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Ganzorig N, Pompei G, Jenkins K, Wang W, Rubino F, Gill K, Kunadian V. Role of physiology in the management of multivessel disease among patients with acute coronary syndrome. ASIAINTERVENTION 2024; 10:157-168. [PMID: 39347110 PMCID: PMC11413640 DOI: 10.4244/aij-d-24-00051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2024] [Accepted: 08/02/2024] [Indexed: 10/01/2024]
Abstract
Multivessel coronary artery disease (CAD), defined as ≥50% stenosis in 2 or more epicardial arteries, is associated with a high burden of morbidity and mortality in acute coronary syndrome (ACS) patients. A salient challenge for managing this cohort is selecting the optimal revascularisation strategy, for which the use of coronary physiology has been increasingly recognised. Fractional flow reserve (FFR) is an invasive, pressure wire-based, physiological index measuring the functional significance of coronary lesions. Understanding this can help practitioners evaluate which lesions could induce myocardial ischaemia and, thus, decide which vessels require urgent revascularisation. Non-hyperaemic physiology-based indices, such as instantaneous wave-free ratio (iFR), provide valid alternatives to FFR. While FFR and iFR are recommended by international guidelines in stable CAD, there is ongoing discussion regarding the role of physiology in patients with ACS and multivessel disease (MVD); growing evidence supports FFR use in the latter. Compelling findings show FFR-guided complete percutaneous coronary intervention (PCI) can reduce adverse cardiovascular events, mortality, and repeat revascularisations in ACS and MVD patients compared to angiography-based PCI. However, FFR is limited in identifying non-flow-limiting vulnerable plaques, which can disadvantage high-risk patients. Here, integrating coronary physiology assessment with intracoronary imaging in decision-making can improve outcomes and quality of life. Further research into novel physiology-based tools in ACS and MVD is needed. This review aims to highlight the key evidence surrounding the role of FFR and other functional indices in guiding PCI strategy in ACS and MVD patients.
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Affiliation(s)
- Nandine Ganzorig
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Graziella Pompei
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Cona, Italy
| | - Kenny Jenkins
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Wanqi Wang
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Francesca Rubino
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
- Department of Cardiology, HartCentrum, Ziekenhuis Netwerk Antwerpen (ZNA) Middelheim, Antwerp, Belgium
| | - Kieran Gill
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Vijay Kunadian
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
- Cardiothoracic Centre, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
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Wu X, Wang K, Li G, Wu J, Jiang J, Gao F, Zhu L, Xu Q, Wang X, Xu M, Chen H, Ma L, Han X, Luo N, Tu S, Wang J, Hu X. Diagnostic Performance of Angiography-Derived Quantitative Flow Ratio in Complex Coronary Lesions. Circ Cardiovasc Imaging 2024; 17:e016046. [PMID: 38502735 DOI: 10.1161/circimaging.123.016046] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 01/23/2024] [Indexed: 03/21/2024]
Abstract
BACKGROUND Quantitative flow ratio derived from computed tomography angiography (CT-QFR) and invasive coronary angiography (Murray law-based quantitative flow ratio [μQFR]) are novel approaches enabling rapid computation of fractional flow reserve without the use of pressure guidewires and vasodilators. However, the feasibility and diagnostic performance of both CT-QFR and μQFR in evaluating complex coronary lesions remain unclear. METHODS Between September 2014 and September 2021, 240 patients with 30% to 90% coronary diameter stenosis who underwent both coronary computed tomography angiography and invasive coronary angiography with fractional flow reserve within 60 days were retrospectively enrolled. The diagnostic performance of CT-QFR and μQFR in detecting functional ischemia among all lesions, especially complex coronary lesions, was analyzed using fractional flow reserve as the reference standard. RESULTS CT-QFR and μQFR analyses were performed on 309 and 289 vessels, respectively. The diagnostic sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for CT-QFR in all lesions at the per-vessel level were 91% (with a 95% CI of 84%-96%), 92% (95% CI, 88%-95%), 83% (95% CI, 75%-90%), 96% (95% CI, 93%-98%), and 92% (95% CI, 88%-95%), with values for μQFR of 90% (95% CI, 81%-95%), 97% (95% CI, 93%-99%), 92% (95% CI, 84%-97%), 96% (95% CI, 92%-98%), and 94% (95% CI, 91%-97%), respectively. Among bifurcation, tandem, and moderate-to-severe calcified lesions, the diagnostic values of CT-QFR and μQFR showed great correlation and agreement with those of invasive fractional flow reserve, achieving an area under the receiver operating characteristic curve exceeding 0.9 for each complex lesion at the vessel level. Furthermore, the accuracies of CT-QFR and μQFR in the gray zone were 85% and 84%, respectively. CONCLUSIONS Angiography-derived quantitative flow ratio (CT-QFR and μQFR) demonstrated remarkable diagnostic performance in complex coronary lesions, indicating its pivotal role in the management of patients with coronary artery disease.
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Affiliation(s)
- Xianpeng Wu
- Department of Cardiology (X. Wu, K.W., G.L., J. Wu, J.J., F.G., L.Z., Q.X., J. Wang, X. Hu), the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- State Key Laboratory of Transvascular Implantation Devices, Hangzhou, China (X. Wu, K.W., G.L., J.J., F.G., L.Z., Q.X., J. Wang, X. Hu)
- Cardiovascular Key Laboratory of Zhejiang Province, Hangzhou, China (X. Wu, K.W., G.L., J.J., F.G., L.Z., Q.X., J. Wang, X. Hu)
| | - Kan Wang
- Department of Cardiology (X. Wu, K.W., G.L., J. Wu, J.J., F.G., L.Z., Q.X., J. Wang, X. Hu), the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- State Key Laboratory of Transvascular Implantation Devices, Hangzhou, China (X. Wu, K.W., G.L., J.J., F.G., L.Z., Q.X., J. Wang, X. Hu)
- Cardiovascular Key Laboratory of Zhejiang Province, Hangzhou, China (X. Wu, K.W., G.L., J.J., F.G., L.Z., Q.X., J. Wang, X. Hu)
| | - Guohua Li
- Department of Cardiology (X. Wu, K.W., G.L., J. Wu, J.J., F.G., L.Z., Q.X., J. Wang, X. Hu), the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- State Key Laboratory of Transvascular Implantation Devices, Hangzhou, China (X. Wu, K.W., G.L., J.J., F.G., L.Z., Q.X., J. Wang, X. Hu)
- Cardiovascular Key Laboratory of Zhejiang Province, Hangzhou, China (X. Wu, K.W., G.L., J.J., F.G., L.Z., Q.X., J. Wang, X. Hu)
| | - Jie Wu
- Department of Cardiology (X. Wu, K.W., G.L., J. Wu, J.J., F.G., L.Z., Q.X., J. Wang, X. Hu), the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Department of Cardiology, Jinhua People's Hospital, Jinhua, China (J. Wu)
| | - Jun Jiang
- Department of Cardiology (X. Wu, K.W., G.L., J. Wu, J.J., F.G., L.Z., Q.X., J. Wang, X. Hu), the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- State Key Laboratory of Transvascular Implantation Devices, Hangzhou, China (X. Wu, K.W., G.L., J.J., F.G., L.Z., Q.X., J. Wang, X. Hu)
- Cardiovascular Key Laboratory of Zhejiang Province, Hangzhou, China (X. Wu, K.W., G.L., J.J., F.G., L.Z., Q.X., J. Wang, X. Hu)
| | - Feng Gao
- Department of Cardiology (X. Wu, K.W., G.L., J. Wu, J.J., F.G., L.Z., Q.X., J. Wang, X. Hu), the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- State Key Laboratory of Transvascular Implantation Devices, Hangzhou, China (X. Wu, K.W., G.L., J.J., F.G., L.Z., Q.X., J. Wang, X. Hu)
- Cardiovascular Key Laboratory of Zhejiang Province, Hangzhou, China (X. Wu, K.W., G.L., J.J., F.G., L.Z., Q.X., J. Wang, X. Hu)
| | - Lingjun Zhu
- Department of Cardiology (X. Wu, K.W., G.L., J. Wu, J.J., F.G., L.Z., Q.X., J. Wang, X. Hu), the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- State Key Laboratory of Transvascular Implantation Devices, Hangzhou, China (X. Wu, K.W., G.L., J.J., F.G., L.Z., Q.X., J. Wang, X. Hu)
- Cardiovascular Key Laboratory of Zhejiang Province, Hangzhou, China (X. Wu, K.W., G.L., J.J., F.G., L.Z., Q.X., J. Wang, X. Hu)
| | - Qiyuan Xu
- Department of Cardiology (X. Wu, K.W., G.L., J. Wu, J.J., F.G., L.Z., Q.X., J. Wang, X. Hu), the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- State Key Laboratory of Transvascular Implantation Devices, Hangzhou, China (X. Wu, K.W., G.L., J.J., F.G., L.Z., Q.X., J. Wang, X. Hu)
- Cardiovascular Key Laboratory of Zhejiang Province, Hangzhou, China (X. Wu, K.W., G.L., J.J., F.G., L.Z., Q.X., J. Wang, X. Hu)
| | - Xinhong Wang
- Department of Radiology (X. Wang, M.X.), the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Mengxi Xu
- Department of Radiology (X. Wang, M.X.), the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Hui Chen
- Department of Cardiology (H.C., L.M.), Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Longhui Ma
- Department of Cardiology (H.C., L.M.), Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Xianjun Han
- Department of Radiology (X. Han, N.L.), Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Nan Luo
- Department of Radiology (X. Han, N.L.), Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Shengxian Tu
- Biomedical Instrument Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China (S.T.)
| | - Jian'an Wang
- Department of Cardiology (X. Wu, K.W., G.L., J. Wu, J.J., F.G., L.Z., Q.X., J. Wang, X. Hu), the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- State Key Laboratory of Transvascular Implantation Devices, Hangzhou, China (X. Wu, K.W., G.L., J.J., F.G., L.Z., Q.X., J. Wang, X. Hu)
- Cardiovascular Key Laboratory of Zhejiang Province, Hangzhou, China (X. Wu, K.W., G.L., J.J., F.G., L.Z., Q.X., J. Wang, X. Hu)
| | - Xinyang Hu
- Department of Cardiology (X. Wu, K.W., G.L., J. Wu, J.J., F.G., L.Z., Q.X., J. Wang, X. Hu), the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- State Key Laboratory of Transvascular Implantation Devices, Hangzhou, China (X. Wu, K.W., G.L., J.J., F.G., L.Z., Q.X., J. Wang, X. Hu)
- Cardiovascular Key Laboratory of Zhejiang Province, Hangzhou, China (X. Wu, K.W., G.L., J.J., F.G., L.Z., Q.X., J. Wang, X. Hu)
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Milovanovic A, Isailovic V, Saveljic I, Filipovic N. Accuracy of analytically determined fractional flow reserve derived from coronary angiography for non-invasive assessment of coronary artery stenosis. Technol Health Care 2024; 32:4613-4626. [PMID: 39177623 PMCID: PMC11613037 DOI: 10.3233/thc-240803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2024] [Accepted: 05/27/2024] [Indexed: 08/24/2024]
Abstract
BACKGROUND Fractional flow reserve (FFR) determined invasively has been globally accepted as the gold standard for determining the functional significance of coronary artery stenoses. However, despite its great importance, the invasive method has certain disadvantages, including the risk of vascular injuries, the need for vasodilation, and significant medical costs. That is why great attention was paid to the development of non-invasive methods that would enable reliable diagnosis without exposing patients to the risk of unwanted consequences. OBJECTIVE This paper aimed to create and verify an alternative, less resource- and time-demanding, non-invasive solution. METHODS The determination of FFR is based on the application of the fundamental laws of fluid dynamics. All energy losses in the coronary artery with stenosis were identified and analyzed in detail. A three-dimensional model of a coronary artery was generated using the corresponding angiographic images. Finally, the pressure due to stenosis was calculated and the FFR was determined. RESULTS The results obtained using the proposed analytical method were compared with available experimental data for 40 patients who experienced the invasive coronary angiography. The coefficient of determination, mean difference and standard deviation values are determined to be 0.726, -0.017 and 0.056, respectively. These values were slightly higher for FFR values above 0.80. CONCLUSION The FFR calculated by the proposed analytical method has a relatively good correlation with clinical data, which leads to the conclusion that it can provide a reliable assessment of the functional significance of coronary stenosis.
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Affiliation(s)
| | - Velibor Isailovic
- Faculty of Engineering, University of Kragujevac, Kragujevac, Serbia
- Bioengineering Research and Development Center, Kragujevac, Serbia
| | - Igor Saveljic
- Institute for Information Technologies, University of Kragujevac, Kragujevac, Serbia
- Bioengineering Research and Development Center, Kragujevac, Serbia
| | - Nenad Filipovic
- Faculty of Engineering, University of Kragujevac, Kragujevac, Serbia
- Bioengineering Research and Development Center, Kragujevac, Serbia
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Koo BK, Hwang D, Park S, Kuramitsu S, Yonetsu T, Kim CH, Zhang J, Yang S, Doh JH, Jeong YH, Choi KH, Lee JM, Ahn JM, Matsuo H, Shin ES, Hu X, Low AF, Kubo T, Nam CW, Yong AS, Harding SA, Xu B, Hur SH, Choo GH, Tan HC, Mullasari A, Hsieh IC, Kakuta T, Akasaka T, Wang J, Tahk SJ, Fearon WF, Escaned J, Park SJ. Practical Application of Coronary Physiologic Assessment: Asia-Pacific Expert Consensus Document: Part 2. JACC. ASIA 2023; 3:825-842. [PMID: 38155788 PMCID: PMC10751650 DOI: 10.1016/j.jacasi.2023.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 07/08/2023] [Indexed: 12/30/2023]
Abstract
Coronary physiologic assessment is performed to measure coronary pressure, flow, and resistance or their surrogates to enable the selection of appropriate management strategy and its optimization for patients with coronary artery disease. The value of physiologic assessment is supported by a large body of clinical data that has led to major recommendations in all practice guidelines. This expert consensus document aims to convey practical and balanced recommendations and future perspectives for coronary physiologic assessment for physicians and patients in the Asia-Pacific region, based on updated information in the field that includes both wire- and image-based physiologic assessment. This is Part 2 of the whole consensus document, which provides theoretical and practical information on physiologic indexes for specific clinical conditions and patient statuses.
