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Jain P, Udelson JE, Kimmelstiel C. Physiologic Guidance for Percutaneous Coronary Intervention: State of the Evidence. Trends Cardiovasc Med 2022:S1050-1738(22)00014-7. [DOI: 10.1016/j.tcm.2022.01.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 01/10/2022] [Accepted: 01/25/2022] [Indexed: 01/10/2023]
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Hidalgo F, Gonzalez-Manzanares R, Ojeda S, Benito-González T, Gutiérrez-Barrios A, De la Torre Hernández JM, Minguito-Carazo C, Izaga-Torralba E, Cabrera-Rubio I, Flores-Vergara G, de Lezo JS, Romero-Moreno M, de Prado AP, Pan M. Instantaneous wave-free ratio for guiding treatment of nonculprit lesions in patients with acute coronary syndrome: A retrospective study. Catheter Cardiovasc Interv 2021; 99:489-496. [PMID: 34862839 DOI: 10.1002/ccd.30025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 10/25/2021] [Accepted: 11/17/2021] [Indexed: 11/05/2022]
Abstract
BACKGROUND The aim of this study was to analyze the feasibility of a physiological coronary evaluation with the instantaneous wave-free ratio (iFR) of nonculprit lesions in patients with acute coronary syndrome (ACS) successfully revascularized. METHODS A multicenter registry including patients of four high-volume PCI centers with ACS and underwent successful revascularization of the culprit vessel and had other nonculprit lesions that were physiologically evaluated with the iFR between January 2017 and December 2019. The primary endpoint was a composite of cardiac death, nonfatal myocardial infarction, probable or definitive stent thrombosis and new revascularization (MACEs). RESULTS A total of 356 patients with 472 nonculprit lesions were included. The mean age was 66 ± 11 years. The clinical presentation was ACS without persistent ST-segment elevation (NSTE-ACS) in 235 patients (66%) and ST-segment elevation myocardial infarction (STEMI) in 121 patients (34%). After a median follow-up period of 21 (14-30) months, the primary endpoint occurred in 32 patients (9%). There were no differences in outcomes regarding clinical presentation (NSTEMI vs. NSTE-ACS, 9.1 vs. 8.9%, padj = 0.570) or iFR induced treatment strategy (patients with all lesions revascularized vs. patients with at least one lesion with an iFR > 0.89 deferred for revascularization, 10.5 vs. 8.4%, padj = 0.476). CONCLUSIONS The use of the iFR to guide percutaneous coronary intervention decision making in nonculprit lesions seems to be feasible, with an acceptable percentage of MACEs at the mid-term follow-up. Patients with deferred revascularization of lesions without physiological significance and patients undergoing complete revascularization had a similar risk of MACEs.
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Affiliation(s)
- Francisco Hidalgo
- Reina Sofía Hospital, Department of Cardiology, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), University of Córdoba, Córdoba, Spain
| | - Rafael Gonzalez-Manzanares
- Reina Sofía Hospital, Department of Cardiology, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), University of Córdoba, Córdoba, Spain
| | - Soledad Ojeda
- Reina Sofía Hospital, Department of Cardiology, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), University of Córdoba, Córdoba, Spain
| | - Tomás Benito-González
- Interventional Cardiology Unit, Department of Cardiology, University Hospital of León, León, Spain
| | | | | | - Carlos Minguito-Carazo
- Interventional Cardiology Unit, Department of Cardiology, University Hospital of León, León, Spain
| | | | - Indira Cabrera-Rubio
- Department of Cardiology, IDIVAL, University Hospital Marqués de Valdecilla, Santander, Spain
| | - Guisela Flores-Vergara
- Reina Sofía Hospital, Department of Cardiology, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), University of Córdoba, Córdoba, Spain
| | - Javier Suárez de Lezo
- Reina Sofía Hospital, Department of Cardiology, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), University of Córdoba, Córdoba, Spain
| | - Miguel Romero-Moreno
- Reina Sofía Hospital, Department of Cardiology, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), University of Córdoba, Córdoba, Spain
| | - Armando Pérez de Prado
- Interventional Cardiology Unit, Department of Cardiology, University Hospital of León, León, Spain
| | - Manuel Pan
- Reina Sofía Hospital, Department of Cardiology, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), University of Córdoba, Córdoba, Spain
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Berntorp K, Persson J, Koul SM, Patel MR, Christiansen EH, Gudmundsdottir I, Yndigegn T, Omerovic E, Erlinge D, Fröbert O, Götberg M. Instantaneous wave-free ratio compared with fractional flow reserve in PCI: A cost-minimization analysis. Int J Cardiol 2021; 344:54-59. [PMID: 34600977 DOI: 10.1016/j.ijcard.2021.09.054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 09/22/2021] [Accepted: 09/27/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND Coronary physiology is a routine diagnostic tool when assessing whether coronary revascularization is indicated. The iFR-SWEDEHEART trial demonstrated similar clinical outcomes when using instantaneous wave-free ratio (iFR) or fractional flow reserve (FFR) to guide revascularization. The objective of this analysis was to assess a cost-minimization analysis of iFR-guided compared with FFR-guided revascularization. METHODS In this cost-minimization analysis we used a decision-tree model from a healthcare perspective with a time-horizon of one year to estimate the cost difference between iFR and FFR in a Nordic setting and a United States (US) setting. Treatment pathways and health care utilizations were constructed from the iFR-SWEDEHEART trial. Unit cost for revascularization and myocardial infarction in the Nordic setting and US setting were derived from the Nordic diagnosis-related group versus Medicare cost data. Unit cost of intravenous adenosine administration and cost per stent placed were based on the average costs from the enrolled centers in the iFR-SWEDEHEART trial. Deterministic and probabilistic sensitivity analyses were carried out to test the robustness of the result. RESULTS The cost-minimization analysis demonstrated a cost saving per patient of $681 (95% CI: $641 - $723) in the Nordic setting and $1024 (95% CI: $934 - $1114) in the US setting, when using iFR-guided compared with FFR-guided revascularization. The results were not sensitive to changes in uncertain parameters or assumptions. CONCLUSIONS IFR-guided revascularization is associated with significant savings in cost compared with FFR-guided revascularization.
