W de Winter
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Ruurt A Jukema
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Pepijn A van Diemen
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Stefan P Schumacher
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Roel S Driessen
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Wynand J Stuijfzand
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Henk Everaars
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Michiel J Bom
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Albert C van Rossum
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Peter M van de Ven
- Department of Epidemiology & Data Science, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Niels J Verouden
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Alexander Nap
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Pieter G Raijmakers
- Department of Radiology, Nuclear Medicine & PET Research, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Ibrahim Danad
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Paul Knaapen
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
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16
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De Winter RW, Schumacher SP, Van Diemen PA, Jukema RA, Somsen YBO, Stuijfzand WJ, Bom MJ, Everaars H, Van Rossum AC, Van De Ven PM, Verouden NJ, Danad I, Raijmakers PG, Nap A, Knaapen P. The effect of chronic total coronary occlusion percutaneous coronary intervention on absolute perfusion in remote myocardium. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.0256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Successful revascularization of a chronic total coronary occlusion (CTO) impacts coronary physiology of the remote myocardial territory.
Purpose
This study evaluated the effect of CTO percutaneous coronary intervention (PCI) on changes in absolute perfusion in remote myocardium as assessed by serial [15O]H2O positron emission tomography (PET) perfusion imaging.
Methods
A total of 164 patients underwent [15O]H2O PET imaging at baseline and 3 months after successful single-vessel revascularization of a CTO to evaluate changes in hyperemic myocardial blood flow (hMBF) and coronary flow reserve (CFR) in the remote myocardial territory supplied by both non-target coronary arteries.
Results
Remote hMBF and CFR improved (2.29±0.67 to 2.48±0.75 mL min–1 g–1 and 2.48±0.76 to 2.74±0.85, respectively) after CTO revascularization (p<0.01 for both). Absolute perfusion indices in the CTO vessel and the remote myocardium showed a positive linear correlation, both before (r=0.75, p<0.01 and r=0.77, p<0.01 for hMBF and CFR, respectively) and after (hMBF: r=0.87, p<0.01 and CFR: r=0.81, p<0.01) CTO PCI. Absolute increases in remote myocardial perfusion were largest in patients with a higher increase in hMBF (βeta [β] 0.56; 95% CI: 0.47–0.65; p<0.01) and CFR (β 0.51 (0.42–0.60); p<0.01) in the CTO territory, independent of clinical, angiographic and procedural characteristics. Furthermore, baseline (hMBF: β −0.24 (−0.39, −0.08); p<0.01 and CFR: β −0.26 (−0.41, −0.11); p<0.01) and post-PCI perfusion (hMBF: β 0.36; (0.27, 0.46); p<0.01 and CFR: β 0.30 (0.21, 0.40); p<0.01) in the CTO vessel were independently associated with the increase in remote myocardial perfusion after CTO PCI.
Conclusions
An overall increase in remote myocardial perfusion was observed following CTO PCI. Absolute perfusion indices in the remote myocardium showed a positive linear correlation with perfusion in the CTO vessel, before and after CTO revascularization. Importantly, baseline, post-PCI and the absolute increase in perfusion in the CTO territory were independently associated with increases in remote myocardial perfusion after revascularization.