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Affiliation(s)
- Bon-Kwon Koo
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Doyeon Hwang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Sungjoon Park
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Shoichi Kuramitsu
- Department of Cardiovascular Medicine, Sapporo Heart Center, Sapporo Cardio Vascular Clinic, Sapporo, Japan
| | - Taishi Yonetsu
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Chee Hae Kim
- Department of Internal Medicine and Cardiovascular Center, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Jinlong Zhang
- Department of Cardiology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Seokhun Yang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Joon-Hyung Doh
- Department of Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Young-Hoon Jeong
- CAU Thrombosis and Biomarker Center, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong, Korea and Department of Internal Medicine, Chung-Ang University School of Medicine, Seoul, Korea
| | - Ki Hong Choi
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joo Myung Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jung-Min Ahn
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hitoshi Matsuo
- Department of Cardiovascular Medicine, Gifu Heart Center, Japan
| | - Eun-Seok Shin
- Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Xinyang Hu
- Department of Cardiology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Adrian F. Low
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore; National University Heart Centre, National University Health System, Singapore
| | - Takashi Kubo
- Department of Cardiology, Tokyo Medical University, Hachioji Medical Center, Tokyo, Japan
| | - Chang-Wook Nam
- Department of Internal Medicine and Cardiovascular Research Institute, Keimyung University Dongsan Hospital, Daegu, Korea
| | - Andy S.C. Yong
- Department of Cardiology, Concord Hospital, University of Sydney, Sydney, Australia
| | - Scott A. Harding
- Department of Cardiology, Wellington Hospital, Wellington, New Zealand
| | - Bo Xu
- Department of Cardiology, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Seung-Ho Hur
- Department of Internal Medicine and Cardiovascular Research Institute, Keimyung University Dongsan Hospital, Daegu, Korea
| | - Gim Hooi Choo
- Department of Cardiology, Cardiac Vascular Sentral KL (CVSKL), Kuala Lumpur, Malaysia
| | - Huay Cheem Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore; National University Heart Centre, National University Health System, Singapore
| | - Ajit Mullasari
- Department of Cardiology, Madras Medical Mission, Chennai, India
| | - I-Chang Hsieh
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Tsunekazu Kakuta
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Takashi Akasaka
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Jian'an Wang
- Department of Cardiology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Seung-Jea Tahk
- Department of Cardiology, Ajou University Medical Center, Suwon, Korea
| | - William F. Fearon
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Javier Escaned
- Hospital Clinico San Carlos IDISSC, Complutense University of Madrid, Madrid, Spain
| | - Seung-Jung Park
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Hwang D, Park SH, Koo BK. Ischemia With Nonobstructive Coronary Artery Disease: Concept, Assessment, and Management. JACC. ASIA 2023; 3:169-184. [PMID: 37181394 PMCID: PMC10167523 DOI: 10.1016/j.jacasi.2023.01.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 01/03/2023] [Accepted: 01/06/2023] [Indexed: 05/16/2023]
Abstract
In daily clinical practice, physicians often encounter patients with angina or those with evidence of myocardial ischemia from noninvasive tests but not having obstructive coronary artery disease. This type of ischemic heart disease is referred to as ischemia with nonobstructive coronary arteries (INOCA). INOCA patients often suffer from recurrent chest pain without adequate management and are associated with poor clinical outcomes. There are several endotypes of INOCA, and each endotype should be treated based on its specific underlying mechanism. Therefore, identifying INOCA and discriminating its underlying mechanisms are important issues and of clinical interest. Invasive physiologic assessment is the first step in the diagnosis of INOCA and discriminating the underlying mechanism; additional provocation tests help physicians identify the vasospastic component in INOCA patients. Comprehensive information acquired from these invasive tests can provide a template for mechanism-specific management for patients with INOCA.
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Affiliation(s)
- Doyeon Hwang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Sang-Hyeon Park
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Bon-Kwon Koo
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
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Di Serafino L, Barbato E, Serino F, Svanerud J, Scalamogna M, Cirillo P, Petitto M, Esposito M, Silvestri T, Franzone A, Piccolo R, Esposito G. Myocardial mass affects diagnostic performance of non-hyperemic pressure-derived indexes in the assessment of coronary stenosis. Int J Cardiol 2023; 370:84-89. [PMID: 36265648 DOI: 10.1016/j.ijcard.2022.10.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 09/09/2022] [Accepted: 10/12/2022] [Indexed: 11/05/2022]
Abstract
UNLABELLED Background Several non-hyperemic pressure-derived Indexes (NHPI) have been introduced for the assessment of coronary stenosis, showing a good correlation with fractional flow reserve (FFR). Notably, either the assessment of NHPI during adenosine administration (NHPIADO) or the Hybrid Approach (NHPIHA), combining NHPI with FFR, have been showed to increase the accuracy of such indexes. It remains unclear whether diagnostic performance might be affected by the extent of the subtended myocardial mass. METHODS We enrolled consecutive patients with an intermediate coronary stenosis assessed with NHPI and FFR. NHPI were also measured during adenosine (ADO) administration (NHPIADO). The amount of jeopardized myocardium was assessed using the Duke Jeopardy Score (DJS). With FFR as reference, we assessed the accuracy of NHPI, NHPIADO and NHPIHA according to the extent of the subtended myocardium. RESULTS One-hundred-seventy stenoses from 151 patients were grouped according to the DJS as follows: A) Small Extent (SE, n = 82); B) Moderate Extent (ME, n = 53); C) Large Extent (LE, n = 35). As compared with FFR, NHPI showed a significantly different accuracy, as assessed by the Youden's index, according to the extent of the jeopardized myocardium (SE: 0.39 ± 0.05, ME: 0.68 ± 0.06, LE: 0.28 ± 0.06, p < 0.001). Conversely, both the NHPIADO (SE: 0.76 ± 0.02, ME: 0.88 ± 0.02, LE: 0.82 ± 0.02, p = 0.72) and NHPIHA (SE: 0.82 ± 0.07, ME: 0.84 ± 0.02, LE: 0.88 ± 0.02, p = 0.70) allowed for a better diagnostic accuracy regardless of the amount of myocardium subtended. CONCLUSIONS Diagnostic performance of NHPI might be affected by the extent of myocardial territory subtended by the coronary stenosis. A hybrid approach might be useful to overcome this limitation.
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Affiliation(s)
- Luigi Di Serafino
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy.
| | - Emanuele Barbato
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy; Cardiovascular Center Aalst, OLV Hospital, Aalst, Belgium
| | - Federica Serino
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | | | - Maria Scalamogna
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Plinio Cirillo
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Marta Petitto
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Mafalda Esposito
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Tania Silvestri
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Anna Franzone
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Raffaele Piccolo
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Giovanni Esposito
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
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Myocardial deformation indices for detection of the functional significance of intermediate left anterior descending coronary artery stenosis: FFR guided study. Int J Cardiovasc Imaging 2022; 38:2625-2633. [DOI: 10.1007/s10554-022-02668-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 05/30/2022] [Indexed: 11/25/2022]
Abstract
AbstractThis study aimed to investigate the diagnostic performance of non-invasive resting myocardial deformation indices in identifying functional significance of intermediate stenosis of the left anterior descending (LAD) artery. Patients with 50–70% LAD stenosis upon coronary angiography were enrolled and divided into group I with fractional flow reserve (FFR) > 0.8 and group II with FFR ≤ 0.8. Patients were subjected to conventional and speckle tracking echocardiography with measurement of myocardial deformation indices including regional peak longitudinal strain (PLS), global longitudinal strain (GLS), Post-systolic strain index (PSI), and time interval between Aortic valve closure (AVC) and PLS. The current study included 200 patients. Group II patients had significantly lower absolute mean values of regional (PLS) and (GLS) compared to group I (− 14.98 ± 5.05 and − 18.73 ± 3.92 vs. − 17.59 ± 3.62 and − 19.20 ± 2.61, p = 0.001 and 0.02, respectively). The FFR values of LAD correlated significantly and negatively with the time interval between AVC and regional PLS (r = − 0.201, p = 0.004) as well as PSI (r = − 0.257, p < 0.001). For identifying cases with FFR ≤ 0.8, the optimal cut-off value of the time interval between AVC and PLS was 76 ms with 77.8% sensitivity and 93.8% specificity. The best cut-off value of PSI was 13%, yielding 50% sensitivity and 87.5% specificity. In patients with intermediate 50–70% LAD coronary artery stenotic lesions, the PSI and the duration between AVC and regional PLS enabled the identification of functionally significant lesions with reasonable diagnostic accuracy.Trial registration ZU-IRB#3199-20-11-2015 Registered 20 November 2015, IRB_123@medicine.zu.edu.eg.
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Weng T, Gan Q, Li Z, Guan S, Han W, Zhai X, Li M, Qi L, Li C, Chen Y, Zhang L, Chang X, Tu S, Qu X. Diagnostic accuracy of CCTA-derived versus angiography-derived quantitative flow ratio (CAREER) study: a prospective study protocol. BMJ Open 2022; 12:e055481. [PMID: 35738652 PMCID: PMC9226950 DOI: 10.1136/bmjopen-2021-055481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Coronary CT angiography (CCTA)-derived quantitative flow ratio (CT-QFR) is a novel non-invasive technology to assess the physiological significance of coronary stenoses, which enables fast and on-site computation of fractional flow reserve (FFR) from CCTA images. The objective of this investigator-initiated, prospective, single-centre clinical trial is to evaluate the diagnostic performance of CT-QFR with respect to angiography-derived QFR, using FFR as the reference standard. METHODS AND ANALYSIS A total of 216 patients who have at least one lesion with a diameter stenosis of 30%-90% in an artery with ≥2.0 mm reference diameter will be enrolled in the study. FFR will be measured during invasive coronary angiography. CT-QFR and QFR will be assessed in two independent core laboratories in a blinded fashion. The primary endpoint is the diagnostic accuracy of CT-QFR in identifying haemodynamically significant coronary stenosis with FFR as the reference standard. The major secondary endpoint is the non-inferiority of CT-QFR compared with QFR in the patients without extensively calcified lesions. ETHICS AND DISSEMINATION The study was approved by the Ethics Committee of Huadong Hospital Affiliated to Fudan University (2020K192). Outcomes will be disseminated through publications in peer-reviewed journals and presentations at scientific conferences. TRIAL REGISTRATION NUMBER NCT04665817.
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Affiliation(s)
- Tingwen Weng
- Department of Cardiology, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Qian Gan
- Department of Cardiology, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Zehang Li
- School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Shaofeng Guan
- Department of Cardiology, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Wenzheng Han
- Department of Cardiology, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Xinrong Zhai
- Department of Cardiology, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Ming Li
- Department of Radiology, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Lin Qi
- Department of Radiology, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Cheng Li
- Department of Radiology, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Yang Chen
- Department of Cardiology, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Liang Zhang
- Department of Cardiology, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Xifeng Chang
- Department of Cardiology, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Shengxian Tu
- School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Xinkai Qu
- Department of Cardiology, Huadong Hospital Affiliated to Fudan University, Shanghai, China
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Lee YJ, Kim YW, Ha J, Kim M, Guagliumi G, Granada JF, Lee SG, Lee JJ, Cho YK, Yoon HJ, Lee JH, Kim U, Jang JY, Oh SJ, Lee SJ, Hong SJ, Ahn CM, Kim BK, Chang HJ, Ko YG, Choi D, Hong MK, Jang Y, Lee JS, Kim JS. Computational Fractional Flow Reserve From Coronary Computed Tomography Angiography—Optical Coherence Tomography Fusion Images in Assessing Functionally Significant Coronary Stenosis. Front Cardiovasc Med 2022; 9:925414. [PMID: 35770218 PMCID: PMC9234158 DOI: 10.3389/fcvm.2022.925414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 05/25/2022] [Indexed: 11/13/2022] Open
Abstract
Background Coronary computed tomography angiography (CTA) and optical coherence tomography (OCT) provide additional functional information beyond the anatomy by applying computational fluid dynamics (CFD). This study sought to evaluate a novel approach for estimating computational fractional flow reserve (FFR) from coronary CTA-OCT fusion images. Methods Among patients who underwent coronary CTA, 148 patients who underwent both pressure wire-based FFR measurement and OCT during angiography to evaluate intermediate stenosis in the left anterior descending artery were included from the prospective registry. Coronary CTA-OCT fusion images were created, and CFD was applied to estimate computational FFR. Based on pressure wire-based FFR as a reference, the diagnostic performance of Fusion-FFR was compared with that of CT-FFR and OCT-FFR. Results Fusion-FFR was strongly correlated with FFR (r = 0.836, P < 0.001). Correlation between FFR and Fusion-FFR was stronger than that between FFR and CT-FFR (r = 0.682, P < 0.001; z statistic, 5.42, P < 0.001) and between FFR and OCT-FFR (r = 0.705, P < 0.001; z statistic, 4.38, P < 0.001). Area under the receiver operating characteristics curve to assess functionally significant stenosis was higher for Fusion-FFR than for CT-FFR (0.90 vs. 0.83, P = 0.024) and OCT-FFR (0.90 vs. 0.83, P = 0.043). Fusion-FFR exhibited 84.5% accuracy, 84.6% sensitivity, 84.3% specificity, 80.9% positive predictive value, and 87.5% negative predictive value. Especially accuracy, specificity, and positive predictive value were superior for Fusion-FFR than for CT-FFR (73.0%, P = 0.007; 61.4%, P < 0.001; 64.0%, P < 0.001) and OCT-FFR (75.7%, P = 0.021; 73.5%, P = 0.020; 69.9%, P = 0.012). Conclusion CFD-based computational FFR from coronary CTA-OCT fusion images provided more accurate functional information than coronary CTA or OCT alone. Clinical Trial Registration [www.ClinicalTrials.gov], identifier [NCT03298282].
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Affiliation(s)
- Yong-Joon Lee
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Young Woo Kim
- Department of Mechanical Engineering, Yonsei University, Seoul, South Korea
| | - Jinyong Ha
- Department of Electrical Engineering, Sejong University, Seoul, South Korea
| | - Minug Kim
- Department of Electrical Engineering, Sejong University, Seoul, South Korea
| | - Giulio Guagliumi
- Department of Cardiovascular, Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - Juan F. Granada
- Cardiovascular Research Foundation, Columbia University Medical Center, New York, NY, United States
| | - Seul-Gee Lee
- Yonsei Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Jung-Jae Lee
- Yonsei Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Yun-Kyeong Cho
- Department of Cardiology, Keimyung University Dongsan Hospital, Daegu, South Korea
| | - Hyuck Jun Yoon
- Department of Cardiology, Keimyung University Dongsan Hospital, Daegu, South Korea
| | - Jung Hee Lee
- Division of Cardiology, Yeungnam University Medical Center, Yeungnam University College of Medicine, Daegu, South Korea
| | - Ung Kim
- Division of Cardiology, Yeungnam University Medical Center, Yeungnam University College of Medicine, Daegu, South Korea
| | - Ji-Yong Jang
- National Health Insurance Service Ilsan Hospital, Goyang, South Korea
| | - Seung-Jin Oh
- National Health Insurance Service Ilsan Hospital, Goyang, South Korea
| | - Seung-Jun Lee
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Sung-Jin Hong
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Chul-Min Ahn
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Byeong-Keuk Kim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Hyuk-Jae Chang
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Young-Guk Ko
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Donghoon Choi
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Myeong-Ki Hong
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Yangsoo Jang
- Division of Cardiology, CHA Bundang Medical Center, CHA University College of Medicine, Seongnam, South Korea
| | - Joon Sang Lee
- Department of Mechanical Engineering, Yonsei University, Seoul, South Korea
- *Correspondence: Joon Sang Lee,
| | - Jung-Sun Kim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
- Jung-Sun Kim,
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Comparison of FFR, iFR, and QFR assessment in patients with severe aortic stenosis and coronary heart disease. Adv Cardiol 2022; 18:118-121. [PMID: 36051833 PMCID: PMC9421517 DOI: 10.5114/aic.2022.118527] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 06/02/2022] [Indexed: 01/10/2023]
Abstract
Introduction Some patients with coronary heart disease are diagnosed with severe aortic stenosis. For further treatment, coronary angiography is performed in these patients. For intermediate lesions, obtaining coronary artery physiological data can facilitate clinical decision-making regarding revascularization. Aim The study compared the physiological significance of coronary artery stenosis using the fractional flow reserve (FFR) method with instantaneous wave-free pressure ratio (iFR) and quantitative flow ratio (QFR) in patients qualified for aortic valve replacement. Material and methods Data were collected on patients hospitalized in the years 2019–2020 at the 2nd Department of Cardiology, University Hospital in Krakow. Results Twelve patients with severe aortic stenosis and borderline lesions in the coronary artery were qualified for physiological assessment. There were 6 women, whose mean age was 73.8 ±7.5 years. The mean left ventricular ejection fraction was 52 ±15%. The mean aortic valve area was 0.80 ±0.16 cm2. The left anterior descending artery was assessed in 12 from 13 cases (92%). In comparison to FFR, all iFR measurements were concordant with FFR. The total agreement between QFR and FFR/iFR assessment was 69%. Conclusions Despite the controversy and uncertainty of some operators regarding the interpretation of the FFR test in patients with severe aortic stenosis, we obtained complete agreement of FFR with iFR assessment. This fact suggests that in patients with severe aortic stenosis the choice of an invasive method to assess the physiological significance of the stenosis in the coronary artery is not crucial – both iFR and FFR allow comparable results.