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Affiliation(s)
- Karolina Berntorp
- Department of Cardiology, Lund University, Skåne University Hospital, Lund, Sweden.
| | - Josefine Persson
- School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden.
| | - Sasha M Koul
- Department of Cardiology, Lund University, Skåne University Hospital, Lund, Sweden.
| | | | | | - Ingibjörg Gudmundsdottir
- Department of Cardiology, Reykjavik University Hospital and University of Iceland, Reykjavik, Iceland.
| | - Troels Yndigegn
- Department of Cardiology, Lund University, Skåne University Hospital, Lund, Sweden.
| | - Elmir Omerovic
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden.
| | - David Erlinge
- Department of Cardiology, Lund University, Skåne University Hospital, Lund, Sweden.
| | - Ole Fröbert
- Örebro University, Faculty of Health, Department of Cardiology, Örebro, Sweden.
| | - Matthias Götberg
- Department of Cardiology, Lund University, Skåne University Hospital, Lund, Sweden.
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Faria D, Lee J, van der Hoef T, Mejía-Rentería H, Echavarria-Pinto M, Baptista S, Cerrato E, Garcia-Garcia H, Davies J, Onuma Y, Samady H, Piek JJ, Serruys PW, Lerman A, Escaned J. Age and functional relevance of coronary stenosis: a post hoc analysis of the ADVISE II trial. EUROINTERVENTION 2021; 17:757-764. [PMID: 33720019 PMCID: PMC9724935 DOI: 10.4244/eij-d-20-01163] [Citation(s) in RCA: 4] [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
BACKGROUND The influence of age-dependent changes on fractional flow reserve (FFR) or instantaneous wave-free ratio (iFR) and the response to pharmacological hyperaemia has not been investigated. AIMS We investigated the impact of age on these indices. METHODS This is a post hoc analysis of the ADVISE II trial, including a total of 690 pressure recordings (in 591 patients). Age-dependent correlations with FFR and iFR were calculated and adjusted for stenosis severity. Patients were stratified into three age terciles. The hyperaemic response to adenosine, calculated as the difference between resting and hyperaemic pressure ratios, and the prevalence of FFR-iFR discordance were assessed. RESULTS Age correlated positively with FFR (r=0.08, 95% CI: 0.01 to 0.15, p=0.015), but not with iFR (r=-0.03, 95% CI: -0.11 to 0.04, p=0.411). The hyperaemic response to adenosine decreased with patient age (0.12±0.07, 0.11±0.06, 0.09±0.05, for the 1st [33-58 years], 2nd [59-69 years] and 3rd [70-94 years] age tertiles, respectively, p<0.001) and showed significant correlation with age (r=-0.14, 95% CI: -0.21 to -0.06, p<0.001). The proportion of patients with FFR ≤0.80+iFR >0.89 discordance doubled in the first age tercile (14.1% vs 7.1% vs 7.0%, p=0.005). CONCLUSIONS The hyperaemic response of the microcirculation to adenosine administration is age dependent. FFR values increase with patient age, while iFR values remain constant across the age spectrum. These findings contribute to explaining differences observed in functional stenosis classification with hyperaemic and non-hyperaemic coronary indices.
