Prognostic role of functional syntax score based on quantitative flow ratio

Background/Introduction

The quantitative flow ratio (QFR) based functional Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery (SYNTAX) score (FSSQFR) takes into consideration not only the anatomy but also the physiology of coronary arteries.

Purpose

To investigate the prognostic value of the FSSQFR.

Methods

We performed an offline QFR analysis in consecutive patients who underwent coronary angiography in a single center. FSSQFR was counted by summing the individual scores only in ischemia-producing lesions (vessel QFR ≤0.8). Patients were divided into low-, intermediate- and high risk according to SS and FSS with the same cutoff. The primary endpoint was the estimation of the predictive value of FSSQFR for the composite outcome of death, myocardial infarction, ischemia-driven revascularization, stroke, hospitalization for heart failure, and life-threatening arrhythmias.

Results

410 patients were included in this study. Baseline characteristics of the population displayed in Table 1. FSSQFR and SS were estimated for all patients. According to SS, 26.6% of patients were high risk, 36.6% were intermediate risk and 36.8% were low cardiovascular risk. After calculating FSSQFR, risk stratification changed in 10% of the study population, more specifically 21.2%, 36.6%, and 42.2% of patients were classified as high-, intermediate- and low-risk respectively. 5% (n=20) of the patients for whom coronary artery bypass grafting would be recommended according to SS, converted in favor of percutaneous coronary intervention after FSSQFR calculation. After a median 30.2 (25.7–33.7) months follow-up period multivariate regression analysis showed FSSQFR was an independent predictor of primary endpoint after adjustment for age, gender, BMI, and hypertension (adjusted OR: 1.03 [95% CI, 1.01–1.06]; P=0.012). The Kaplan-Meier estimate for the primary endpoint was 15%, 18.7%, and 32.2% in the low, intermediate, and high FSSQFR group, respectively (log-rank P=0.001; Figure 1A) and cardiac death was 2.3%, 8.7%, and 12.6% in the low, intermediate, and high FSSQFR group, respectively (log-rank P=0.003; Figure 1B).

Conclusions

In our study, FSSQFR showed discordance with classical anatomical SS leading to risk re-stratification of patients with coronary disease and possible alternative treatment strategy and also was found to be an independent predictor of higher cardiovascular adverse events.

Funding Acknowledgement

Type of funding sources: None.

Prognostic role of discordance between plain coronary angiography and quantitative flow ratio in revascularization guidance

Background/Introduction

Percutaneous coronary intervention (PCI) guided by functional coronary stenosis severity has been associated with less clinical adverse events compared with plain coronary angiography. Quantitative flow ratio (QFR) has proven to be a reliable tool for functional assessment of coronary lesions.

Purpose

To investigate the prognostic role and the extend of disagreement between plain coronary angiography and QFR in guiding the decision to treat a coronary lesion.

Methods

We retrospectively performed an offline QFR analysis in consecutive patients who underwent coronary angiography in a single center. Patients with referral for coronary artery bypass graft surgery after coronary angiography were excluded. We aimed to measure QFR in all vessels of each patient. Patients were divided in two groups according to the concordance or discordance of the two methods. Patients with at least one vessel with QFR value ≥0.80 treated with PCI and/or at least one vessel with QFR value <0.80 not treated with PCI were included in the discordance group. The remaining patients formed the concordance group. Primary endpoint was the composite outcome of cardiovascular death, myocardial infraction and ischemia-driven revascularization.

Results

Overall, we included 549 patients in the study. Concordance between plain coronary angiography and QFR was present in 404 (73.6%) patients, while discordance between the two methods was found in 145 patients (26.4%). Baseline patient characteristics are displayed in Figure 1. Patients in the discordance group were older, with more extended coronary artery disease and higher SYNTAX score. After a median follow-up period of 30.5 (26.4–33.7) months, multivariate regression analysis showed significant higher rate of the composite outcome in the discordance group (OR: 2.975 95% CI 1.782–4.967, p<0.001) (Figure 2).

Conclusion

In our study, discordance between plain coronary angiography and QFR in revascularization guidance was present in approximately one fourth of patients and was found to be a strong independent predictor of higher cardiovascular adverse events.

Funding Acknowledgement

Type of funding sources: None.

Discordance between plain coronary angiography and quantitative flow ratio in revascularization guidance

Background/Introduction

Functional coronary stenosis severity has been associated with less clinical adverse events compared with plain invasive coronary angiography in guiding revascularization. Quantitative flow ratio (QFR) has proven to be a reliable tool of functional assessment of coronary lesions.

Purpose

To investigate the level of agreement between plain coronary angiography and QFR in guiding the decision to treat a coronary lesion.

Methods

We retrospectively performed an offline QFR analysis in consecutive patients who underwent coronary angiography in a single center. Patients with referral for coronary artery bypass graft surgery were excluded. We aimed to measure QFR in all vessels of each patient. All vessels with calculated QFR were divided into four groups based on whether percutaneous coronary intervention (PCI) was performed and on the QFR result with a cut-off point <0.8 indicating revascularization: Group A (PCI+, QFR <0.8); group B (PCI−, QFR >0.8); group C (PCI+, QFR >0.8); group D (PCI−, QFR <0.8) (Figure 1).