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11
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Geng Y, Wu X, Liu H, Zheng D, Xia L. Index of microcirculatory resistance: state-of-the-art and potential applications in computational simulation of coronary artery disease. J Zhejiang Univ Sci B 2022; 23:123-140. [PMID: 35187886 DOI: 10.1631/jzus.b2100425] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
The dysfunction of coronary microcirculation is an important cause of coronary artery disease (CAD). The index of microcirculatory resistance (IMR) is a quantitative evaluation of coronary microcirculatory function, which provides a significant reference for the prediction, diagnosis, treatment, and prognosis of CAD. IMR also plays a key role in investigating the interaction between epicardial and microcirculatory dysfunctions, and is closely associated with coronary hemodynamic parameters such as flow rate, distal coronary pressure, and aortic pressure, which have been widely applied in computational studies of CAD. However, there is currently a lack of consensus across studies on the normal and pathological ranges of IMR. The relationships between IMR and coronary hemodynamic parameters have not been accurately quantified, which limits the application of IMR in computational CAD studies. In this paper, we discuss the research gaps between IMR and its potential applications in the computational simulation of CAD. Computational simulation based on the combination of IMR and other hemodynamic parameters is a promising technology to improve the diagnosis and guide clinical trials of CAD.
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Affiliation(s)
- Yingyi Geng
- Key Laboratory for Biomedical Engineering of Ministry of Education, Institute of Biomedical Engineering, Zhejiang University, Hangzhou 310027, China
| | - Xintong Wu
- Key Laboratory for Biomedical Engineering of Ministry of Education, Institute of Biomedical Engineering, Zhejiang University, Hangzhou 310027, China
| | - Haipeng Liu
- Research Centre of Intelligent Healthcare, Faculty of Health and Life Science, Coventry University, Coventry CV1 5FB, UK
| | - Dingchang Zheng
- Research Centre of Intelligent Healthcare, Faculty of Health and Life Science, Coventry University, Coventry CV1 5FB, UK.
| | - Ling Xia
- Key Laboratory for Biomedical Engineering of Ministry of Education, Institute of Biomedical Engineering, Zhejiang University, Hangzhou 310027, China.
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12
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Vassilev D, Mileva N, Collet C, Nikolov P, Karamfiloff K, Naunov V, Sonck J, Hristova I, Georgieva D, Rigatelli G, Kassab GS, Gil RJ. Determinants of functional significance of coronary bifurcation lesions and clinical outcomes after physiology-guided treatment. IJC HEART & VASCULATURE 2022; 38:100929. [PMID: 35024426 PMCID: PMC8728425 DOI: 10.1016/j.ijcha.2021.100929] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 12/11/2021] [Accepted: 12/14/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To determine the rate of functionally significant (fractional flow reserve, FFR ≤ 0.80) coronary bifurcation stenoses that are considered anatomically significant based on angiographic estimation and to define predictors of functional significance of stenoses in main vessel and side branch. BACKGROUND To date, the rate of functionally significant stenoses in angiographic significant coronary bifurcation stenoses has not been specifically determined. METHODS Patients with significant angiographic bifurcation lesions defined as diameter stenosis >50% in main vessel and/or side branch were included. FFR was performed in main vessel (MV) and side branch (SB) before and after percutaneous coronary intervention (PCI). The protocol was approved by the local ethics committee. RESULTS Overall, 171 patients with bifurcation lesions were included. Mean FFR in MV was 0.80 ± 0.01 and 0.84 ± 0.09 in SB. 46% (n = 78) of bifurcation lesions were functionally significant when assessed with FFR. Diameter stenosis in main vessel, lesion length, side branch territory and SYNTAX score (SS) were found as predictors for lesion functional severity (main vessel FFR ≤ 0.80). At the time of follow-up, there were no differences between the treated and deferred group regarding rates of all-cause death, cardio-vascular death, MACEs and POCE. CONCLUSION Less than half of all angiographic significant bifurcation lesions were functionally significant when assessed with FFR. There was no difference in clinical outcomes at mean time of three years follow-up in treated and deferred lesion.
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Affiliation(s)
- Dobrin Vassilev
- “Alexandrovska” University Hospital, Cardiology Department, Medical University Sofia, Bulgaria
- Ruse University “Angel Kanchev”, Department of Healthcare, Studentska-8 Street, Ruse, Bulgaria
| | - Niya Mileva
- “Alexandrovska” University Hospital, Cardiology Department, Medical University Sofia, Bulgaria
- Cardiovascular Center OLV Ziekenhuis, Aalst, Belgium
| | - Carlos Collet
- Cardiovascular Center OLV Ziekenhuis, Aalst, Belgium
| | - Pavel Nikolov
- “Alexandrovska” University Hospital, Cardiology Department, Medical University Sofia, Bulgaria
| | - Kiril Karamfiloff
- “Alexandrovska” University Hospital, Cardiology Department, Medical University Sofia, Bulgaria
| | - Vladimir Naunov
- “Alexandrovska” University Hospital, Cardiology Department, Medical University Sofia, Bulgaria
| | - Jeroen Sonck
- Cardiovascular Center OLV Ziekenhuis, Aalst, Belgium
| | - Irinka Hristova
- Ruse University “Angel Kanchev”, Department of Healthcare, Studentska-8 Street, Ruse, Bulgaria
| | - Despina Georgieva
- Ruse University “Angel Kanchev”, Department of Healthcare, Studentska-8 Street, Ruse, Bulgaria
| | - Gianluca Rigatelli
- Section of Cardiovascular Diagnosis and Endoluminal Interventions, Rovigo General Hospital, Rovigo, Italy
| | | | - Robert J. Gil
- Mossakowski Medical Research Institute, Polish Academy of Science, Warsaw, Poland
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13
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Di Serafino L, Magliulo F, Barbato E, Cirillo P, Esposito M, Serino F, Ziviello F, Stabile E, Franzone A, Piccolo R, Borgia F, Morisco C, Rapacciuolo A, Esposito G. ADDED Index or Percentage Diameter of Residual Coronary Stenosis to Risk-Stratify Patients Presenting With STEMI. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2022; 34:92-98. [PMID: 33547023 DOI: 10.1016/j.carrev.2021.01.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 01/26/2021] [Accepted: 01/26/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND We compared the prognostic value of the ADDED Index with visually estimated diameter (DS) of residual coronary stenosis (RS) in STEMI patients after successful PCI of the culprit lesion. Even though associated with a positive outcome, the functional assessment of non-culprit stenosis remains largely underused, especially in STEMI patients. The Angiography-DeriveD hEmoDynamic index (ADDED index) showed high accuracy to predict FFR and it might be used to better guide the diagnostic and therapeutic work-up of such patients. METHODS We retrospectively included 596 patients grouped on the basis of either the ADDED Index (ADDED Negative (<2.23, n = 153) vs ADDED Positive (≥2.23, n = 129)) or the DS of the RS (RS Negative (<50%, n = 177) vs RS Positive (≥50%, n = 105)). Patients without any RS served as control (n = 314). Primary endpoints were: 1) major adverse cardiac events (MACE), composite of all-cause death, myocardial infarction (MI), clinically driven revascularizations (CDR); 2) non-culprit vessel oriented clinical events (VOCE), composite of all-cause death, non-culprit vessel related MI and CDR. RESULTS At 24 months the rate of both MACE and VOCE was significantly higher in both the ADDED Positive and RS Positive groups. However, differently from patients in whom complete revascularization was deferred on the basis of the angiography (RS Negative), no additional risk was found for patients in the ADDED Negative group. CONCLUSIONS In STEMI patients with MVD deferring treatment of RS on the basis of the ADDED index, rather than the visually estimated DS, is associated with a favorable clinical outcome.
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Affiliation(s)
- Luigi Di Serafino
- Department of Advanced Biomedical Sciences - University of Naples Federico II, Naples, Italy.
| | - Fabio Magliulo
- Department of Advanced Biomedical Sciences - University of Naples Federico II, Naples, Italy
| | - Emanuele Barbato
- Department of Advanced Biomedical Sciences - University of Naples Federico II, Naples, Italy
| | - Plinio Cirillo
- Department of Advanced Biomedical Sciences - University of Naples Federico II, Naples, Italy
| | - Mafalda Esposito
- Department of Advanced Biomedical Sciences - University of Naples Federico II, Naples, Italy
| | - Federica Serino
- Department of Advanced Biomedical Sciences - University of Naples Federico II, Naples, Italy
| | - Francesca Ziviello
- Department of Advanced Biomedical Sciences - University of Naples Federico II, Naples, Italy
| | - Eugenio Stabile
- Department of Advanced Biomedical Sciences - University of Naples Federico II, Naples, Italy
| | - Anna Franzone
- Department of Advanced Biomedical Sciences - University of Naples Federico II, Naples, Italy
| | - Raffaele Piccolo
- Department of Advanced Biomedical Sciences - University of Naples Federico II, Naples, Italy
| | - Francesco Borgia
- Department of Advanced Biomedical Sciences - University of Naples Federico II, Naples, Italy
| | - Carmine Morisco
- Department of Advanced Biomedical Sciences - University of Naples Federico II, Naples, Italy
| | - Antonio Rapacciuolo
- Department of Advanced Biomedical Sciences - University of Naples Federico II, Naples, Italy
| | - Giovanni Esposito
- Department of Advanced Biomedical Sciences - University of Naples Federico II, Naples, Italy
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14
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Li C, Leng X, He J, Xia Y, Jiang W, Pan Y, Dong L, Sun Y, Hu X, Wang J, Xiang J, Jiang J. Diagnostic Performance of Angiography-Based Fractional Flow Reserve for Functional Evaluation of Coronary Artery Stenosis. Front Cardiovasc Med 2021; 8:714077. [PMID: 34712703 PMCID: PMC8546292 DOI: 10.3389/fcvm.2021.714077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 09/15/2021] [Indexed: 11/13/2022] Open
Abstract
Background: A new method for calculating fraction flow reserve (FFR) without pressure-wire (angiography-derived FFR) based on invasive coronary angiography (ICA) images can be used to evaluate the functional problems of coronary stenosis. Objective: The aim of this study was to assess the diagnostic performance of a novel method of calculating the FFR compared to wire-based FFR using retrospectively collected data from patients with stable angina. Methods: Three hundred patients with stable angina pectoris who underwent ICA and FFR measurement were included in this study. Two ICA images with projections >25° apart at the end-diastolic frame were selected for 3D reconstruction. Then, the contrast frame count was performed in an angiographic run to calculate the flow velocity. Based on the segmented vessel, calculated velocity, and aortic pressure, AccuFFRangio distribution was calculated through the pressure drop equation. Results: Using FFR ≤ 0.8 as a reference, we evaluated AccuFFRangio performance for 300 patients with its accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). Comparison of AccuFFRangio with wire-measured FFR resulted in an area under the curve (AUC) of 0.954 (per-vessel, p < 0.0001). Accuracy for AccuFFRangio was 93.7% for Pa set from measurement and 87% for Pa = 100 mmHg in this clinical study. Overall sensitivity, specificity, PPV, and NPV for per-vessel were 90, 95, 86.7, 96.3, and 57.5, 97.7, 90.2, 86.3%, respectively. Overall accuracy, sensitivity, specificity, PPV, and NPV for 2-dimensional (2D) quantitative coronary angiography (QCA) were 63.3, 42.5, 70.9, 34.7, and 77.2%, respectively. The average processing time of AccuFFRangio was 4.30 ± 1.87 min. Conclusions: AccuFFRangio computed from coronary ICA images can be an accurate and time-efficient computational tool for detecting lesion-specific ischemia of coronary artery stenosis.
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Affiliation(s)
- Changling Li
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | | | - Jingsong He
- ArteryFlow Technology Co., Ltd., Hangzhou, China
| | - Yongqing Xia
- ArteryFlow Technology Co., Ltd., Hangzhou, China
| | - Wenbing Jiang
- Department of Cardiology, The Third Clinical Institute Affiliated to Wenzhou Medical University, Wenzhou, China
| | - Yibin Pan
- Department of Cardiology, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, China
| | - Liang Dong
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yong Sun
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xinyang Hu
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jian'an Wang
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | | | - Jun Jiang
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
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15
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Gewirtz H. PET 18F-flurpridaz quantitative measurements of myocardial blood flow: Added value for diagnosis of coronary artery disease? Of course! J Nucl Cardiol 2021; 28:2330-2334. [PMID: 32020502 DOI: 10.1007/s12350-020-02043-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 01/14/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Henry Gewirtz
- Department of Medicine (Cardiology Division), Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA.
- Cardiac Unit, Massachusetts General Hospital, Boston, MA, 02114, USA.
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16
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Eslami V, Safi M, Namazi MH, Pishgahi M, Eftekharzade A, Eftekharzadeh SA. Value of Delta Fractional Flow Reserve (ΔFFR) For Predicting Coronary Ischemic Lesions. Galen Med J 2021; 9:e1528. [PMID: 34466551 PMCID: PMC8344029 DOI: 10.31661/gmj.v9i0.1528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 08/05/2020] [Accepted: 08/09/2020] [Indexed: 12/03/2022] Open
Abstract
Background: The decrease in fractional flow reserve (FFR) after adenosine administration from baseline FFR value (termed as ΔFFR) may reflect the compensatory capacity of the microvascular circulation and thus may predict significant coronary stenotic lesions. We aimed to investigate whether baseline FFR and ΔFFR can help identify the coronary ischemic lesion and its severity. Materials and Methods: This cross-sectional study was performed on 154 consecutive patients (Mean age 62.42 ± 9.36 years) that underwent coronary angiography and with definitive intermediate coronary lesions at any of the coronary vessels. FFR was calculated by dividing the mean distal intracoronary pressure by the mean arterial pressure. ΔFFR was also defined as the difference between baseline FFR and hyperemic FFR (considering FFR<0.75 as the criteria for ischemia). Results: The area under receiver-operating characteristic curve for baseline FFR was found as 0.933, and for ΔFFR was 0.946 indicated high values of both indices for predicting ischemic lesions. The best cut-off point for baseline FFR and ΔFFR for discriminating ischemic lesions from the normal condition was 89.5 (yielding a sensitivity of 92.2% and a specificity of 68.0%) and 9.5 (yielding a sensitivity of 96.0% and a specificity of 85.3%), respectively. Conclusion: Our study could successfully demonstrate the high value of both baseline FFR and ΔFFR for predicting coronary ischemic lesions with the cut-off values of <89.5 and >9.5, respectively.