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Affiliation(s)
- Daniel Faria
- Interventional Cardiology Unit, Hospital Clinico San Carlos IDISSC, Complutense University of Madrid, Madrid, Spain,Department of Cardiology, Hospital Professor Doutor Fernando Fonseca, Amadora, Portugal
| | - Joo Lee
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Tim van der Hoef
- Amsterdam UMC, University of Amsterdam, Heart Center, Department of Interventional Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Hernán Mejía-Rentería
- Interventional Cardiology Unit, Hospital Clinico San Carlos IDISSC, Complutense University of Madrid, Madrid, Spain
| | - Mauro Echavarria-Pinto
- Interventional Cardiology Unit, Hospital Clinico San Carlos IDISSC, Complutense University of Madrid, Madrid, Spain,Hospital General ISSSTE Querétaro, Facultad de Medicina, Universidad Autónoma de Querétaro, Santiago de Querétaro, México
| | - Sérgio Baptista
- Department of Cardiology, Hospital Professor Doutor Fernando Fonseca, Amadora, Portugal,University Clinic of Cardiology, Faculty of Medicine at University of Lisbon, Lisbon, Portugal
| | - Enrico Cerrato
- Interventional Cardiology Unit, San Luigi Gonzaga University Hospital, Orbassano, Italy,Rivoli Infermi Hospital, Turin, Italy
| | - Hector Garcia-Garcia
- Interventional Cardiology, Medstar Washington Hospital Center, Washington, DC, USA
| | - Justin Davies
- Faculty of Medicine, National Heart & Lung Institute, Imperial College London, London, United Kingdom
| | - Yoshinobu Onuma
- Department of Interventional Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Habib Samady
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Jan J. Piek
- Amsterdam UMC, University of Amsterdam, Heart Center, Department of Interventional Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Patrick W. Serruys
- Department of Cardiology, National University of Ireland, Galway, Ireland
| | - Amir Lerman
- Department of Cardiovascular Disease, Mayo Clinic, Rochester, MN, USA
| | - Javier Escaned
- Interventional Cardiology, Hospital Clinico San Carlos, Calle del Prof Martín Lagos, 28040 Madrid, Spain
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Milzi A, Dettori R, Marx N, Reith S, Burgmaier M. Quantitative flow ratio (QFR) identifies functional relevance of non-culprit lesions in coronary angiographies of patients with acute myocardial infarction. Clin Res Cardiol 2021; 110:1659-1667. [PMID: 34251507 PMCID: PMC8484103 DOI: 10.1007/s00392-021-01897-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 06/14/2021] [Indexed: 11/24/2022]
Abstract
INTRODUCTION In patients with acute myocardial infarction (AMI) and multivessel coronary disease, revascularization of non-culprit lesions guided by proof of ischemia usually requires staged ischemia testing. Quantitative flow ratio (QFR) has been shown to be effective in assessing the hemodynamic relevance of lesions in stable coronary disease. However, its suitability in AMI patients is unknown. In this study, we tested the diagnostic value of QFR based on acute angiograms (aQFR) during AMI to assess the hemodynamic relevance of non-culprit lesions. METHODS We retrospectively assessed the diagnostic efficiency of aQFR in 280 vessels from 220 patients, comparing it with staged ischemia testing using elective coronary angiography with FFR (n = 47), stress cardiac MRI (n = 200) or SPECT (n = 33). RESULTS aQFR showed a very good diagnostic efficiency (AUC = 0.887, 95% CI 0.832-0.943, p < 0.001) in predicting ischemia of non-culprit lesions, significantly superior to coronary lesion's geometry as assessed by quantitative coronary angiography. The optimal cut-off for aQFR to predict ischemia was 0.80 (sensitivity = 83.7%, specificity = 86.1%). Maintaining a predefined level of 95% sensitivity and specificity, we created a decision model based on aQFR: lesions with aQFR ≤ 0.75 should be treated, lesions with aQFR ≥ 0.92 do not yield any hemodynamic relevance, and lesions in the "grey zone" (aQFR 0.75-0.92) benefit from further ischemia testings. This model would allow to reduce staged ischemia tests by 46.8% without a relevant loss in diagnostic efficiency. CONCLUSION Our data demonstrate that aQFR allows an effective assessment of hemodynamic relevance of non-culprit lesions in AMI and may guide interventions of non-culprit coronary lesions.
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Affiliation(s)
- Andrea Milzi
- Department of Cardiology, University Hospital, RWTH Aachen University, Aachen, Germany.
- Department of Internal Medicine I, University Hospital of the RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Germany.
| | - Rosalia Dettori
- Department of Cardiology, University Hospital, RWTH Aachen University, Aachen, Germany
| | - Nikolaus Marx
- Department of Cardiology, University Hospital, RWTH Aachen University, Aachen, Germany
| | - Sebastian Reith
- Department of Cardiology, University Hospital, RWTH Aachen University, Aachen, Germany
| | - Mathias Burgmaier
- Department of Cardiology, University Hospital, RWTH Aachen University, Aachen, Germany
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Zimbardo G, Cialdella P, DI Giusto F, Migliaro S, Anastasia G, Petrolati E, Galante D, D'Amario D, Leone AM. Physiological assessment after percutaneous coronary intervention: the hard truth. Panminerva Med 2021; 63:519-528. [PMID: 34486363 DOI: 10.23736/s0031-0808.21.04363-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Physiologically guided revascularization, using Fractional Flow Reserve (FFR) or instantaneous wave free ratio (iFR) has been demonstrated to be associated with better long-term outcomes compared to an angiographically-guided strategy, mainly avoiding inappropriate coronary stenting and its associated adverse events. On the contrary, the role of invasive physiological assessment after percutaneous coronary intervention (PCI) is much less well established. However, a large body of evidence suggests that a relevant proportion of patients undergoing PCI with a satisfying angiographic result show instead a suboptimal functional product with a potentially negative prognostic impact. For this reason, many efforts have been focused to identify interventional strategies to physiologically optimize PCI. Measuring the functional result after as PCI, especially when performed after a physiological assessment, implies that the operator is ready to accept the hard truth of an unsatisfactory physiological result despite angiographically optimal and, consequently, to optimize the product with some additional effort. The aim of this review is to bridge this gap in knowledge by better defining the paradigm shift of invasive physiological assessment from a simple tool for deciding whether an epicardial stenosis has to be treated to a thoroughly physiological approach to PCI with the suggestion of a practical flow chart.