Funding Acknowledgement
Type of funding sources: None. Figure 1Figure 2
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Affiliation(s)
- R W De Winter
- Amsterdam UMC - Location VUmc, Cardiology, Amsterdam, Netherlands (The)
| | - S P Schumacher
- Amsterdam UMC - Location VUmc, Cardiology, Amsterdam, Netherlands (The)
| | - P A Van Diemen
- Amsterdam UMC - Location VUmc, Cardiology, Amsterdam, Netherlands (The)
| | - R A Jukema
- Amsterdam UMC - Location VUmc, Cardiology, Amsterdam, Netherlands (The)
| | - Y B O Somsen
- Amsterdam UMC - Location VUmc, Cardiology, Amsterdam, Netherlands (The)
| | - W J Stuijfzand
- Amsterdam UMC - Location VUmc, Cardiology, Amsterdam, Netherlands (The)
| | - M J Bom
- Amsterdam UMC - Location VUmc, Cardiology, Amsterdam, Netherlands (The)
| | - H Everaars
- Amsterdam UMC - Location VUmc, Cardiology, Amsterdam, Netherlands (The)
| | - A C Van Rossum
- Amsterdam UMC - Location VUmc, Cardiology, Amsterdam, Netherlands (The)
| | - P M Van De Ven
- Amsterdam UMC - Location VUmc, Epidemiology and biostatistics, Amsterdam, Netherlands (The)
| | - N J Verouden
- Amsterdam UMC - Location VUmc, Cardiology, Amsterdam, Netherlands (The)
| | - I Danad
- Amsterdam UMC - Location VUmc, Cardiology, Amsterdam, Netherlands (The)
| | - P G Raijmakers
- Amsterdam UMC - Location VUmc, Radiology and nuclear medicine, Amsterdam, Netherlands (The)
| | - A Nap
- Amsterdam UMC - Location VUmc, Cardiology, Amsterdam, Netherlands (The)
| | - P Knaapen
- Amsterdam UMC - Location VUmc, Cardiology, Amsterdam, Netherlands (The)
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17
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Jukema RA, Diemen Van PA, Driessen RS, Stuijfzand J, Raijmakers PG, Winter De RW, Ven Van De PM, Rossum Van AC, Knaapen P, Danad I. A 7-year warranty period for chest pain patients with a non-ischaemic [15O]H2O positron emission tomography: a follow-up of 273 individuals. Eur Heart J Cardiovasc Imaging 2021. [DOI: 10.1093/ehjci/jeab111.068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
Background
A normal perfusion scan is associated with a favourable outcome. The aim of the present study is to determine the warranty period of normal hyperemic myocardial blood flow (MBF) derived with quantitative [15O]H2O positron emission tomography (PET) in symptomatic individuals with cardiovascular risk factors.
Methods
A total of 539 patients referred for baseline adenosine [15O]H2O PET MBF imaging because of suspected coronary artery disease (CAD) were investigated. A PET scan was considered normal if the hyperemic MBF was > 2.3 ml/min/g. The warranty period was predefined as < 2% annual event rate. The primary endpoint was a composite of late revascularizations, myocardial infarction and all-cause mortality.
Results
In a total of 273 patients (mean age 57.2 ± 9.1; 34.4% male) with a normal PET scan, 19 events occurred during a median follow-up of 6.8 years (interquartile range 4.9-7.7). Events included 10 late revascularizations, 2 myocardial infarctions and 7 deaths. The annual event rate exceeded 2% in the 8th year of follow-up, resulting in a warranty period of 7 years (see Figure 1).
Conclusion
In patients referred for suspected CAD a normal hyperemic perfusion derived by [15O]H2O PET confers a 7-year warranty period against late revascularization, myocardial infarction and all-cause mortality.
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Affiliation(s)
- RA Jukema
- Amsterdam UMC - Location VUmc, Amsterdam, Netherlands (The)
| | - PA Diemen Van
- Amsterdam UMC - Location VUmc, Amsterdam, Netherlands (The)
| | - RS Driessen
- Amsterdam UMC - Location VUmc, Amsterdam, Netherlands (The)
| | - J Stuijfzand
- Amsterdam UMC - Location VUmc, Amsterdam, Netherlands (The)
| | - PG Raijmakers
- Amsterdam UMC - Location VUmc, Amsterdam, Netherlands (The)
| | - RW Winter De
- Amsterdam UMC - Location VUmc, Amsterdam, Netherlands (The)
| | - PM Ven Van De
- Amsterdam UMC - Location VUmc, Amsterdam, Netherlands (The)
| | - AC Rossum Van
- Amsterdam UMC - Location VUmc, Amsterdam, Netherlands (The)
| | - P Knaapen
- Amsterdam UMC - Location VUmc, Amsterdam, Netherlands (The)
| | - I Danad
- Amsterdam UMC - Location VUmc, Amsterdam, Netherlands (The)
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18
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De Winter RW, Jukema RA, Van Diemen PA, Schumacher SP, Driessen RS, Stuijfzand WJ, Bom MJ, Everaars H, Van De Ven PM, Verouden NJ, Nap A, Van Rossum AC, Danad I, Raijmakers PG, Knaapen P. Impact of coronary revascularization on regional artery-specific coronary flow capacity: a serial [15O]H2O positron emission tomography perfusion imaging study. Eur Heart J Cardiovasc Imaging 2021. [DOI: 10.1093/ehjci/jeaa356.350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
Background. Coronary flow capacity (CFC) combines absolute hyperemic myocardial blood flow (hMBF) and coronary flow reserve (CFR) in a graphical representation of the severity of myocardial perfusion impairment. Studies evaluating the impact of coronary revascularization on CFC as assessed by [15O]H2O positron emission tomography (PET) are lacking.