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Affiliation(s)
- Vahid Eslami
- Shahid Beheshti University of Medical Sciences, Cardiovascular Research Center, Tehran, Iran
| | - Morteza Safi
- Shahid Beheshti University of Medical Sciences, Cardiovascular Research Center, Tehran, Iran
| | - Mohammad hasan Namazi
- Shahid Beheshti University of Medical Sciences, Cardiovascular Research Center, Tehran, Iran
| | - Mehdi Pishgahi
- Shahid Beheshti University of Medical Sciences, Cardiovascular Research Center, Tehran, Iran
| | - Amir Eftekharzade
- Shahid Beheshti University of Medical Sciences, Cardiovascular Research Center, Tehran, Iran
| | - Sayyed Ali Eftekharzadeh
- Shahid Beheshti University of Medical Sciences, Cardiovascular Research Center, Tehran, Iran
- Correspondence to: Sayyed Ali Eftekharzadeh, Shahid Beheshti University of Medical Sciences, Cardiovascular Research Center, Tehran, Iran Telephone Number: 09121811609 Email Address:
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17
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Jiang W, Pan Y, Hu Y, Leng X, Jiang J, Feng L, Xia Y, Sun Y, Wang J, Xiang J, Li C. Diagnostic accuracy of coronary computed tomography angiography-derived fractional flow reserve. Biomed Eng Online 2021; 20:77. [PMID: 34348731 PMCID: PMC8340407 DOI: 10.1186/s12938-021-00914-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 07/26/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Fractional flow reserve (FFR) is a widely used gold standard to evaluate ischemia-causing lesions. A new method of non-invasive approach, termed as AccuFFRct, for calculating FFR based on coronary computed tomography angiography (CCTA) and computational fluid dynamics (CFD) has been proposed. However, its diagnostic accuracy has not been validated. OBJECTIVES This study sought to present a novel approach for non-invasive computation of FFR and evaluate its diagnostic performance in patients with coronary stenosis. METHODS A total of 54 consecutive patients with 78 vessels from a single center who underwent CCTA and invasive FFR measurement were retrospectively analyzed. The CT-derived FFR values were computed using a novel CFD-based model (AccuFFRct, ArteryFlow Technology Co., Ltd., Hangzhou, China). Diagnostic performance of AccuFFRct and CCTA in detecting hemodynamically significant coronary artery disease (CAD) was evaluated using the invasive FFR as a reference standard. RESULTS Diagnostic accuracy, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for AccuFFRct in detecting FFR ≤ 0.8 on per-patient basis were 90.7, 89.5, 91.4, 85.0 and 94.1%, respectively, while those of CCTA were 38.9, 100.0, 5.71, 36.5 and 100.0%, respectively. The correlation between AccuFFRct and FFR was good (r = 0.76 and r = 0.65 on per-patient and per-vessel basis, respectively, both p < 0.0001). Area under the curve (AUC) values of AccuFFRct for identifying ischemia per-patient and per-vessel basis were 0.945 and 0.925, respectively. There was much higher accuracy, specificity and AUC for AccuFFRct compared with CCTA. CONCLUSIONS AccuFFRct computed from CCTA images alone demonstrated high diagnostic performance for detecting lesion-specific ischemia, it showed superior diagnostic power than CCTA and eliminated the risk of invasive tests, which could be an accurate and time-efficient computational tool for diagnosing ischemia and assisting clinical decision-making.
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Affiliation(s)
- Wenbing Jiang
- Department of Cardiology, The Third Clinical Institute Affiliated to Wenzhou Medical University, Wenzhou, China
| | - Yibin Pan
- Department of Cardiology, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, China
| | - Yumeng Hu
- ArteryFlow Technology Co., Ltd, Hangzhou, China
| | | | - Jun Jiang
- Department of Cardiology, The Second Affiliated Hospital of Zhejiang University School of Medicine, 88 Jiefang Road, Hangzhou, 310009, China
| | - Li Feng
- ArteryFlow Technology Co., Ltd, Hangzhou, China
| | | | - Yong Sun
- Department of Cardiology, The Second Affiliated Hospital of Zhejiang University School of Medicine, 88 Jiefang Road, Hangzhou, 310009, China
| | - Jian'an Wang
- Department of Cardiology, The Second Affiliated Hospital of Zhejiang University School of Medicine, 88 Jiefang Road, Hangzhou, 310009, China
| | | | - Changling Li
- Department of Cardiology, The Second Affiliated Hospital of Zhejiang University School of Medicine, 88 Jiefang Road, Hangzhou, 310009, China.
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18
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Abstract
PURPOSE OF REVIEW Percutaneous coronary intervention (PCI) is a commonly used treatment option in coronary artery disease (CAD). Reduced major adverse cardiovascular events (MACE) in those randomized to PCI compared to optimal medical therapy have been demonstrated only if it is performed for physiologically significant coronary lesions. Despite data demonstrating improved outcomes primarily in stable CAD and then acute settings, physiology-guided PCI remains underutilized. This review summarizes the evidence and commonly used methods for physiologic assessment of coronary stenosis. RECENT FINDINGS Fractional flow reserve (FFR) is the gold standard for the analysis of lesion severity. Its use is limited by the need for adenosine, which adds time, complexity, and potential adverse effects. Non-hyperemic instantaneous wave-free ratio-guided revascularization and quantitative flow reserve ratio assessment both have shown safety and effectiveness with improved patient outcomes. Coronary physiological assessment solves the ambiguity of coronary angiography. Detecting physiologically significant stenoses is crucial to decide which lesion needs to be treated. Technological advances have led to the development of new assessment indices in addition to FFR.
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19
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Rubio M, Lo KB, Ram P, Rubio CS, Co M, Varadarajan P, Amanullah AM, Truong HT, Khouzam RN, Abudayyeh I. Prognostic Value of Left Ventricular Global Strain Analysis by Two-Dimensional Speckle-Tracking Echocardiography in Non-Hemodynamically Significant Intermediate Coronary Lesions. Curr Probl Cardiol 2021; 46:100787. [PMID: 33508531 DOI: 10.1016/j.cpcardiol.2021.100787] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 12/30/2020] [Indexed: 11/15/2022]
Abstract
Intermediate coronary lesions represent a major challenge for the invasive and noninvasive cardiologist. Left ventricular strain calculation by speckle tracking echocardiography has the capacity to analyze the motion of the cardiac tissue. This study aimed to evaluate its usefulness and prognostic significance in nonhemodynamically significant intermediate coronary lesions. We studied 247 patients who underwent a clinically indicated coronary angiogram. Each of the patients had a single nonrevascularized nonhemodynamically significant intermediate severity coronary lesion (ISCL) with a fractional flow reserve greater than 0.80. The left ventricular global longitudinal strain (GLS) was calculated using speckle-tracking echocardiography with TomTec 2D Cardiac Performance Analysis (Unterschleissheim, Germany). An abnormal GLS was defined as less than -20%. The primary endpoints were revascularization of the target lesion, admissions for major adverse cardiac events (MACE), and cardiac-related mortality, all within 2 years. On multivariate logistic regression data analysis, we found that patients with an ISCL and abnormal GLS had an increased risk for admissions due to MACE (odds ratio [OR] 1.06, P < 0.05, confidence interval [CI] 95%, 1.005-1.120], and an increased risk of cardiac-related death (OR 1.12, P < 0.05, CI 95% 1.012-1.275). There was no difference in the need for target lesion revascularization among individuals with normal and abnormal GLS (1.00, P 0.88, CI 95% .950-1.061). Left ventricular strain analysis by speckle-tracking echocardiography showed an independent prognostic value in patients with nonrevascularized nonhemodynamically significant coronary lesions.
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Affiliation(s)
- Manolo Rubio
- Division of Cardiovascular Diseases, The University of Tennessee Health Science Center, Memphis, TN.
| | - Kevin B Lo
- Department of Medicine, Einstein Medical Center, Philadelphia, PA
| | - Pradhum Ram
- Department of Cardiology, Emory University Hospital, Atlanta, GA
| | - Cindy S Rubio
- Mexican Institute of Social Security, Mexico City, Mexico
| | - Michael Co
- Department of Cardiology, Loma Linda University Medical Center, Loma Linda, CA
| | | | - Aman M Amanullah
- Department of Cardiology, Einstein Medical Center, Philadelphia, PA
| | - Huu T Truong
- Department of Cardiology, VA Loma Linda Healthcare System, Loma Linda, CA
| | - Rami N Khouzam
- Division of Cardiovascular Diseases, The University of Tennessee Health Science Center, Memphis, TN
| | - Islam Abudayyeh
- Department of Cardiology, Loma Linda University Medical Center, Loma Linda, CA
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20
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Kleczyński P, Dziewierz A, Rzeszutko Ł, Dudek D, Legutko J. Borderline coronary lesion assessment with quantitative flow ratio and its relation to the instantaneous wave-free ratio. Adv Med Sci 2021; 66:1-5. [PMID: 33190031 DOI: 10.1016/j.advms.2020.10.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 09/15/2020] [Accepted: 10/31/2020] [Indexed: 01/10/2023]
Abstract
PURPOSE Quantitative flow ratio (QFR) is a recently developed image-based index for the assessment of borderline coronary artery disease. We sought to investigate a correlation between QFR and instantaneous wave-free ratio (iFR) for the assessment of intermediate coronary stenoses. MATERIALS AND METHODS Patients with borderline coronary lesions (40-90% by visual assessment) undergoing iFR assessment were enrolled. QFR was derived from a modeled hyperemic flow velocity derived from angiography without adenosine-induced hyperemia. Pressure wire-derived iFR served as the reference. RESULTS Values of QFR and iFR from 110 vessels with a mean percent diameter stenosis of 44.6 ± 12.0% were compared. Mean iFR was 0.90 ± 0.07 and 38 (34.5%) had iFR ≤0.89. Mean QFR was 0.81 ± 0.10 and 44 (40%) had QFR ≤0.80. A good agreement between QFR and iFR measurements was confirmed with a mean difference of 0.09 (95%CI -0.027 to 0.207) and intraclass correlation coefficient of 0.87 (95%CI 0.81-0.91). The overall diagnostic accuracy (AUC in ROC analysis) of QFR in detecting iFR ≤0.89 was 0.87 (95%CI 0.79-0.93; p < 0.001). Regarding iFR ≤0.89, the optimal cutoff value of QFR was 0.79 with sensitivity, specificity, and accuracy of 76.3%, 83.3%, and 80.0%, respectively. A 100% sensitivity was observed for a QFR cutoff value of 0.88 and a 100% specificity for a QFR cutoff value of 0.69. CONCLUSIONS Our study confirmed good QFR diagnostic performance and correlation with iFR for detecting the functional ischemia caused by intermediate lesions in coronary arteries. However, the pressure wire assessment with iFR might be warranted in 2/3 of patients after QFR assessment.
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21
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Patel P, Rao R, Sethi P, Mukherjee A, Varadarajan P, Pai RG. Functional Assessment of Coronary Artery Lesions-Old and New Kids on the Block. Int J Angiol 2021; 30:40-47. [PMID: 34025094 PMCID: PMC8128490 DOI: 10.1055/s-0041-1723942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Angiography is inaccurate in assessing functional significance of coronary lesions, and often stenoses deemed severe on angiographic assessment do not restrict coronary blood flow at rest or with maximal dilatation. Angiography-guided revascularization has not shown improvement in hard clinical outcomes in stable ischemic heart disease (SIHD). Most current guidelines for SIHD recommend invasive functional assessment of lesions to guide revascularization if prior evidence of ischemia is not available. There has been several recent advances and development of novel methods in this arena. Various contemporary clinical trials have been undertaken for validation of these indices. Here we review the physiological basis, tools, techniques, and evidence base for various invasive (resting as well as hyperemic) and noninvasive methods for functional assessment of coronary lesions. Left main stenosis, bifurcation lesions, serial stenosis, and acute coronary syndrome each causes unique disequilibrium that may affect measurements and require special considerations for accurate functional assessment.