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Affiliation(s)
| | | | - Federico DI Giusto
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Stefano Migliaro
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Gianluca Anastasia
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Edoardo Petrolati
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Domenico Galante
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Domenico D'Amario
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Antonio M Leone
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy -
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Verdoia M, Nardin M, Viola O, Brancati MF, Soldà PL, Marcolongo M, De Luca G. Impact of sex on the functional assessment of intermediate coronary lesions by instantaneous wave-free ratio. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2021; 37:105-109. [PMID: 34275742 DOI: 10.1016/j.carrev.2021.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/02/2021] [Accepted: 07/06/2021] [Indexed: 11/03/2022]
Abstract
Sex differences in coronary physiology and in the pathogenesis of coronary artery disease (CAD) have been previously described. Contrasting data have been reported, so far, about the impact of sex on the assessment of the functional significance of intermediate coronary stenoses by fractional flow reserve (FFR) or instantaneous wave-free ratio (iFR). The present study aimed at assessing the sex differences in the results of iFR in a cohort of patients undergoing coronary angiography. METHODS We included patients undergoing coronary angiography and the functional assessment of intermediate (40 to 70%) coronary lesions in 2 centers. iFR measurement was performed by pressure-recording guidewire and automatically calculated at the core laboratory using the manufacturers' dedicated software. Quantitative parameters of the coronary lesions were calculated by an automatic edge-detection system. Minimal luminal diameter (MLD), reference diameter (RD), percent diameter stenosis, and length of the lesion were measured. Positive iFR was considered for values < 0.90. RESULTS We included 325 patients undergoing coronary angiography and iFR evaluation of 371 intermediate coronary stenoses, including 20.6% of women. Females were older, displayed lower body weight and hemoglobin, lower rate of active smoking (p < 0.001) and previous PCI (p = 0.04), lower platelet count (p = 0.001) and creatinine (p = 0.02). Systolic blood pressure and heart rate at admission were more elevated in women (p = 0.001 and p = 0.05, respectively). At angiography, multivessel coronary artery disease was more uncommon (p = 0.001) and proximal lesions were more frequently assessed by iFR (p = 0.04). Mean values of iFR did not differ with sex and neither the percentage of positive iFR (19.1% vs 18.8%, p = 0.99, adjusted OR[95%CI] = 0.51[0.18-1.48], p = 0.22). CONCLUSION Among patients undergoing functional assessment of intermediate coronary lesions by instantaneous wave-free ratio, no impact of sex was observed on the absolute values or the rate of positivity of iFR.
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Affiliation(s)
- Monica Verdoia
- Division of Cardiology Ospedale degli Infermi, ASL Biella, Italy.
| | - Matteo Nardin
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy
| | - Orazio Viola
- Division of Cardiology Ospedale degli Infermi, ASL Biella, Italy
| | | | - Pier Luigi Soldà
- Division of Cardiology Ospedale degli Infermi, ASL Biella, Italy
| | - Marco Marcolongo
- Division of Cardiology Ospedale degli Infermi, ASL Biella, Italy
| | - Giuseppe De Luca
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy
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Paradies V, Waldeyer C, Laforgia PL, Clemmensen P, Smits PC. Completeness of revascularisation in acute coronary syndrome patients with multivessel disease. EUROINTERVENTION 2021; 17:193-201. [PMID: 34167938 PMCID: PMC9725070 DOI: 10.4244/eij-d-20-00957] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/04/2021] [Indexed: 11/23/2022]
Abstract
A significant proportion of patients presenting with acute coronary syndromes (ACS) have multivessel disease (MVD). Despite the abundance of clinical trials in this area, several questions regarding the procedure of complete coronary revascularisation remain unanswered. This state-of-the-art review summarises the latest evidence on complete revascularisation (CR) in this subset of patients and critically appraises clinical decision making based on non-culprit lesion (NCL) assessment. Future areas of research are put into perspective.
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Affiliation(s)
- Valeria Paradies
- Department of Cardiology, Maasstad Hospital, Rotterdam, the Netherlands
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59
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McInerney A, Travieso Gonzalez A, Castro Mejía A, Tirado-Conte G, Mejía-Rentería H, Cerrato E, Nombela-Franco L, Jiménez-Quevedo P, Salinas P, Macaya Ten F, Núñez Gil I, Fernandez Ortiz A, Macaya C, Escaned J, Gonzalo N. Long-term outcomes after deferral of revascularization of in-stent restenosis using fractional flow reserve. Catheter Cardiovasc Interv 2021; 99:723-729. [PMID: 34156742 DOI: 10.1002/ccd.29823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 05/16/2021] [Accepted: 06/05/2021] [Indexed: 11/08/2022]
Abstract
OBJECTIVES To investigate the outcomes of deferred coronary revascularization in patients with non-significant in-stent restenosis (ISR) by physiological assessment. BACKGROUND The pathophysiology and natural history of ISR is markedly different from de-novo stenoses. There is a paucity of data on the safety of deferral of revascularization of ISR using physiological assessment. METHODS In this single centre study, using a propensity-score matched analysis, we compared the long-term clinical outcomes of patients with ISR and de-novo disease deferred based on intracoronary physiology. Matching was on a 1:2 basis of ISR to de-novo stenosis. The primary end point was major adverse cardiovascular events (MACE) a composite of all-cause mortality, target lesion revascularization or target vessel myocardial infarction at 36 months. RESULTS Matched cohorts of 56 ISR and 112 de-novo stenoses were analyzed. The median percentage stenosis was 50% in both groups (p = 0.403). Deferral was based on fractional flow reserve (FFR). The mean FFR was 0.86 across both groups (p = 0.942). At 36-months, freedom from MACE was similar between groups; 86.2% versus 92.8% log rank p=0.180 for ISR and de-novo lesions, respectively. Neither were there differences in the individual components of MACE. CONCLUSIONS Deferral of coronary revascularization in patients with ISR based on its functional impact is associated to similar long-term safety as in de-novo coronary stenosis.