Purpose. The present study explored the impact of coronary revascularization on regional, artery-specific CFC as assessed by [15O]H2O PET.
Methods. A total of 315 patients (mean age 62 ± 10 years) underwent absolute myocardial perfusion imaging at baseline and directly after either percutaneous or surgical coronary revascularization (at 110 ± 50 days). Revascularized perfusion regions were stratified in 3 CFC groups at baseline: severely reduced CFC (defined as myocardial ischemia), moderately reduced CFC and normal CFC.
Results. Baseline CFC was severely reduced in 262 vessels (70%), moderately reduced in 95 vessels (25%) and normal in 17 vessels (5%). Regional, artery-specific CFC, hMBF and CFR improved after successful revascularization (P < 0.01). In 127/262 regions, CFC increased from severely reduced to moderately reduced and in 29/262 to normal flow after revascularization (p < 0.01 for both). Additionally, 28/95 revascularized regions increased from moderately reduced to normal flow (P = 0.18). Changes in hMBF (severe vs. moderate vs. normal: 0.84 ± 0.73; 0.41 ± 0.60 and 0.35 ± 0.84 mL·min-1·g-1 ) and CFR (0.92 ± 0.83; 0.49 ± 1.00 and -0.39 ± 1.15) were significantly different comparing baseline CFC groups (both p < 0.01). Furthermore, mixed-model analysis including traditional CAD risk factors revealed that baseline CFC and gender were independent predictors of changes in CFC, hMBF and CFR between baseline and follow-up.
Conclusions. Successful revascularization demonstrated a significant and positive impact on regional, artery-specific CFC, hMBF and CFR. Improvements were largest among lower baseline CFC groups. Furthermore, baseline CFC was an independent predictor of change in CFC, hMBF and CFR. These results suggest that the assessment of flow capacity by [15O]H2O PET prior to revascularization may aid in the selection of regions in which absolute myocardial perfusion is most likely to improve.
Abstract Figure 1.
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Affiliation(s)
- RW De Winter
- Amsterdam UMC - Location VUmc, Cardiology, Amsterdam, Netherlands (The)
| | - RA Jukema
- Amsterdam UMC - Location VUmc, Cardiology, Amsterdam, Netherlands (The)
| | - PA Van Diemen
- Amsterdam UMC - Location VUmc, Cardiology, Amsterdam, Netherlands (The)
| | - SP Schumacher
- Amsterdam UMC - Location VUmc, Cardiology, Amsterdam, Netherlands (The)
| | - RS Driessen
- Amsterdam UMC - Location VUmc, Cardiology, Amsterdam, Netherlands (The)
| | - WJ Stuijfzand
- Amsterdam UMC - Location VUmc, Cardiology, Amsterdam, Netherlands (The)
| | - MJ Bom
- Amsterdam UMC - Location VUmc, Cardiology, Amsterdam, Netherlands (The)
| | - H Everaars
- Amsterdam UMC - Location VUmc, Cardiology, Amsterdam, Netherlands (The)
| | - PM Van De Ven
- Amsterdam UMC - Location VUmc, Epidemiology and biostatistics, Amsterdam, Netherlands (The)
| | - NJ Verouden
- Amsterdam UMC - Location VUmc, Cardiology, Amsterdam, Netherlands (The)
| | - A Nap
- Amsterdam UMC - Location VUmc, Cardiology, Amsterdam, Netherlands (The)
| | - AC Van Rossum
- Amsterdam UMC - Location VUmc, Cardiology, Amsterdam, Netherlands (The)
| | - I Danad
- Amsterdam UMC - Location VUmc, Cardiology, Amsterdam, Netherlands (The)
| | - PG Raijmakers
- Amsterdam UMC - Location VUmc, Radiology and nuclear medicine, Amsterdam, Netherlands (The)
| | - P Knaapen
- Amsterdam UMC - Location VUmc, Cardiology, Amsterdam, Netherlands (The)
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Jukema RA, Ahmed TAN, Tardif JC. Does low-density lipoprotein cholesterol induce inflammation? If so, does it matter? Current insights and future perspectives for novel therapies. BMC Med 2019; 17:197. [PMID: 31672136 PMCID: PMC6824020 DOI: 10.1186/s12916-019-1433-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 09/26/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Dyslipidemia and inflammation are closely interrelated contributors in the pathogenesis of atherosclerosis. Disorders of lipid metabolism initiate an inflammatory and immune-mediated response in atherosclerosis, while low-density