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Affiliation(s)
- Prashant Patel
- Department of Cardiology, St. Bernardine Medical Center, San Bernardino, California
- UC Riverside School of Medicine, University of California, Riverside, California
| | - Ravi Rao
- Department of Cardiology, St. Bernardine Medical Center, San Bernardino, California
- UC Riverside School of Medicine, University of California, Riverside, California
| | - Prabhdeep Sethi
- Department of Cardiology, St. Bernardine Medical Center, San Bernardino, California
- UC Riverside School of Medicine, University of California, Riverside, California
| | - Ashis Mukherjee
- Department of Cardiology, St. Bernardine Medical Center, San Bernardino, California
- UC Riverside School of Medicine, University of California, Riverside, California
| | - Padmini Varadarajan
- Department of Cardiology, St. Bernardine Medical Center, San Bernardino, California
- UC Riverside School of Medicine, University of California, Riverside, California
| | - Ramdas G. Pai
- Department of Cardiology, St. Bernardine Medical Center, San Bernardino, California
- UC Riverside School of Medicine, University of California, Riverside, California
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22
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Yamagishi M, Tamaki N, Akasaka T, Ikeda T, Ueshima K, Uemura S, Otsuji Y, Kihara Y, Kimura K, Kimura T, Kusama Y, Kumita S, Sakuma H, Jinzaki M, Daida H, Takeishi Y, Tada H, Chikamori T, Tsujita K, Teraoka K, Nakajima K, Nakata T, Nakatani S, Nogami A, Node K, Nohara A, Hirayama A, Funabashi N, Miura M, Mochizuki T, Yokoi H, Yoshioka K, Watanabe M, Asanuma T, Ishikawa Y, Ohara T, Kaikita K, Kasai T, Kato E, Kamiyama H, Kawashiri M, Kiso K, Kitagawa K, Kido T, Kinoshita T, Kiriyama T, Kume T, Kurata A, Kurisu S, Kosuge M, Kodani E, Sato A, Shiono Y, Shiomi H, Taki J, Takeuchi M, Tanaka A, Tanaka N, Tanaka R, Nakahashi T, Nakahara T, Nomura A, Hashimoto A, Hayashi K, Higashi M, Hiro T, Fukamachi D, Matsuo H, Matsumoto N, Miyauchi K, Miyagawa M, Yamada Y, Yoshinaga K, Wada H, Watanabe T, Ozaki Y, Kohsaka S, Shimizu W, Yasuda S, Yoshino H. JCS 2018 Guideline on Diagnosis of Chronic Coronary Heart Diseases. Circ J 2021; 85:402-572. [PMID: 33597320 DOI: 10.1253/circj.cj-19-1131] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
| | - Nagara Tamaki
- Department of Radiology, Kyoto Prefectural University of Medicine Graduate School
| | - Takashi Akasaka
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Graduate School
| | - Kenji Ueshima
- Center for Accessing Early Promising Treatment, Kyoto University Hospital
| | - Shiro Uemura
- Department of Cardiology, Kawasaki Medical School
| | - Yutaka Otsuji
- Second Department of Internal Medicine, University of Occupational and Environmental Health, Japan
| | - Yasuki Kihara
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences
| | - Kazuo Kimura
- Division of Cardiology, Yokohama City University Medical Center
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School
| | | | | | - Hajime Sakuma
- Department of Radiology, Mie University Graduate School
| | | | - Hiroyuki Daida
- Department of Cardiovascular Medicine, Juntendo University Graduate School
| | | | - Hiroshi Tada
- Department of Cardiovascular Medicine, University of Fukui
| | | | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University
| | | | - Kenichi Nakajima
- Department of Functional Imaging and Artificial Intelligence, Kanazawa Universtiy
| | | | - Satoshi Nakatani
- Division of Functional Diagnostics, Department of Health Sciences, Osaka University Graduate School of Medicine
| | | | - Koichi Node
- Department of Cardiovascular Medicine, Saga University
| | - Atsushi Nohara
- Division of Clinical Genetics, Ishikawa Prefectural Central Hospital
| | | | | | - Masaru Miura
- Department of Cardiology, Tokyo Metropolitan Children's Medical Center
| | | | | | | | - Masafumi Watanabe
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University
| | - Toshihiko Asanuma
- Division of Functional Diagnostics, Department of Health Sciences, Osaka University Graduate School
| | - Yuichi Ishikawa
- Department of Pediatric Cardiology, Fukuoka Children's Hospital
| | - Takahiro Ohara
- Division of Community Medicine, Tohoku Medical and Pharmaceutical University
| | - Koichi Kaikita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University
| | - Tokuo Kasai
- Department of Cardiology, Uonuma Kinen Hospital
| | - Eri Kato
- Department of Cardiovascular Medicine, Department of Clinical Laboratory, Kyoto University Hospital
| | | | - Masaaki Kawashiri
- Department of Cardiovascular and Internal Medicine, Kanazawa University
| | - Keisuke Kiso
- Department of Diagnostic Radiology, Tohoku University Hospital
| | - Kakuya Kitagawa
- Department of Advanced Diagnostic Imaging, Mie University Graduate School
| | - Teruhito Kido
- Department of Radiology, Ehime University Graduate School
| | | | | | | | - Akira Kurata
- Department of Radiology, Ehime University Graduate School
| | - Satoshi Kurisu
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences
| | - Masami Kosuge
- Division of Cardiology, Yokohama City University Medical Center
| | - Eitaro Kodani
- Department of Internal Medicine and Cardiology, Nippon Medical School Tama Nagayama Hospital
| | - Akira Sato
- Department of Cardiology, University of Tsukuba
| | - Yasutsugu Shiono
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Hiroki Shiomi
- Department of Cardiovascular Medicine, Kyoto University Graduate School
| | - Junichi Taki
- Department of Nuclear Medicine, Kanazawa University
| | - Masaaki Takeuchi
- Department of Laboratory and Transfusion Medicine, Hospital of the University of Occupational and Environmental Health, Japan
| | | | - Nobuhiro Tanaka
- Department of Cardiology, Tokyo Medical University Hachioji Medical Center
| | - Ryoichi Tanaka
- Department of Reconstructive Oral and Maxillofacial Surgery, Iwate Medical University
| | | | | | - Akihiro Nomura
- Innovative Clinical Research Center, Kanazawa University Hospital
| | - Akiyoshi Hashimoto
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University
| | - Kenshi Hayashi
- Department of Cardiovascular Medicine, Kanazawa University Hospital
| | - Masahiro Higashi
- Department of Radiology, National Hospital Organization Osaka National Hospital
| | - Takafumi Hiro
- Division of Cardiology, Department of Medicine, Nihon University
| | | | - Hitoshi Matsuo
- Department of Cardiovascular Medicine, Gifu Heart Center
| | - Naoya Matsumoto
- Division of Cardiology, Department of Medicine, Nihon University
| | | | | | | | - Keiichiro Yoshinaga
- Department of Diagnostic and Therapeutic Nuclear Medicine, Molecular Imaging at the National Institute of Radiological Sciences
| | - Hideki Wada
- Department of Cardiology, Juntendo University Shizuoka Hospital
| | - Tetsu Watanabe
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University
| | - Yukio Ozaki
- Department of Cardiology, Fujita Medical University
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
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Kayaert P, Coeman M, Gevaert S, De Pauw M, Haine S. Physiology-Based Revascularization of Left Main Coronary Artery Disease. J Interv Cardiol 2021; 2021:4218769. [PMID: 33628144 PMCID: PMC7892248 DOI: 10.1155/2021/4218769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 01/12/2021] [Accepted: 01/22/2021] [Indexed: 01/10/2023] Open
Abstract
It is of critical importance to correctly assess the significance of a left main lesion. Underestimation of significance beholds the risk of inappropriate deferral of revascularization, whereas overestimation may trigger major but unnecessary interventions. This article addresses the invasive physiological assessment of left main disease and its role in deciding upon revascularization. It mainly focuses on the available evidence for fractional flow reserve and instantaneous wave-free ratio, their interpretation, and limitations. We also discuss alternative invasive physiological indices and imaging, as well as the link between physiology, ischemia, and prognosis.
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Affiliation(s)
- Peter Kayaert
- Department of Cardiology, Ghent University Hospital, Ghent, Belgium
| | - Mathieu Coeman
- Department of Cardiology, Jan Yperman Ziekenhuis, Ypres, Belgium
| | - Sofie Gevaert
- Department of Cardiology, Ghent University Hospital, Ghent, Belgium
| | - Michel De Pauw
- Department of Cardiology, Ghent University Hospital, Ghent, Belgium
| | - Steven Haine
- Department of Cardiology, Antwerp University Hospital, Antwerp, Belgium
- Department of Cardiovascular Diseases, University of Antwerp, Antwerp, Belgium
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24
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Corban M, Prasad A, Gulati R, Lerman L, Lerman A. Sex-specific differences in coronary blood flow and flow velocity reserve in symptomatic patients with non-obstructive disease. EUROINTERVENTION 2021; 16:1079-1084. [PMID: 31589144 PMCID: PMC9724856 DOI: 10.4244/eij-d-19-00520] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS Reduced coronary flow velocity reserve (CFVR) is associated with adverse cardiovascular outcomes. Whether CFVR and coronary blood flow (CBF) are similar in men and women with chest pain and non-obstructive CAD remains unknown. We hypothesised sex differences in CFVR and CBF. METHODS AND RESULTS A total of 1,683 patients with signs/symptoms of ischaemia and angiographically unobstructed coronary arteries (<40% angiographic stenosis) underwent coronary vasomotion evaluation. CFVR was measured as hyperaemic/resting average velocity in the LAD. Mid-LAD diameter was measured with quantitative angiography and CBF calculated at rest (rCBF) and hyperaemia (hCBF). Resting microvascular resistance (rMR) was calculated as mean arterial pressure/rCBF. Of the total number of patients, 1,096 (65%) were women, median age 51 [42, 59] years. Compared to men, women had lower median CFVR (2.7 [2.4, 3.2] vs 3.1 [2.7, 3.6], p<0.001), higher rCBF (49.7 [34.0, 71.1] vs 45.9 [31.8, 68.7] ml/min, p=0.04), lower hCBF (139.5 [93.0, 195.2] vs 147.1 [95.7, 218.6] ml/min, p=0.02), but similar rMR (p=0.82). Female sex was an independent predictor of lower CFVR, higher rCBF, and lower hCBF. CONCLUSIONS Compared to men, women with signs/symptoms of ischaemia and non-obstructive CAD have lower CFVR, higher rCBF, and lower hCBF. Female sex is a predictor of these sex-specific differences. The clinical diagnostic and prognostic implications of sex differences in coronary physiology need further evaluation.
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Affiliation(s)
- Michel Corban
- Department of Cardiovascular Diseases, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Abhiram Prasad
- Department of Cardiovascular Diseases, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Rajiv Gulati
- Department of Cardiovascular Diseases, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Lilach Lerman
- Department of Cardiovascular Diseases, Mayo Clinic College of Medicine and Science, Rochester, MN, USA,Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Amir Lerman
- Mayo Clinic, Division of Cardiovascular Diseases, 200 First Street SW, Rochester, MN 55905, USA. E-mail:
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25
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Rumbinaite E, Karuzas A, Verikas D, Kazakauskaite E, Venckus V, Jakuška P, Benetis R, Vaskelyte JJ. Detection of Functionally Significant Coronary Artery Disease: Role of Regional Post Systolic Shortening. J Cardiovasc Echogr 2020; 30:131-139. [PMID: 33447503 PMCID: PMC7799071 DOI: 10.4103/jcecho.jcecho_55_19] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Revised: 04/26/2020] [Accepted: 09/02/2020] [Indexed: 11/17/2022] Open
Abstract
Background: The main goal of this manuscript was to evaluate the diagnostic value of the global and regional postsystolic shortening (PSS) parameters, assessed by two-dimensional (2D) speckle-tracking echocardiography, at rest and during dobutamine stress for the detection of functionally significant coronary artery stenoses in patients with moderate pretest probability of stable coronary artery disease (CAD). Methods: Dobutamine stress echocardiography (DSE) and adenosine stress myocardial perfusion imaging by cardiac magnetic resonance (CMR-MPI) were performed on 83 patients with moderate pretest probability of stable CAD and left ventricle ejection fraction ≥55%. CAD was defined as ≥50% diameter stenoses on invasive coronary artery angiography (CAA) validated as hemodynamically significant by CMR-MPI. According to invasive CAA and CMR-MPI results, patients were divided into two groups: Nonpathologic CAD (−) group: 38 (45.8%) and pathologic CAD (+) group: 45 (54.2%). Results: There were no significant differences in clinical characteristics, conventional 2D echocardiography between the two groups at rest and during low dobutamine dose. Regional postsystolic index (PSI) during recovery phase had the highest area under the receiver operating characteristic curve (AUC) (AUC 0.882, sensitivity 87%, specificity 92%) for the detection of functionally significant one-vessel disease. During high dobutamine dose, regional PSI had sensitivity 78% and specificity 81% (AUC 0.78) to detect significant CAD. Regional PSI remained the same tendency remains for the detection of multiple-vessel CAD. Other myocardial deformation parameters were less sensitive and specific during high dobutamine dose and recovery phase. Conclusions: PSS parameters showed to be sensitive and specific in detecting hemodynamically significant coronary artery stenosis in patients with stable CAD with moderate pretest probability. The study revealed that the assessment of regional PSI performed during recovery improves the diagnostic accuracy of DSE for the detection of functionally significant CAD.
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Affiliation(s)
- Egle Rumbinaite
- Department of Cardiology, Medical Academy, Lithuanian University of Health Sciences, Eiveniu str. 2, Kaunas, 50009, Lithuania
| | - Arnas Karuzas
- Department of Cardiology, Medical Academy, Lithuanian University of Health Sciences, Eiveniu str. 2, Kaunas, 50009, Lithuania
| | - Dovydas Verikas
- Department of Cardiology, Medical Academy, Lithuanian University of Health Sciences, Eiveniu str. 2, Kaunas, 50009, Lithuania
| | - Egle Kazakauskaite
- Department of Cardiology, Medical Academy, Lithuanian University of Health Sciences, Eiveniu str. 2, Kaunas, 50009, Lithuania
| | - Vilius Venckus
- Department of Cardiac, Thoracic and Vascular Surgery, Medical Academy, Lithuanian University of Health Sciences. Eiveniu str. 2, Kaunas, 50009, Lithuania
| | - Povilas Jakuška
- Department of Cardiac, Thoracic and Vascular Surgery, Medical Academy, Lithuanian University of Health Sciences. Eiveniu str. 2, Kaunas, 50009, Lithuania
| | - Rimantas Benetis
- Department of Cardiac, Thoracic and Vascular Surgery, Medical Academy, Lithuanian University of Health Sciences. Eiveniu str. 2, Kaunas, 50009, Lithuania
| | - Justina Jolanta Vaskelyte
- Department of Cardiology, Medical Academy, Lithuanian University of Health Sciences, Eiveniu str. 2, Kaunas, 50009, Lithuania
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Ulacia P, Rimac G, Lalancette S, Belleville C, Mongrain R, Plante S, Rusza Z, Matsuo H, Bertrand OF. A novel fiber-optic based 0.014″ pressure wire: Designs of the OptoWire™, development phases, and the O 2 first-in-man results. Catheter Cardiovasc Interv 2020; 99:59-67. [PMID: 33090670 DOI: 10.1002/ccd.29321] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 09/12/2020] [Accepted: 09/28/2020] [Indexed: 02/24/2024]
Abstract
OBJECTIVES To review the technical limitations of available pressure-wires, present the design evolution of a nitinol fiber-optic pressure wire and to summarize the First-in-Man (FIM) O2 pilot study results. BACKGROUND Despite increasing use of physiology assessment of coronary lesions, several technical limitations persist. We present technical details, design evolution and early clinical results with a novel 0.014" nitinol fiber-optic based pressure-wire. METHODS AND RESULTS The 0.014' OptoWire™ (Opsens Medical, Quebec, Canada) was designed to combine improved handling properties compared to standard pressure-wires and to offer extremely reliable pressure recording and transmission due to fiber-optic properties compared to piezo-electric sensors and electrical wires. In vitro assessment showed that OptoWire™ steerability, pushability and torquability properties were closer to regular PCI wires than standard electrical pressure wires. In the First-in-Man O2 study, 60 patients were recruited at 2 centers in Canada. A total of 103 lesions were assessed with the OptoWire™ and OptoMonitor™, 75 lesions at baseline and 28 lesions post-PCI (without disconnection). In all crossed lesions (n = 100, 97%), mean Pd/Pa and FFR could be adequately measured. In 11 cases assessed successively with OptoWire™ and Aegis™ (Abbott Vascular, USA) bland-Altman analysis showed a mean difference of 0.002 ± 0.052 mmHg (p = .91) for Pd/Pa and 0.01 ± 0.06 for FFR calculation (p = .45). There was no device-related complication. Upon these initial results, several design changes aimed to improve overall performance including torquability, stiffness, resistance to kink and pressure drift were completed. CONCLUSION The novel 0.014" fiber-optic OptoWire™ provides superior wire handling with reduced risk of pressure drift allowing reliable pre- and post-PCI physiology assessment.