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Affiliation(s)
- Angela McInerney
- Hospital Clínico San Carlos IDISSC, Complutense University of Madrid, Madrid, Spain
| | | | - Alex Castro Mejía
- Hospital Clínico San Carlos IDISSC, Complutense University of Madrid, Madrid, Spain
| | | | | | - Enrico Cerrato
- Hospital Clínico San Carlos IDISSC, Complutense University of Madrid, Madrid, Spain.,San Luigi Gonzaga University Hospital, Orbassano and Rivoli Infermi Hospital, Rivoli (Turin), Italy
| | - Luis Nombela-Franco
- Hospital Clínico San Carlos IDISSC, Complutense University of Madrid, Madrid, Spain
| | | | - Pablo Salinas
- Hospital Clínico San Carlos IDISSC, Complutense University of Madrid, Madrid, Spain
| | - Fernando Macaya Ten
- Hospital Clínico San Carlos IDISSC, Complutense University of Madrid, Madrid, Spain
| | - Ivan Núñez Gil
- Hospital Clínico San Carlos IDISSC, Complutense University of Madrid, Madrid, Spain
| | | | - Carlos Macaya
- Hospital Clínico San Carlos IDISSC, Complutense University of Madrid, Madrid, Spain
| | - Javier Escaned
- Hospital Clínico San Carlos IDISSC, Complutense University of Madrid, Madrid, Spain
| | - Nieves Gonzalo
- Hospital Clínico San Carlos IDISSC, Complutense University of Madrid, Madrid, Spain
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Taglieri N, Ghetti G, Bruno AG, Marco V, Reggiani MLB, Bonfiglioli R, Massarelli G, Gatto L, Bruno M, Paoletti G, Fanti S, Saia F, Prati F, Galiè N. Optical coherence tomography assessment of macrophages accumulation in non-ST-segment elevation acute coronary syndromes. J Cardiovasc Med (Hagerstown) 2021; 21:860-865. [PMID: 33017123 DOI: 10.2459/jcm.0000000000001015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS To investigate in patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS) the prevalence and the features of optical coherence tomography (OCT)-detected macrophages accumulation in culprit plaques as compared with nonculprit plaques (NCP). METHODS The study is a post-hoc analysis of a prospective study aimed at evaluating the relationship between aortic inflammation as assessed by F-fluorodeoxyglucose-PET and features of coronary plaque vulnerability as assessed by OCT. We enrolled 32 patients with first NSTE-ACS who successfully underwent three-vessel OCT. RESULTS The median age was 65 (54-72) years and 27 patients (84%) were men. Culprit plaques were clinically defined. Overall, the rate of lipid plaques and lipid plaques containing macrophages were 6.4 and 4.2 per patient, respectively. Culprit plaques had a smaller minimal luminal area, a higher extension of lipid component and a thinner fibrous cap than NCPs. Macrophages accumulations were more likely found in culprit plaque (84 vs. 61%, P = 0.015) in which they had also a higher circumferential extension. On univariable analysis, macrophages accumulation extension had a higher association with culprit plaques (odds ratio = 4.42; 95% confidence interval; 2.54-9.15, P < 0.001) than the mere presence of macrophages accumulation (odds ratio = 3.36; 95% confidence interval; 1.30-8.66, P = 0.012). Culprit plaques with thrombus had a lower distance between macrophages accumulation and the luminal surface than culprit plaque with no thrombus (0.06 vs. 0.1 mm; P = 0.04). CONCLUSION In patients with NSTE-ACS, macrophages accumulations are more likely present in culprit plaque in which they disclose also a greater extension compared with those observed in NCP. The distance between macrophages accumulation and the luminal surface is lower in thrombotic culprit plaque than that in nonthrombotic culprit plaque.
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Affiliation(s)
- Nevio Taglieri
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Alma Mater Studiorum Università di Bologna, Bologna
| | - Gabriele Ghetti
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Alma Mater Studiorum Università di Bologna, Bologna
| | - Antonio G Bruno
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Alma Mater Studiorum Università di Bologna, Bologna
| | | | - Maria L Bacchi Reggiani
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Alma Mater Studiorum Università di Bologna, Bologna
| | - Rachele Bonfiglioli
- Dipartimento di Medicina Specialistica, Istituto di Medicina Nucleare, Diagnostica e Sperimentale, Alma Mater Studiorum Università di Bologna, Bologna
| | - Giulia Massarelli
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Alma Mater Studiorum Università di Bologna, Bologna
| | - Laura Gatto
- CLI Foundation, Rome.,Dipartimento di Scienze Cardiovascolari, Ospedale San Giovanni Addolorata Roma, Roma
| | - Matteo Bruno
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Alma Mater Studiorum Università di Bologna, Bologna
| | | | - Stefano Fanti
- Dipartimento di Medicina Specialistica, Istituto di Medicina Nucleare, Diagnostica e Sperimentale, Alma Mater Studiorum Università di Bologna, Bologna
| | - Francesco Saia
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Alma Mater Studiorum Università di Bologna, Bologna
| | - Francesco Prati
- CLI Foundation, Rome.,UniCamillus-International Medical University, Rome Italy
| | - Nazzareno Galiè
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Alma Mater Studiorum Università di Bologna, Bologna
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61