Results

We identified 785 patients with available coronary angiography satisfying the technical requirements of QFR software. QFR measurement in at least one vessel was feasible in 546 patients (70%). Mean age was 65.6 (±10.9) and 80% of patients were male. Acute coronary syndrome was the indication for coronary angiography in 36% of the cohort. QFR was calculated in 1193 vessels (∼51% of total vessels). In particular, QFR analysis was feasible in 448 (57%) left anterior descending (LAD), 457 (58%) left circumflex (LCX), and 288 (37%) right coronary arteries (RCA) coronary arteries. The most common reason for inability to calculate QFR was the absence of appropriate projections (30% of the missing cases). A mismatch in treatment strategy between coronary angiography and QFR result was detected in 151 (12.7%) vessels. In 78 (6.6%) cases PCI was performed while QFR was measured above 0.8 (group C). In 73 (6.1%) cases PCI was not performed while QFR was measured below 0.8 (Group D) (Figure 1). Among mismatch cases LAD was more likely to fall within group D whereas RCA was more often related with group C.

Conclusion

Discordance between plain coronary angiography and quantitative flow ratio regarding the decision to perform or to defer PCI was found in a relatively high proportion among patients undergoing coronary angiography. Prognostic evidence is warranted to determine the clinical significance of the mismatch between the two methods.

Funding Acknowledgement

Type of funding sources: None. Figure 1

“Stifflammation” in hypertension is a predictor of future cardiovascular hospitalizations

Background/Introduction

Hypertension is associated with increased cardiovascular risk, inflammation and arterial stiffness.

Purpose

We sought to investigate the role of inflammation and arterial stiffness in the prognosis of cardiovascular hospitalizations in hypertensive patients over an extended follow-up.

Methods

One hundred and seventy-three patients (mean age 52.5±13.2 years, 57% males) untreated hypertensives at baseline without cardiovascular disease, were included in the study. Arterial stiffness was assessed with carotid-femoral pulse wave velocity (PWV). High-sensitivity C-reactive protein (hsCRP) was measured in venous blood samples. Other markers of subclinical organ damage [left ventricular mass index (LVMI) by echocardiography and estimated glomerular filtration rate (eGFR)] were also evaluated in all patients.

Results

During 13.6±0.4 years of follow-up, forty-four patients (25.4%) patients were admitted in hospital due to cardiovascular causes. In multivariable logistic regression analysis, only higher hsCRP (Odds Ratio [OR] = 3.34, 95% Confidence intervals [CI]: 1.22–9.51, P=0.02) and increased PWV (OR = 1.48, 95% Confidence intervals [CI]: 1.03–2.12, P=0.036) were associated with higher risk of cardiovascular hospitalizations, which was independent of age, gender, systolic blood pressure, LVMI and presence of diabetes. In further analysis, receiver operating characteristic (ROC) curves were generated to evaluate the ability of hsCRP and PWV to discriminate subjects with cardiovascular hospitalization. The area under the curve (AUC) and 95% CIs of the ROC curves were AUC=0.69 (95% CI: 0.59–0.78, p<0.001) for hsCRP and AUC=0.74 (95% CI: 0.65–0.83, P<0.001) for PWV (Figure).

Conclusions

Our study shows the independent complimentary prognostic role of inflammation and arterial stiffness in the prognosis of hypertensives even in studies with extended follow-up.

Funding Acknowledgement

Type of funding sources: None. ROC curves for the prediction of outcome

Conservative management of acute coronary syndromes in chronic kidney disease patients: a deadly sin

Background/Introduction

Chronic kidney disease (CKD) is associated with worse prognosis in acute coronary syndromes (ACS).

Purpose

We sought to investigate the prognostic effect of non-invasive management of ACS in CKD patients in a tertiary University Hospital.

Methods

Two hundred and one patients (mean age 66.5±13.6 years, 150 males) admitted to our Hospital with ACS from 2016–2017 were included in the study. Patients were followed for a median of 2 years post the index event. CKD was defined by an estimated glomerular filtration rate (eGFR) <60 ml/min/m2, as assessed by the Modification of Diet in Renal Disease (MDRD) equation. We grouped patients into four groups according to their CKD status and whether they underwent coronary angiography or not. The primary outcome was all-cause death and secondary outcomes were cardiovascular and non-cardiovascular death.

Results

The majority of patients (n=120, 60%) presented with non-ST elevation ACS (NSTE-ACS), whereas 81 patients as ST-elevation myocardial infarction (STEMI) (40%). Fifty-four patients (27%) were identified as CKD patients (of whom 5 were on dialysis). Overall, 29 patients (14.4%) did not undergo coronary angiography. Patients at a higher age and with CKD were more likely to not undergo angiography. Thirty-seven (18.4%) died during follow-up (25 non-cardiovascular deaths and 12 cardiovascular deaths). Patients with conservative treatment and CKD had the worse prognosis (Hazard ratio [HR] =11.00, 95% Confidence intervals [CI] 4.00 to 30.24, p<0.001) followed by non-CKD patients with conservative treatment (HR=4.37, 95% CI 1.20 to 15.90, p=0.025) compared to non-CKD patients treated invasively (reference group) after adjusting for age, gender, STEMI/NSTE-ACS diagnosis (Figure). Results were similar for non-cardiovascular death, whereas regarding cardiovascular death only the group with CKD and conservative treatment had a lower survival compared to the reference group (HR=26.5, 95% CI 2.9 to 241.7, p=0.004)

Conclusions

Patients with ACS and CKD are less likely to receive invasive management and have higher mortality from both cardiovascular and non-cardiovascular causes than patients without CKD. Conservative management of ACS was associated with higher long-term mortality versus invasive management in all patients, regardless of CKD status.

Funding Acknowledgement

Type of funding sources: None.