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Affiliation(s)
- Paola Ulacia
- Department of Cardiology, Research Center, Quebec Heart-Lung Institute, Quebec, Quebec, Canada
- Department of Mechanical Engineering, McGill University, Montreal, Quebec, Canada
| | - Goran Rimac
- Department of Cardiology, Research Center, Quebec Heart-Lung Institute, Quebec, Quebec, Canada
| | | | | | - Rosaire Mongrain
- Department of Mechanical Engineering, McGill University, Montreal, Quebec, Canada
| | - Sylvain Plante
- Department of Cardiology, Southlake Hospital, New Market, Ontario, Canada
| | - Zoltan Rusza
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Hitoshi Matsuo
- Department of Cardiovascular Medicine, Gifu Heart Center, Tokyo, Japan
| | - Olivier F Bertrand
- Department of Cardiology, Research Center, Quebec Heart-Lung Institute, Quebec, Quebec, Canada
- Department of Mechanical Engineering, McGill University, Montreal, Quebec, Canada
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How atherosclerosis defines ischemia: Atherosclerosis quantification and characterization as a method for determining ischemia. J Cardiovasc Comput Tomogr 2020; 14:394-399. [DOI: 10.1016/j.jcct.2019.10.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 10/04/2019] [Accepted: 10/27/2019] [Indexed: 01/23/2023]
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Ziada KM, Shishehbor MH. From the Coronary to the Peripheral Microcirculation: Using a Validated Concept to Develop a Novel Index. JACC Cardiovasc Interv 2020; 13:986-988. [PMID: 32113929 DOI: 10.1016/j.jcin.2019.12.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 12/17/2019] [Indexed: 11/26/2022]
Affiliation(s)
- Khaled M Ziada
- Division of Cardiovascular Medicine, Gill Heart and Vascular Institute, University of Kentucky, Lexington, Kentucky.
| | - Mehdi H Shishehbor
- Harrington Heart and Vascular Institute, University Hospitals of Cleveland, Case Western Reserve University School of Medicine, Cleveland, Ohio
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Rekik S. [Intracoronary adenosine induced-atrial fibrillation during fractional flow reserve evaluation]. Ann Cardiol Angeiol (Paris) 2019; 68:371-374. [PMID: 31471041 DOI: 10.1016/j.ancard.2019.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 07/22/2019] [Indexed: 06/10/2023]
Abstract
Fractional flow reserve (FFR) measurement for functional evaluation of haemodynamic relevance of coronary artery stenoses is a well established and straightforward method applied on daily basis in cardiac catheterization laboratory; it is known to be reliable, reproducible and secure associated with a low rate of adverse events. We report the case of a 68-year-old man with no history of arrhythmias in whom intracoronary injection of adenosine for FFR assessment immediately induced atrial fibrillation mandating hospitalization for pharmacological cardioversion.
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Affiliation(s)
- S Rekik
- Service de cardiologie, centre hospitalier nord Franche-Comté, 100, route de Moval, 90400 Trevenans, France.
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Fukunaga M, Fujii K, Mintz GS, Kawasaki D, Nakata T, Miki K, Imanaka T, Tamaru H, Shibuya M, Masuyama T. Distribution of pressure gradients along the left anterior descending artery in patients with angiographically normal arteries. Catheter Cardiovasc Interv 2019; 96:E67-E74. [DOI: 10.1002/ccd.28544] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 09/08/2019] [Accepted: 10/01/2019] [Indexed: 11/06/2022]
Affiliation(s)
- Masashi Fukunaga
- Cardiovascular DivisionHyogo College of Medicine Nishinomiya Japan
| | - Kenichi Fujii
- Cardiovascular DivisionHyogo College of Medicine Nishinomiya Japan
- Division of Cardiology, Department of Medicine IIKansai Medical University Hirakata Japan
| | - Gary S. Mintz
- Caridovascular Research Foundation New York New York
| | - Daizo Kawasaki
- Cardiovascular DivisionHyogo College of Medicine Nishinomiya Japan
| | - Tsuyoshi Nakata
- Cardiovascular DivisionHyogo College of Medicine Nishinomiya Japan
| | - Kojiro Miki
- Cardiovascular DivisionHyogo College of Medicine Nishinomiya Japan
| | - Takahiro Imanaka
- Cardiovascular DivisionHyogo College of Medicine Nishinomiya Japan
| | - Hiroto Tamaru
- Cardiovascular DivisionHyogo College of Medicine Nishinomiya Japan
| | - Masahiko Shibuya
- Cardiovascular DivisionHyogo College of Medicine Nishinomiya Japan
| | - Toru Masuyama
- Cardiovascular DivisionHyogo College of Medicine Nishinomiya Japan
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Qureshi AI, Asif A, Waqas MA, Aytac E, Gurkas E, Saleem MA, Wallery SS. Assessment of Cerebral Vasodilatory Capacity as Part of Catheter-Based Cerebral Angiography. J Neuroimaging 2019; 30:90-96. [PMID: 31565831 DOI: 10.1111/jon.12665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Revised: 09/01/2019] [Accepted: 09/11/2019] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND AND PURPOSE Cerebral vasodilatory capacity assessment for risk stratification in patients with extracranial arterial stenosis or occlusion may be useful. We describe a new method that assesses cerebral vasodilatory capacity as part of catheter-based cerebral angiography. METHODS We prospectively assessed regional cerebral blood volume (rCBV) in the arterial distribution of interest using a controlled contrast injection in the common carotid or the subclavian arteries. rCBV maps were created using a predefined algorithm based on contrast distribution in the venous phase (voxel size: .466 mm3 ). rCBV maps were acquired again after selective administration of intra-arterial nicardipine (2.0 mg) distal to the stenosis. Two independent observers graded the change in rCBV in 10 predefined anatomical regions within the tributaries of the artery of interest (0 = reduction, 1 = no change, 2 = increase) and total rCBV change scores were summated. RESULTS Twenty-five patients with internal carotid artery stenosis (n = 18; 0-90% in severity) or extracranial vertebral artery stenosis (n = 7; 0-100% in severity) were assessed. There was an increase in rCBV in a tributary of the artery of interest in 18 of 25 after intra-arterial nicardipine (mean score: 11.98; range 0-19.5). There was no change or decrease in rCBV in 7 of 25 patients. The mean rCBV change score was similar in patients with an assessment of internal carotid artery or vertebral artery distributions (12.2 ± 5.3; 11.4 ± 2.5; P = .68). CONCLUSION Selective vasodilatory response to intra-arterial nicardipine in the affected arterial distribution during catheter-based cerebral angiography may provide new data for risk stratification.
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Affiliation(s)
- Adnan I Qureshi
- Zeenat Qureshi Stroke Institute, St. Cloud, MN and Mercyhealth Rockford Hospital, Rockford, IL.,Department of Neurology, University of Missouri, Columbia, MO
| | - Ahmer Asif
- Zeenat Qureshi Stroke Institute, St. Cloud, MN and Mercyhealth Rockford Hospital, Rockford, IL
| | - Muhammad A Waqas
- Zeenat Qureshi Stroke Institute, St. Cloud, MN and Mercyhealth Rockford Hospital, Rockford, IL
| | - Emrah Aytac
- Zeenat Qureshi Stroke Institute, St. Cloud, MN and Mercyhealth Rockford Hospital, Rockford, IL.,Zeenat Qureshi Stroke Institute, Department of Neurology, Firat University, Elazig, Turkey
| | - Erdem Gurkas
- Zeenat Qureshi Stroke Institute, St. Cloud, MN and Mercyhealth Rockford Hospital, Rockford, IL.,Department of Neurology, SBU Gulhane Training and Research Hospital, Ankara, Turkey
| | - Muhammad A Saleem
- Zeenat Qureshi Stroke Institute, St. Cloud, MN and Mercyhealth Rockford Hospital, Rockford, IL
| | - Shawn S Wallery
- Zeenat Qureshi Stroke Institute, St. Cloud, MN and Mercyhealth Rockford Hospital, Rockford, IL
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Kamangar S, Salman Ahmed N, Badruddin IA, Al-Rawahi N, Husain A, Govindaraju K, Yunus Khan T. Effect of stenosis on hemodynamics in left coronary artery based on patient-specific CT scan. Biomed Mater Eng 2019; 30:463-473. [DOI: 10.3233/bme-191067] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Long-term outcomes after fractional flow reserve-guided percutaneous coronary intervention in patients with severe coronary stenosis. JOURNAL OF GERIATRIC CARDIOLOGY : JGC 2019; 16:329-337. [PMID: 31105753 PMCID: PMC6503473 DOI: 10.11909/j.issn.1671-5411.2019.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Objective To explore the safety and efficacy of FFR-guided percutaneous coronary intervention (PCI) in vessels with severe diameter stenosis. Methods & Results Of 1090 patients undergoing fractional flow reserve (FFR) assessment from 2002 to 2009, we identified 167 patients in whom FFR was measured in at least one 70%–89% stenotic lesion. These patients were subdivided into an FFR-defer group (n = 49) if PCI was deferred (FFR > 0.80), and an FFR-perform group (n = 118) if PCI was performed (FFR ≤ 0.80). Comparatively, an additional 1176 patients undergoing PCI in at least one lesion with 70%–89% stenosis but without measurement of FFR served as a control (angiography-guided) group. Clinical outcomes were compared during a median follow-up of 49.0 months. The 5-year Kaplan-Meier estimated revascularization rates were 16% in the FFR-defer group and 33% in the FFR-perform group (P = 0.046). The incidence of major adverse cardiac events were comparable in these two groups (HR = 0.82, 95% CI: 0.37–1.82, P = 0.63). The number of stents placed was significantly lower in the FFR-guided group (0.9 ± 0.8 vs. 1.4 ± 0.8, P < 0.001). Conclusions Functional revascularization for lesions with visually severe stenosis is clinically safe and associated with fewer stents use. This study suggests that extending the use of FFR to more severe coronary lesions may be reasonable.
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ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/STS 2017 appropriate use criteria for coronary revascularization in patients with stable ischemic heart disease. J Thorac Cardiovasc Surg 2019; 157:e131-e161. [DOI: 10.1016/j.jtcvs.2018.11.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Coronary Physiology in the Cardiac Catheterization Laboratory. J Clin Med 2019; 8:jcm8020255. [PMID: 30781631 PMCID: PMC6406799 DOI: 10.3390/jcm8020255] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 02/09/2019] [Accepted: 02/14/2019] [Indexed: 01/10/2023] Open
Abstract
Coronary angiography has been the principle modality for assessing the severity of atherosclerotic coronary artery disease for several decades. However, there is a complex relationship between angiographic coronary stenosis and the presence or absence of myocardial ischemia. Recent technological advances now allow for the assessment of coronary physiology in the catheterization laboratory at the time of diagnostic coronary angiography. Early studies focused on coronary flow reserve (CFR) but more recent work has demonstrated the physiologic accuracy and prognostic value of the fractional flow reserve (FFR) and instantaneous wave free ratio (iFR) for the assessment of coronary artery disease. These measurements have been validated in large multi-center clinical trials and have become indispensable tools for guiding revascularization in the cardiac catheterization laboratory. The physiological assessment of chest pain in the absence of epicardial coronary artery disease involves coronary thermodilution to obtain the index of microcirculatory resistance (IMR) or Doppler velocity measurement to determine the coronary flow velocity reserve (CFVR). Physiology-based coronary artery assessment brings "personalized medicine" to the catheterization laboratory and allows cardiologists and referring providers to make decisions based on objective findings and evidence-based treatment algorithms. The purpose of this review is to describe the theory, technical aspects, and relevant clinical trials related to coronary physiology assessment for an intended audience of general medical practitioners.
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Papaioannou TG, Kalantzis C, Katsianos E, Sanoudou D, Vavuranakis M, Tousoulis D. Personalized Assessment of the Coronary Atherosclerotic Arteries by Intravascular Ultrasound Imaging: Hunting the Vulnerable Plaque. J Pers Med 2019; 9:8. [PMID: 30682871 PMCID: PMC6463043 DOI: 10.3390/jpm9010008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Accepted: 01/21/2019] [Indexed: 02/07/2023] Open
Abstract
The term "vulnerable plaque" is commonly used to refer to an atherosclerotic plaque that is prone to rupture and the formation of thrombosis, which can lead to several cardiovascular and cerebrovascular events. Coronary artery atherosclerosis has a wide variety of different phenotypes among patients who may have a substantially variable risk for plaque rupture and cardiovascular events. Mounting evidence has proposed three distinctive histopathological mechanisms: plaque rupture, plaque erosion and calcified nodules. Studies have demonstrated the characteristics of plaques with high vulnerability such as the presence of a thin fibrous cap, a necrotic lipid-rich core, abundant infiltrating macrophages and neovascularization. However, traditional coronary angiographic imaging fails to determine plaque vulnerability features, and its ability to individualize treatment strategies is limited. In recent decades, catheter-based intravascular ultrasound imaging (IVUS) modalities have been developed to identify vulnerable plaques and ultimately vulnerable patients. The aim is to individualize prediction, prevention and treatment of acute coronary events based on the identification of specific features of high-risk atherosclerotic plaques, and to identify the most appropriate interventional procedures for their treatment. In this context, the aim of this review is to discuss how personalized assessment of coronary atherosclerotic arteries can be achieved by intravascular ultrasound imaging focusing on vulnerable plaque detection.
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Affiliation(s)
- Theodore G Papaioannou
- Biomedical Engineering Unit, First Department of Cardiology, Hippokration Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece.
| | - Charalampos Kalantzis
- Biomedical Engineering Unit, First Department of Cardiology, Hippokration Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece.
| | - Efstratios Katsianos
- Biomedical Engineering Unit, First Department of Cardiology, Hippokration Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece.
| | - Despina Sanoudou
- Fourth Department of Internal Medicine, "Attikon" Hospital, Medical School, National and Kapodistrian University of Athens, 12462 Athens, Greece.
| | - Manolis Vavuranakis
- Third Department of Cardiology, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece.
| | - Dimitrios Tousoulis
- Biomedical Engineering Unit, First Department of Cardiology, Hippokration Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece.
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Zhang L, Qi X, Jia X. Effect of Different Methods of Administration of Diltiazem on Clinical Efficacy in Patients with Acute ST-Segment Elevation Myocardial Infarction. Med Sci Monit 2018; 24:6544-6550. [PMID: 30223281 PMCID: PMC6149237 DOI: 10.12659/msm.912576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND The aim of this study was to investigate the optimal route of administration of diltiazem in emergency PCI and to provide the best clinical treatment for ASTEMI patients. MATERIAL AND METHODS A total of 90 patients with ASTEMI treated in our hospital from January 2015 to January 2016 were selected. Prior to thrombus aspiration, a thrombus aspiration catheter was used to perform diltiazem injection at the distal end of the infarct-related artery (IRA). We chose the acute ST-elevation myocardial infarction (ASTEMI) patients treated with direct PCI to compare different administration routes of diltiazem. The occurrence of major adverse cardiac events (MACEs) was closely observed during hospitalization and was obtained through outpatient visits or telephone follow-ups over the next 6 months. RESULTS Intracoronary infusion of diltiazem at the distal end of the culprit vessel, compared to conventional coronary mouth and intravenous injection, was significantly improved in thrombolysis in myocardial infarction (TIMI) frame count immediately after PCI stent implantation, ST-segment drop rate after 90 min, and left ventricular ejection fraction (LVEF) after 1 week. Furthermore, the peak value of high-sensitivity cardiac troponin I (hs-cTnI), a marker for myocardial injury, was the lowest. White blood cell count, neutrophil count, mean platelet volume (MPV), and high-sensitivity C-reactive protein (hs-CRP) were significantly lower than with the other 2 administration routes, and there was no effect on intracoronary pressure or heart rate. CONCLUSIONS Patients with ASTEMI who underwent emergency PCI treatment had good clinical outcomes using intracoronary diltiazem at the distal end of the culprit vessel.