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Collet JP, Thiele H, Barbato E, Barthélémy O, Bauersachs J, Bhatt DL, Dendale P, Dorobantu M, Edvardsen T, Folliguet T, Gale CP, Gilard M, Jobs A, Jüni P, Lambrinou E, Lewis BS, Mehilli J, Meliga E, Merkely B, Mueller C, Roffi M, Rutten FH, Sibbing D, Siontis GC. Guía ESC 2020 sobre el diagnóstico y tratamiento del síndrome coronario agudo sin elevación del segmento ST. Rev Esp Cardiol (Engl Ed) 2021. [DOI: 10.1016/j.recesp.2020.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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62
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Collet JP, Thiele H, Barbato E, Barthélémy O, Bauersachs J, Bhatt DL, Dendale P, Dorobantu M, Edvardsen T, Folliguet T, Gale CP, Gilard M, Jobs A, Jüni P, Lambrinou E, Lewis BS, Mehilli J, Meliga E, Merkely B, Mueller C, Roffi M, Rutten FH, Sibbing D, Siontis GCM. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J 2021; 42:1289-1367. [PMID: 32860058 DOI: 10.1093/eurheartj/ehaa575] [Citation(s) in RCA: 2739] [Impact Index Per Article: 913.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Al-Lamee R, Rajkumar CA, Ganesananthan S, Jeremias A. Optimising physiological endpoints of percutaneous coronary intervention. EUROINTERVENTION 2021; 16:e1470-e1483. [PMID: 33792544 PMCID: PMC9753914 DOI: 10.4244/eij-d-20-00988] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Invasive coronary physiology to select patients for coronary revascularisation has become established in contemporary guidelines for the management of stable coronary artery disease. Compared to revascularisation based on angiography alone, the use of coronary physiology has been shown to improve clinical outcomes and cost efficiency. However, recent data from randomised controlled trials have cast doubt upon the value of ischaemia testing to select patients for revascularisation. Importantly, 20-40% of patients have persistence or recurrence of angina after angiographically successful percutaneous coronary intervention (PCI). This state-of-the-art review is focused on the transitioning role of invasive coronary physiology from its use as a dichotomous test for ischaemia with fixed cut-points, towards its utility for real-time guidance of PCI to optimise physiological results. We summarise the contemporary evidence base for ischaemia testing in stable coronary artery disease, examine emerging indices which allow advanced physiological guidance of PCI, and discuss the rationale and evidence base for post-PCI physiological assessments to assess the success of revascularisation.
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Affiliation(s)
- Rasha Al-Lamee
- National Heart and Lung Institute, Imperial College London, 2nd Floor, B Block, Hammersmith Hospital, Du Cane Road, London, W12 0HS, United Kingdom
| | - Christopher A. Rajkumar
- National Heart and Lung Institute, Imperial College London, London, United Kingdom,Imperial College Healthcare NHS Trust, London, United Kingdom
| | | | - Allen Jeremias
- Department of Cardiology, St. Francis Hospital, The Heart Center, Roslyn, NY, USA
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64
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Andò G, D'Ascenzo F. Instantaneous wave-free ratio during primary percutaneous coronary intervention: life is simple, and the simple thing is the right thing. Minerva Cardiol Angiol 2021; 69:288-290. [PMID: 33703867 DOI: 10.23736/s2724-5683.21.05628-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Giuseppe Andò
- Section of Cardiology, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy -
| | - Fabrizio D'Ascenzo
- Division of Cardiology, Department of Medical Sciences, University of Turin, Turin, Italy
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65
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Verdoia M, Gioscia R, Nardin M, Viola O, Brancati MF, Soldà PL, Marcolongo M, De Luca G. Preprocedural β-Blockers in the Functional Assessment of Intermediate Coronary Lesions by Instantaneous Wave-Free Ratio. Angiology 2021; 72:687-692. [PMID: 33626884 DOI: 10.1177/0003319721996170] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
AIM Instantaneous wave-free ratio (iFR) has emerged as the strategy of choice for the assessment of intermediate coronary lesions. The impact of preprocedural β-blockers therapy on the iFR was the aim of this study. METHODS We included patients undergoing functional assessment of intermediate (40%-70%) coronary lesions in 2 centers. The iFR measurement was performed by pressure-recording guidewire and calculated at the core laboratory using the manufacturers' dedicated software. Minimal luminal diameter, reference diameter, percent diameter stenosis, and length of the lesion were measured. Positive iFR was considered for values <0.90. RESULTS We included 197 patients undergoing functional evaluation of 223 coronary lesions. Patients on β-blockers (69%) had more frequently hypertension (P = .05); previous myocardial infarction (P = .01); therapy with clopidogrel (P = .02), statins, and aspirin; and acute coronary syndrome at presentation (P < .001, respectively). Mean iFR values were slightly higher in patients on β-blockers (0.94 ± 0.06 vs 0.92 ± 0.06, P = .11). The rate of positive iFR was significantly lower with β-blockers (14.9% vs 27.5%, P = .04). On multivariate analysis, β-blockers use was a predictor of the significance of coronary stenoses (odds ratio [OR] = 0.48; 95% CI = 0.23-0.98; P = .05) together with lesion length (OR = 1.04; 95% CI = 1.01-1.07; P = .007). CONCLUSION Among patients undergoing iFR, preprocedural β-blockers are associated with higher absolute values and a lower rate of positive iFR.