lipoprotein cholesterol (LDL-C) lowering has possible pleiotropic anti-inflammatory effects that extend beyond lipid lowering. MAIN TEXT Activation of the immune system/inflammasome destabilizes the plaque, which makes it vulnerable to rupture, resulting in major adverse cardiac events (MACE). The activated immune system potentially accelerates atherosclerosis, and atherosclerosis activates the immune system, creating a vicious circle. LDL-C enhances inflammation, which can be measured through multiple parameters like high-sensitivity C-reactive protein (hsCRP). However, multiple studies have shown that CRP is a marker of residual risk and not, itself, a causal factor. Recently, anti-inflammatory therapy has been shown to decelerate atherosclerosis, resulting in fewer MACE. Nevertheless, an important side effect of anti-inflammatory therapy is the potential for increased infection risk, stressing the importance of only targeting patients with high residual inflammatory risk. Multiple (auto-)inflammatory diseases are potentially related to/influenced by LDL-C through inflammasome activation. CONCLUSIONS Research suggests that LDL-C induces inflammation; inflammation is of proven importance in atherosclerotic disease progression; anti-inflammatory therapies yield promise in lowering (cardiovascular) disease risk, especially in selected patients with high (remaining) inflammatory risk; and intriguing new anti-inflammatory developments, for example, in nucleotide-binding leucine-rich repeat-containing pyrine receptor inflammasome targeting, are currently underway, including novel pathway interventions such as immune cell targeting and epigenetic interference. Long-term safety should be carefully monitored for these new strategies and cost-effectiveness carefully evaluated.
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Affiliation(s)
- Ruurt A Jukema
- Department of Medicine, VU University Medical Centre Amsterdam, Amsterdam, the Netherlands. .,Department of Medicine, Montreal Heart Institute, Université de Montréal, Montreal, Canada.
| | | | - Jean-Claude Tardif
- Department of Medicine, Montreal Heart Institute, Université de Montréal, Montreal, Canada
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Jukema JB, Bagnasco DE, Jukema RA. Waterpipe smoking: not necessarily less hazardous than cigarette smoking : Possible consequences for (cardiovascular) disease. Neth Heart J 2014; 22:91-9. [PMID: 24307377 PMCID: PMC3931860 DOI: 10.1007/s12471-013-0501-0] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Context Cigarette smoking has declined over the last years in modern countries. On the contrary, waterpipe smoking has increased, especially among young people visiting waterpipe bars. Unfortunately, most waterpipe smokers seem to know little about the possible cardiovascular and other health consequences of waterpipe smoking. Objective To describe by narrative literature review the known adverse consequences for the human body caused by smoking the waterpipe compared with the consequences of smoking normal cigarettes. Also, to get a picture of public awareness of these consequences as deducted from the literature and a small new survey in the Netherlands. Results/Conclusions Tobacco smoking is associated with serious adverse (cardiovascular) health effects, and there is no evidence that these effects are less serious if a waterpipe is used. The increasing use together with the limited amount of awareness and attention for the possible health consequences of smoking the waterpipe is worrisome. Especially considering the increasing acceptance and use of the waterpipe among the youth. Therefore we recommend more systematic research into the possible health hazards of waterpipe smoking. In the meantime education campaigns and materials are needed to raise public awareness on the possible health risks of waterpipe use.
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Affiliation(s)
- J B Jukema
- Medical Faculty, Free University, Amsterdam, the Netherlands,
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