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Affiliation(s)
- Lanfang Zhang
- Department of Internal Medicine, Hebei Medical University, Shijiazhuang, Hebei, China (mainland)
| | - Xiaoyong Qi
- Department of Internal Medicine, Hebei Medical University, Shijiazhuang, Hebei, China (mainland).,Department of Cardiology, Hebei General Hospital, Shijiazhuang, Hebei, China (mainland)
| | - Xinwei Jia
- Department of Cardiology, Affiliated Hospital of Hebei University, Baoding, Hebei, China (mainland)
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Elfaramawy A, Hassan M, Nagy M, ElGuindy A, Elmahdy MF. Impact of fractional flow reserve on decision-making in daily clinical practice: A single center experience in Egypt. Egypt Heart J 2018; 70:161-165. [PMID: 30190641 PMCID: PMC6123341 DOI: 10.1016/j.ehj.2017.12.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 12/11/2017] [Indexed: 11/29/2022] Open
Abstract
Background Fractional flow reserve (FFR) is the reference standard for the assessment of the functional significance of coronary artery stenoses, but remains underutilized. Our aims were to study whether FFR changed the decision for treatment of intermediate coronary lesions and to assess the clinical outcome in the deferred and intervention groups. Methods In this retrospective study, coronary angiograms of patients with moderately stenotic lesions (40–70%) for which FFR was performed were re-analyzed by three experienced interventional cardiologists (blinded to FFR results) to determine its angiographic significance and whether to defer or perform an intervention. Results We revised 156 equivocal lesions of 151 patients. The clinical presentation were stable angina (65.6%) and acute coronary syndrome in (34.4%). All reviewers had concordant agreement to do PCI in 59 (37.8%) lesions based on angiographic assessment. Interestingly 23 (39%) of these lesions were functionally non-significant by FFR. The reviewers agreed to defer 97 (62.2%) lesions, however, 32 (33%) of these lesions were functionally significant by FFR and necessitated PCI. MACE were similar in both groups (1.5% vs 2.4%, p = 1.0). Conclusion Mismatches between visually- and FFR- estimated significance of intermediate coronary stenosis are frequently encountered across a wide spectrum of clinical presentations. FFR leads to a change in decision for coronary intervention. The clinical and cost implications of such changes-in areas with limited resources- needs further evaluation.
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Key Words
- ACS, acute coronary syndrome
- CABG, coronary artery bypass graft surgery
- CAD, coronary artery disease
- FFR, fractional flow reserve
- Fractional flow reserve
- Intermediate coronary artery lesion
- MACE, major adverse cardiac events
- MI, myocardial infarction
- NSTEMI, non ST segment elevation myocardial infarction
- OPD, outpatient department
- PCI, percutaneous coronary intervention
- QCA, quantitative coronary angiographic
- STEMI, ST segment elevation myocardial infarction
- TLR, target lesion revascularization
- Visual assessment
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Affiliation(s)
- Amr Elfaramawy
- Cardiology Department, Cairo University, Cairo, Egypt.,Cardiology Department, Aswan Heart Center, Aswan, Egypt
| | - Mohamed Hassan
- Cardiology Department, Cairo University, Cairo, Egypt.,Cardiology Department, Aswan Heart Center, Aswan, Egypt
| | - Michael Nagy
- Cardiology Department, Aswan Heart Center, Aswan, Egypt
| | - Ahmed ElGuindy
- Cardiology Department, Aswan Heart Center, Aswan, Egypt.,National Heart and Lung Institute, Imperial College London, UK
| | - Mahmoud F Elmahdy
- Cardiology Department, Cairo University, Cairo, Egypt.,Cardiology Department, Aswan Heart Center, Aswan, Egypt
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Li L, Liu QW, Li Z, Wang L, Wang JH, Song L, Li B. The utility of high-sensitivity C-reactive protein levels in patients with moderate coronary lesions and gray-zone fractional flow reserve. Anatol J Cardiol 2018; 20:143-151. [PMID: 30109863 PMCID: PMC6237940 DOI: 10.14744/anatoljcardiol.2018.80148] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/19/2018] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVE It remains controversial whether patients with fractional flow reserve (FFR) values of 0.75-0.80 (gray-zone) should be treated with percutaneous coronary intervention (PCI). This study aimed to evaluate the prediction of high-sensitivity C-reactive protein (hs-CRP) levels to guide treatment selection in gray-zone patients. METHODS This prospective interventional trial was conducted between January 2015 and March 2016. A total of 785 patients with stable angina and single-vessel stenosis with moderate coronary lesions were admitted to hospital in this period. After measurement of hs-CRP levels, coronary angiography, and FFR, gray-zone patients (n=308) were included in the study and were divided into four groups on the basis of a cutoff hs-CRP level of 3 mg/L and then on the basis of whether they underwent PCI or not. Patients in groups I (≥3 mg/L, n=70) and III (<3 mg/L, n=84) underwent PCI, whereas those in groups II (≥3 mg/L, n=70) and IV (<3 mg/L, n=84) were administered only drugs. Major adverse clinical events (MACEs) included cardiac death, nonfatal myocardial infarction (MI), target vessel revascularization (TVR), and PCI or coronary artery bypass grafting (CABG). These parameters were also evaluated during follow-up. RESULTS The total Kaplan-Meier curves showed macrodistribution differences among the four groups (p<0.05). There was a significantly increased MACE incidence in group II compared with group I or IV (p=0.039 or 0.006, respectively), and an increased incidence in group I compared with group III (p=0.028). However, there were no differences in MACE incidence between groups III and IV (p=0.095) despite the fact that these patients received different treatments. CONCLUSION Among FFR gray-zone patients, hs-CRP level was a predictor of MACE and risk stratification could guide treatment selection. Increased hs-CRP levels (≥3 mg/L) are an indication for urgent PCI whereas normal levels (<3 mg/L) are an indication for delayed PCI treatment. Patients with identical FFR values could require different treatment.
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Affiliation(s)
| | | | | | | | | | | | - Bin Li
- Department of Surgery Center, Shandong Provincial Hospital Affiliated to Shandong University; Jinan-China.
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Ahmadi A, Stanger D, Puskas J, Taggart D, Chandrashekhar Y, Narula J. Is there a role for fractional flow reserve in coronary artery bypass graft (CABG) planning? Ann Cardiothorac Surg 2018; 7:546-551. [PMID: 30094220 PMCID: PMC6082788 DOI: 10.21037/acs.2018.07.01] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 07/12/2018] [Indexed: 12/21/2022]
Abstract
The concept of significant lesions has substantially evolved over the last decade. With growing evidence for use of fractional flow reserve (FFR) as a determinant of lesion-specific ischemia and its superiority to angiography-guided revascularization and medical therapy, the field of percutaneous revascularization has shifted to rely exclusively on FFR instead of luminal stenosis alone in guiding revascularization. This transition to physiological assessment has not yet made it to the realm of surgical revascularization. FFR-guided therapy has been shown to be superior to angiography-guided therapy mainly by safe deferral of about 1/3rd of lesions, leading to less periprocedural events and better outcomes. Is it possible that utilization of FFR-guided CABG would lead to less complicated procedures, shorter operating times, more frequent off pump CABG procedures and more hybrid procedures? Can FFR-guided CABG improve the cardiovascular outcomes as compared to current standard of practice? In the following paragraphs we review the concept of FFR, the evidence behind FFR-guided therapy, the emerging data regarding use FFR-guided CABG and discuss where the revascularization field is headed.
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Affiliation(s)
- Amir Ahmadi
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai Hospital, New York, New York, USA
- Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Dylan Stanger
- Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - John Puskas
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai Hospital, New York, New York, USA
| | - David Taggart
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Y. Chandrashekhar
- Department of Cardiology, Veterans Administration Hospital and University of Minnesota School of Medicine, Minneapolis, USA
| | - Jagat Narula
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai Hospital, New York, New York, USA
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Wang BJ, Geng J, Li QJ, Hu TT, Xu B, Ma SR. Clinical effect of selective interventional therapy on sub-acute ST-segment elevation myocardial infarction under the guidance of fractional flow reserve and coronary arteriography. Eur J Med Res 2018; 23:27. [PMID: 29793533 PMCID: PMC5968604 DOI: 10.1186/s40001-018-0319-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 04/23/2018] [Indexed: 11/23/2022] Open
Abstract
Objective This study aims to compare the clinical effects of selective interventional therapy (PCI) under the guidance of fractional flow reserve (FFR) and coronary arteriography. Methods Patients with sub-acute ST-segment elevation myocardial infarction (sub-acute STEMI), who were under selective PCI treatment between April 2012 and June 2014, were included into this study. These patients were divided into two groups, based on FFR measurements: FFR-PCI group and radiography-PCI group. Then, differences in clinical symptoms, coronary angiography, intervention, and endpoint events were compared between these two groups. Results A total of 592 patients with sub-acute STEMI were included in this study (207 patients in the FFR-PCI group and 385 patients in the radiography-PCI group). No statistical differences were observed in baseline clinical data and coronary angiography results between these two groups. Mean stent number was greater in the radiography-PCI group (1.22 ± 0.32) than in the FFR-PCI group (1.10 ± 0.29), and the difference was statistically significant (P = 0.019). During the follow-up period, 78 adverse events occurred (21 adverse events in the FFR-PCI group and 57 adverse events in the radiography-PCI group); and no statistical significance was observed between these two groups (log-rank P = 0.112). Conclusion Selective PCI treatment in patients with sub-acute STEMI under FFR acquired similar effects, compared to PCI treatment under the guidance of radiography, which can reduce the mean stent number.
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Affiliation(s)
- Bing-Jian Wang
- Department of Cardiology, Huai'an First People's Hospital, Nanjing Medical University, No. 6 West Beijing Road, Huaiyin District, Huai'an, 223300, China
| | - Jin Geng
- Department of Cardiology, Huai'an First People's Hospital, Nanjing Medical University, No. 6 West Beijing Road, Huaiyin District, Huai'an, 223300, China
| | - Qian-Jun Li
- Department of Cardiology, Huai'an First People's Hospital, Nanjing Medical University, No. 6 West Beijing Road, Huaiyin District, Huai'an, 223300, China
| | - Ting-Ting Hu
- Department of Cardiology, Huai'an First People's Hospital, Nanjing Medical University, No. 6 West Beijing Road, Huaiyin District, Huai'an, 223300, China
| | - Biao Xu
- Department of Cardiology, Drum Tower Hospital, Nanjing Medical University, Nanjing, 210008, China
| | - Shu-Ren Ma
- Department of Cardiology, Huai'an First People's Hospital, Nanjing Medical University, No. 6 West Beijing Road, Huaiyin District, Huai'an, 223300, China.
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Ahmadi A, Leipsic J, Øvrehus KA, Gaur S, Bagiella E, Ko B, Dey D, LaRocca G, Jensen JM, Bøtker HE, Achenbach S, De Bruyne B, Nørgaard BL, Narula J. Lesion-Specific and Vessel-Related Determinants of Fractional Flow Reserve Beyond Coronary Artery Stenosis. JACC Cardiovasc Imaging 2018; 11:521-530. [DOI: 10.1016/j.jcmg.2017.11.020] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 11/07/2017] [Accepted: 11/08/2017] [Indexed: 11/25/2022]
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Reynolds HR, Hausvater A, Carney K. Test Selection for Women with Suspected Stable Ischemic Heart Disease. J Womens Health (Larchmt) 2018; 27:867-874. [PMID: 29583082 DOI: 10.1089/jwh.2017.6587] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Ischemic heart disease (IHD) is the leading cause of death and disability among women in the United States. Identifying IHD in women presenting with stable symptoms and stratifying their risk for an IHD event can be challenging for providers, with several different tests available. This article is meant to serve as a practical guide for clinicians treating women with potentially ischemic symptoms. Evidence and American Heart Association (AHA) recommendations regarding test selection are reviewed, with a focus on the information to be gained from each test. We outline suggested courses of action to be taken in the case of a positive or negative test. Regardless of the initial test result, clinicians should view a woman's symptom presentation as an opportunity to review and modify her risk of cardiovascular events.
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Affiliation(s)
- Harmony R Reynolds
- Soter Center for Women's Cardiovascular Research, Leon H. Charney Division of Cardiology, Department of Medicine, NYU School of Medicine , New York, New York
| | - Anais Hausvater
- Soter Center for Women's Cardiovascular Research, Leon H. Charney Division of Cardiology, Department of Medicine, NYU School of Medicine , New York, New York
| | - Kerrilynn Carney
- Soter Center for Women's Cardiovascular Research, Leon H. Charney Division of Cardiology, Department of Medicine, NYU School of Medicine , New York, New York
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Qureshi AI, Saleem MA, Naseem N, Wallery SS. A New Technique for the Assessment of Cerebral Vasodilatory Capacity as Part of Catheter-Based Cerebral Angiography. J Stroke Cerebrovasc Dis 2018; 27:1822-1827. [PMID: 29571761 DOI: 10.1016/j.jstrokecerebrovasdis.2018.02.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 02/10/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Previous studies have demonstrated the value of cerebral vasodilatory capacity assessment for risk stratification in patients with extracranial arterial stenosis or occlusion. We describe a new method that assesses cerebral vasodilatory capacity as part of catheter-based cerebral angiography. METHODS We assessed regional cerebral blood volume (rCBV) in the arterial distribution of interest using a controlled contrast injection through a diagnostic catheter placed in the common carotid or the subclavian artery. rCBV maps were created using predefined algorithm based on contrast distribution in the venous phase (voxel size 0.466 mm3) into high, intermediate, low, and no detectable rCBV regions. rCBV maps were acquired again after the administration of intra-arterial nicardipine (1.5-2.5 mg), and percentage increases of the area of various grades of rCBV were calculated. RESULTS Three patients with internal carotid artery stenosis (32% - 64% in severity) and 1 patient with extracranial vertebral artery stenosis (46% in severity) were assessed. There was a variable but consistent increase in the area of high rCBV in the ipsilateral hemisphere in 3 patients with internal carotid artery flow (5.5%-24.5%) and the cerebellum (9.6%) in 1 patient with vertebral artery flow assessments. The increase in high rCBV was most prominent in the patient who received 2.5 mg (24.5%) and least prominent in a patient who received 1.5 mg (5.5%) of intra-arterial nicardipine. There was a concurrent reduction in areas of intermediate and low rCBV (shift) in 3 patients, and there was an increase in all areas of rCBV grades (addition) in 1 patient. CONCLUSIONS Selective assessment of cerebral vasodilatory response in the affected arterial distribution is feasible during catheter-based cerebral angiography.
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Affiliation(s)
- Adnan I Qureshi
- Zeenat Qureshi Stroke Institute, St. Cloud, Minnesota; University of Illinois and Mercyhealth, Rockford, Illinois
| | - Muhammad A Saleem
- Zeenat Qureshi Stroke Institute, St. Cloud, Minnesota; Mercyhealth, Janesville, Wisconsin.