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Affiliation(s)
- Monica Verdoia
- Division of Cardiology, Ospedale degli Infermi, ASL Biella, Italy.,Eastern Piedmont University, Novara Italy
| | - Rocco Gioscia
- Department of Cardiology Azienda Ospedaliero-Universitaria "Maggiore della Carità", Novara, Italy
| | - Matteo Nardin
- Department of Cardiology Azienda Ospedaliero-Universitaria "Maggiore della Carità", Novara, Italy
| | - Orazio Viola
- Division of Cardiology, Ospedale degli Infermi, ASL Biella, Italy
| | | | - Pier Luigi Soldà
- Division of Cardiology, Ospedale degli Infermi, ASL Biella, Italy
| | - Marco Marcolongo
- Division of Cardiology, Ospedale degli Infermi, ASL Biella, Italy
| | - Giuseppe De Luca
- Eastern Piedmont University, Novara Italy.,Department of Cardiology Azienda Ospedaliero-Universitaria "Maggiore della Carità", Novara, Italy
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66
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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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67
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Beijnink CWH, Thim T, van der Heijden DJ, Klem I, Al-Lamee R, Vos JL, Koop Y, Dijkgraaf MGW, Beijk MAM, Kim RJ, Davies J, Raposo L, Baptista SB, Escaned J, Piek JJ, Maeng M, van Royen N, Nijveldt R. Instantaneous wave-free ratio guided multivessel revascularisation during percutaneous coronary intervention for acute myocardial infarction: study protocol of the randomised controlled iMODERN trial. BMJ Open 2021; 11:e044035. [PMID: 33452200 PMCID: PMC7813313 DOI: 10.1136/bmjopen-2020-044035] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION Recent randomised clinical trials showed benefit of non-culprit lesion revascularisation in ST-elevation myocardial infarction (STEMI) patients. However, it remains unclear whether revascularisation should be performed at the index procedure or at a later stage. METHODS AND ANALYSIS The instantaneous wave-free ratio (iFR) Guided Multivessel Revascularisation During Percutaneous Coronary Intervention for Acute Myocardial Infarction trial is a multicentre, randomised controlled prospective open-label trial with blinded evaluation of endpoints. After successful primary percutaneous coronary intervention (PCI), eligible STEMI patients with residual non-culprit lesions are randomised, to instantaneous wave-free ratio guided treatment of non-culprit lesions during the index procedure versus deferred cardiac MR-guided management within 4 days to 6 weeks. The primary endpoint of the study is the combined occurrence of all-cause death, recurrent myocardial infarction and hospitalisation for heart failure at 12 months follow-up. Clinical follow-up includes questionnaires at 3 months and outpatient visits at 6 months and 12 months after primary PCI. Furthermore, a cost-effectiveness analysis will be performed. ETHICS AND DISSEMINATION Permission to conduct this trial has been granted by the Medical Ethical Committee of the Amsterdam University Medical Centres (loc. VUmc, ID NL60107.029.16). The primary results of this trial will be shared in a main article and subgroup analyses or spin-off studies will be shared in secondary papers. TRIAL REGISTRATION NUMBER NCT03298659.
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Affiliation(s)
| | - Troels Thim
- Department of Cardiology, Aarhus University Hospital, Aarhus N, Denmark
| | | | - Igor Klem
- Cardiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Rasha Al-Lamee
- Cardiology, Imperial College London Faculty of Medicine, London, UK
| | | | - Yvonne Koop
- Cardiology, Radboudumc, Nijmegen, The Netherlands
| | - Marcel G W Dijkgraaf
- Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam UMC - Locatie AMC, Amsterdam, The Netherlands
| | - Marcel A M Beijk
- Cardiology, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | - Raymond J Kim
- Cardiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Justin Davies
- Faculty of Medicine, Imperial College London, London, UK
| | - Luis Raposo
- Cardiology, Centro Hospitalar de Lisboa Ocidental EPE, Lisboa, Portugal
| | | | - Javier Escaned
- Interventional Cardiology, Hospital Clínico Universitario San Carlos, Madrid, Spain
| | - Jan J Piek
- Cardiology, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | - Michael Maeng
- Department of Cardiology, Aarhus University Hospital, Aarhus N, Denmark
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68
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Al‐Nooryani A, Aboushokka W, Mehmedbegovic Z, Beleslin B. A case of mild-to-intermediate left-main lesion with high-risk plaque features: "Blindness of physiology" for PCI guidance? Clin Case Rep 2020; 8:2813-2817. [PMID: 33363828 PMCID: PMC7752358 DOI: 10.1002/ccr3.3197] [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: 05/31/2020] [Revised: 06/28/2020] [Accepted: 07/05/2020] [Indexed: 11/09/2022] Open
Abstract
In patients presenting with acute coronary syndrome without ST elevation, both FFR and OCT imaging may be necessary to adequately interrogate patients with intermediate and ambiguous left-main coronary stenosis.