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AL-Obaidi FR, Fearon WF, Yong AS. Invasive physiological indices to determine the functional significance of coronary stenosis. IJC HEART & VASCULATURE 2018; 18:39-45. [PMID: 29876502 PMCID: PMC5988484 DOI: 10.1016/j.ijcha.2018.02.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 02/13/2018] [Indexed: 01/10/2023]
Abstract
Physiological measurements are now commonly used to assess coronary lesions in the cardiac catheterisation laboratory, and this practice is evidence-based and supported by clinical guidelines. Fractional flow reserve is currently the gold standard method to determine whether coronary lesions are functionally significant, and is used to guide revascularization. There are however several other physiological measurements that have been proposed as alternatives to the fractional flow reserve. This review aims to comprehensively discuss physiological indices that can be used in the cardiac catheterisation laboratory to determine the functional significance of coronary lesions. We will focus on their advantages and disadvantages, and the current evidence supporting their use.
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Affiliation(s)
- Firas R. AL-Obaidi
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
- College of Medicine, University of Thi Qar, Iraq
| | - William F. Fearon
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Andy S.C. Yong
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
- ANZAC Research Institute, Concord Hospital, Sydney, Australia
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Motwani M, Motlagh M, Gupta A, Berman DS, Slomka PJ. Reasons and implications of agreements and disagreements between coronary flow reserve, fractional flow reserve, and myocardial perfusion imaging. J Nucl Cardiol 2018; 25:104-119. [PMID: 26715599 DOI: 10.1007/s12350-015-0375-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Revised: 12/02/2015] [Indexed: 01/10/2023]
Abstract
Information on coronary physiology and myocardial blood flow (MBF) in patients with suspected angina is increasingly important to inform treatment decisions. A number of different techniques including myocardial perfusion imaging (MPI), noninvasive estimation of MBF, and coronary flow reserve (CFR), as well as invasive methods for CFR and fractional flow reserve (FFR) are now readily available. However, despite their incorporation into contemporary guidelines, these techniques are still poorly understood and their interpretation to guide revascularization decisions is often inconsistent. In particular, these inconsistencies arise when there are discrepancies between the various techniques. The purpose of this article is therefore to review the basic principles, techniques, and clinical value of MPI, FFR, and CFR-with particular focus on interpreting their agreements and disagreements.
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Affiliation(s)
- Manish Motwani
- Departments of Imaging and Medicine and the Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Mahsaw Motlagh
- Departments of Imaging and Medicine and the Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Anuj Gupta
- Division of Cardiovascular Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Daniel S Berman
- Departments of Imaging and Medicine and the Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Piotr J Slomka
- Departments of Imaging and Medicine and the Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
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Ahn SG, Suh J, Hung OY, Lee HS, Bouchi YH, Zeng W, Gandhi R, Eshtehardi P, Gogas BD, Samady H. Discordance Between Fractional Flow Reserve and Coronary Flow Reserve: Insights From Intracoronary Imaging and Physiological Assessment. JACC Cardiovasc Interv 2018; 10:999-1007. [PMID: 28521932 DOI: 10.1016/j.jcin.2017.03.006] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 02/15/2017] [Accepted: 03/06/2017] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The aim of this study was to investigate the epicardial and microvascular substrates associated with discordances between fractional flow reserve (FFR) and coronary flow reserve (CFR) values. BACKGROUND Discordances between FFR and CFR remain poorly characterized. METHODS FFR, hyperemic stenosis resistance (HSR), and intravascular ultrasound were performed as indexes of epicardial function and CFR and hyperemic microvascular resistance (HMR) as measures of microvascular function in 94 patients with moderate coronary stenosis. Maximal plaque burden (PBmax), HSR, and HMR were calculated in 4 quadrants based on values of FFR ≤0.80 and CFR ≤2.0 as follows: concordant normal (preserved FFR and CFR), concordant abnormal (low FFR and CFR), discordant low FFR and preserved CFR, and discordant preserved FFR and low CFR. RESULTS Sixty-four patients (68%) had concordant FFR and CFR findings, and 30 patients (32%) had discordant FFR and CFR. Compared with patients with preserved FFR and CFR, those with low FFR and CFR had higher PBmax (p = 0.003), higher HSR (p < 0.001), and similar HMR. Among patients with preserved FFR, those with reduced CFR had similar PBmax and HSR but a trend toward higher HMR (p = 0.058) compared with patients with preserved CFR. Among patients with reduced FFR, those with preserved CFR had lower PBmax (p = 0.004), a trend toward lower HSR (p = 0.065), and lower HMR (p = 0.03) compared with patients with reduced CFR. Furthermore, compared with patients with preserved FFR and low CFR, those with low FFR and preserved CFR had higher HSR (p = 0.022) but lower HMR (p = 0.003). CONCLUSIONS In patients with moderate coronary stenosis, preserved FFR and low CFR is associated with increased microvascular resistance, while low FFR and preserved CFR has modest epicardial stenosis and preserved microvascular function.
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Affiliation(s)
- Sung Gyun Ahn
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia; Division of Cardiology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jon Suh
- Division of Cardiology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea; Division of Cardiology, Department of Internal Medicine, SoonChunHyang University Bucheon Hospital, Bucheon, Korea
| | - Olivia Y Hung
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Hee Su Lee
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Yasir H Bouchi
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Wenjie Zeng
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Rounak Gandhi
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Parham Eshtehardi
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Bill D Gogas
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Habib Samady
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia.
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Papafaklis MI, Mavrogiannis MC, Siogkas PK, Lakkas LS, Katsouras CS, Fotiadis DI, Michalis LK. Functional assessment of lesion severity without using the pressure wire: coronary imaging and blood flow simulation. Expert Rev Cardiovasc Ther 2017; 15:863-877. [PMID: 28902523 DOI: 10.1080/14779072.2017.1379899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 08/24/2017] [Indexed: 01/10/2023]
Abstract
Hemodynamic indices derived from measurements with the pressure wire (primarily fractional flow reserve [FFR]) have been established as a reliable tool for assessing coronary stenoses and improving clinical decision making. However, the use of the pressure wire constitutes a hurdle for the universal adoption of physiology-guided patient management. Technological advancements have enabled the large-scale application of blood flow simulation (computational fluid dynamics [CFD]) to medical imaging, thereby enabling the virtual assessment of coronary physiology. Areas covered: This review summarizes the stand-alone non-invasive (coronary computed tomographic imaging) and invasive (coronary angiography) imaging approaches which were initially used for predicting FFR, and focuses on the use of blood flow modeling for functional assessment of coronary lesions in clinical practice. Expert commentary: Validation studies of CFD-derived methodologies for functional assessment have shown that virtual indices correlate well and have good diagnostic accuracy compared to pressure wire-FFR despite inherent limitations of spatial resolution and assumptions regarding boundary conditions in flow modeling. Beyond point-to-point agreement with FFR, further studies are needed to demonstrate the clinical safety/efficacy of these computational tools regarding patient outcomes. Such evidence base could support the incorporation of these methodologies into routine patient management for decision making and reliable risk stratification.
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Affiliation(s)
- Michail I Papafaklis
- a Second Department of Cardiology , University Hospital of Ioannina , Ioannina , Greece
- b Michailideion Cardiac Center, Medical School , University of Ioannina , Ioannina , Greece
| | - Michail C Mavrogiannis
- b Michailideion Cardiac Center, Medical School , University of Ioannina , Ioannina , Greece
| | - Panagiotis K Siogkas
- c Unit of Medical Technology and Intelligent Information Systems, Department of Materials Science , University of Ioannina , Ioannina , Greece
| | - Lampros S Lakkas
- a Second Department of Cardiology , University Hospital of Ioannina , Ioannina , Greece
| | - Christos S Katsouras
- a Second Department of Cardiology , University Hospital of Ioannina , Ioannina , Greece
| | - Dimitrios I Fotiadis
- b Michailideion Cardiac Center, Medical School , University of Ioannina , Ioannina , Greece
- c Unit of Medical Technology and Intelligent Information Systems, Department of Materials Science , University of Ioannina , Ioannina , Greece
| | - Lampros K Michalis
- a Second Department of Cardiology , University Hospital of Ioannina , Ioannina , Greece
- b Michailideion Cardiac Center, Medical School , University of Ioannina , Ioannina , Greece
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Patel MR, Calhoon JH, Dehmer GJ, Grantham JA, Maddox TM, Maron DJ, Smith PK. ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/STS 2017 Appropriate Use Criteria for Coronary Revascularization in Patients With Stable Ischemic Heart Disease : A Report of the American College of Cardiology Appropriate Use Criteria Task Force, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and Society of Thoracic Surgeons. J Nucl Cardiol 2017; 24:1759-1792. [PMID: 28608183 DOI: 10.1007/s12350-017-0917-9] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The American College of Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, and American Association for Thoracic Surgery, along with key specialty and subspecialty societies, have completed a 2-part revision of the appropriate use criteria (AUC) for coronary revascularization. In prior coronary revascularization AUC documents, indications for revascularization in acute coronary syndromes and stable ischemic heart disease (SIHD) were combined into 1 document. To address the expanding clinical indications for coronary revascularization, and to align the subject matter with the most current American College of Cardiology/American Heart Association guidelines, the new AUC for coronary artery revascularization were separated into 2 documents addressing SIHD and acute coronary syndromes individually. This document presents the AUC for SIHD.Clinical scenarios were developed to mimic patient presentations encountered in everyday practice. These scenarios included information on symptom status; risk level as assessed by noninvasive testing; coronary disease burden; and, in some scenarios, fractional flow reserve testing, presence or absence of diabetes, and SYNTAX score. This update provides a reassessment of clinical scenarios that the writing group felt were affected by significant changes in the medical literature or gaps from prior criteria. The methodology used in this update is similar to the initial document but employs the recent modifications in the methods for developing AUC, most notably, alterations in the nomenclature for appropriate use categorization.A separate, independent rating panel scored the clinical scenarios on a scale of 1 to 9. Scores of 7 to 9 indicate that revascularization is considered appropriate for the clinical scenario presented. Scores of 1 to 3 indicate that revascularization is considered rarely appropriate for the clinical scenario, whereas scores in the mid-range of 4 to 6 indicate that coronary revascularization may be appropriate for the clinical scenario.As seen with the prior coronary revascularization AUC, revascularization in clinical scenarios with high symptom burden, high-risk features, and high coronary disease burden, as well as in patients receiving antianginal therapy, are deemed appropriate. Additionally, scenarios assessing the appropriateness of revascularization before kidney transplantation or transcatheter valve therapy are now rated. The primary objective of the AUC is to provide a framework for the assessment of practice patterns that will hopefully improve physician decision making.
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Affiliation(s)
- Manesh R Patel
- Duke University Health System, Duke Clinical Research Institute, Durham, NC, USA.
| | - John H Calhoon
- Department of Cardiothoracic Surgery, Heart and Vascular Institute, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Gregory J Dehmer
- Baylor Scott & White - Temple Memorial, Temple, TX, USA
- Health Science Center, Texas A&M University, Bryan, TX, USA
| | - James Aaron Grantham
- Saint Luke's Hospital, Kansas City, MO, USA
- Kansas City School of Medicine, University of Missouri, Kansas City, MO, USA
| | - Thomas M Maddox
- VA Eastern Colorado Health Care System, Denver, CO, USA
- University of Colorado, Aurora, CO, USA
| | - David J Maron
- Stanford University School of Medicine, Stanford, CA, USA
| | - Peter K Smith
- Division of Cardiovascular and Thoracic Surgery, Duke University, Durham, NC, USA
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Lee JM, Koo BK, Shin ES, Nam CW, Doh JH, Hu X, Ye F, Chen S, Yang J, Chen J, Tanaka N, Yokoi H, Matsuo H, Takashima H, Shiono Y, Hwang D, Park J, Kim KJ, Akasaka T, Wang J. Clinical Outcomes of Deferred Lesions With Angiographically Insignificant Stenosis But Low Fractional Flow Reserve. J Am Heart Assoc 2017; 6:JAHA.117.006071. [PMID: 28862970 PMCID: PMC5586447 DOI: 10.1161/jaha.117.006071] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background Data are limited regarding outcomes of deferred lesions in patients with angiographically insignificant stenosis but low fractional flow reserve (FFR). We investigated the natural history of angiographically insignificant stenosis with low FFR among patients who underwent routine 3‐vessel FFR measurement. Methods and Results From December 2011 to March 2014, 1136 patients with 3298 vessels underwent routine 3‐vessel FFR measurement (3V FFR‐FRIENDS study, ClinicalTrials.gov identifier NCT01621438), and this study analyzed the 2‐year clinical outcomes of 1024 patients with 2124 lesions with angiographically insignificant stenosis (percentage of diameter stenosis <50%), in which revascularization was deferred. All lesions were classified according to FFR values, using a cutoff of 0.80 (high FFR >0.80 versus low FFR ≤0.80). The primary end point was outcome of major adverse cardiovascular events (a composite of cardiac death, myocardial infarction, and ischemia‐driven revascularization) at 2 years. Mean angiographic percentage of diameter stenosis and FFR of total lesions were 32.5±10.3% and 0.91±0.08%, respectively. Among the total lesions with angiographically insignificant stenosis, 8.7% showed low FFR (185 lesions). The incidence of lesions with low FFR was 2.5%, 3.8%, 9.0%, and 15.1% in categories of percentage of diameter stenosis <20%, 20% to 30%, 30% to 40%, and 40% to 50%, respectively. At 2‐year follow‐up, the low‐FFR group showed a significantly higher risk of major adverse cardiovascular events compared with the high FFR group (3.3% versus 1.2%, hazard ratio: 3.371; 95% CI, 1.346–8.442; P=0.009). In multivariable analysis, low FFR was the most powerful independent predictor of future MACE in deferred lesions with angiographically insignificant stenosis (adjusted hazard ratio: 2.617; 95% CI, 1.026–6.679; P=0.044). Conclusions In deferred angiographically insignificant stenosis, lesions with low FFR showed significantly higher event rates than those with high FFR. FFR was an independent predictor of future major adverse cardiovascular events in lesions with angiographically insignificant stenosis. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT01621438.
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Affiliation(s)
- Joo Myung Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Bon-Kwon Koo
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea .,Institute on Aging, Seoul National University, Seoul, Korea
| | - Eun-Seok Shin
- Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, South Korea
| | - Chang-Wook Nam
- Department of Medicine, Keimyung University Dongsan Medical Center, Daegu, South Korea
| | - Joon-Hyung Doh
- Department of Medicine, Inje University Ilsan Paik Hospital, Goyang, South Korea
| | - Xinyang Hu
- Department of Cardiology, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Zhejiang, China
| | - Fei Ye
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Shaoliang Chen
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Junqing Yang
- Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Jiyan Chen
- Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Nobuhiro Tanaka
- Department of Cardiology, Tokyo Medical University, Tokyo, Japan
| | | | - Hitoshi Matsuo
- Department of Cardiology, Gifu Heart Center, Gifu, Japan
| | | | | | - Doyeon Hwang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Jonghanne Park
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Kyung-Jin Kim
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | | | - Jianan Wang
- Department of Cardiology, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Zhejiang, China
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