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Affiliation(s)
| | | | - Zlatko Mehmedbegovic
- Clinic for CardiologyClinical Center of SerbiaBelgradeSerbia
- Medical FacultyUniversity of BelgradeBelgradeSerbia
| | - Branko Beleslin
- Clinic for CardiologyClinical Center of SerbiaBelgradeSerbia
- Medical FacultyUniversity of BelgradeBelgradeSerbia
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69
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Montone RA, Meucci MC, Niccoli G. The management of non-culprit coronary lesions in patients with acute coronary syndrome. Eur Heart J Suppl 2020; 22:L170-L175. [PMID: 33239995 PMCID: PMC7673623 DOI: 10.1093/eurheartj/suaa175] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
About 50% of patients diagnosed with ST-segment elevation myocardial infarction have multivessel disease on coronary angiography. Recent evidence has shown that a staged percutaneous coronary intervention (PCI) strategy of non-culprit lesions, achieving complete revascularization, significantly reduces the rate of recurrent cardiovascular events compared with a PCI strategy limited to culprit lesion. Although functional evaluation of intermediate coronary stenoses by functional flow reserve (FFR) or instantaneous wave-free ratio (iFR) is widely used to detect residual myocardial ischaemia, the reliability of the study of non-culprit lesions in the acute phase of heart attack is controversial. On the other hand, the excess of new events in patients with acute coronary syndrome in whom PCI was deferred on the basis of FFR/iFR compared to patients with stable CAD could be due to both an inadequate functional evaluation and an intrinsic higher risk, related to the presence of untreated vulnerable plaques. In this context, intra-coronary imaging has shown that the presence of vulnerability features in non-culprit plaques is associated with an increased rate of ischaemic recurrence.
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Affiliation(s)
- Rocco A Montone
- Istituto di Cardiologia, Università Cattolica del Sacro Cuore, Roma
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70
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Di Mario C, Demola P. Morphology and physiology together: Is optical coherence tomography the one-stop-shop of invasive cardiology? Cardiol J 2020; 27:345-346. [PMID: 32929703 DOI: 10.5603/cj.2020.0111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 07/02/2020] [Indexed: 01/10/2023] Open
Affiliation(s)
- Carlo Di Mario
- Structural Interventional Cardiology, Careggi University Hospital, Florence, Italy.
| | - Pierluigi Demola
- Structural Interventional Cardiology, Careggi University Hospital, Florence, Italy
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71
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Michail M, Thakur U, Mehta O, Ramzy JM, Comella A, Ihdayhid AR, Cameron JD, Nicholls SJ, Hoole SP, Brown AJ. Non-hyperaemic pressure ratios to guide percutaneous coronary intervention. Open Heart 2020; 7:e001308. [PMID: 33004619 PMCID: PMC7534727 DOI: 10.1136/openhrt-2020-001308] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 07/03/2020] [Accepted: 08/07/2020] [Indexed: 01/10/2023] Open
Abstract
The use of fractional flow reserve (FFR) in guiding revascularisation improves patient outcomes and has been well-established in clinical guidelines. Despite this, the uptake of FFR has been limited, likely attributable to the perceived increase in procedural time and use of hyperaemic agents that can cause patient discomfort. This has led to the development of instantaneous wave-free ratio (iFR), an alternative non-hyperaemic pressure ratio (NHPR). Since its inception, the use of iFR has been supported by an increasing body of evidence and is now guideline recommended. More recently, other commercially available NHPRs including diastolic hyperaemia-free ratio and resting full-cycle ratio have emerged. Studies have demonstrated that these indices, in addition to mean distal coronary artery pressure to mean aortic pressure ratio, are mathematically analogous (with specific nuances) to iFR. Additionally, there is increasing data demonstrating the equivalent diagnostic performance of alternative NHPRs in comparison with iFR and FFR. These NHPRs are now integral within most current pressure wire systems and are commonly available in the catheter laboratory. It is therefore key to understand the fundamental differences and evidence for NHPRs to guide appropriate clinical decision-making.
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Affiliation(s)
- Michael Michail
- Monash Cardiovascular Research Centre and MonashHeart, Monash University and Monash Health, Melbourne, Victoria, Australia
- Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Udit Thakur
- Monash Cardiovascular Research Centre and MonashHeart, Monash University and Monash Health, Melbourne, Victoria, Australia
| | - Ojas Mehta
- Monash Cardiovascular Research Centre and MonashHeart, Monash University and Monash Health, Melbourne, Victoria, Australia
| | - John M Ramzy
- Monash Cardiovascular Research Centre and MonashHeart, Monash University and Monash Health, Melbourne, Victoria, Australia
| | - Andrea Comella
- Monash Cardiovascular Research Centre and MonashHeart, Monash University and Monash Health, Melbourne, Victoria, Australia
| | - Abdul Rahman Ihdayhid
- Monash Cardiovascular Research Centre and MonashHeart, Monash University and Monash Health, Melbourne, Victoria, Australia
| | - James D Cameron
- Monash Cardiovascular Research Centre and MonashHeart, Monash University and Monash Health, Melbourne, Victoria, Australia
| | - Stephen J Nicholls
- Monash Cardiovascular Research Centre and MonashHeart, Monash University and Monash Health, Melbourne, Victoria, Australia
| | - Stephen P Hoole
- Department of Interventional Cardiology, Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Adam J Brown
- Monash Cardiovascular Research Centre and MonashHeart, Monash University and Monash Health, Melbourne, Victoria, Australia
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72
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Kim CH, Koo BK, Dehbi HM, Lee JM, Doh JH, Nam CW, Shin ES, Cook CM, Al-Lamee R, Petraco R, Sen S, Malik IS, Nijjer SS, Mejía-Rentería H, Alegria-Barrero E, Alghamdi A, Altman J, Baptista SB, Bhindi R, Bojara W, Brugaletta S, Silva PC, Di Mario C, Erglis A, Gerber RT, Going O, Härle T, Hellig F, Indolfi C, Janssens L, Jeremias A, Kharbanda RK, Khashaba A, Kikuta Y, Krackhardt F, Laine M, Lehman SJ, Matsuo H, Meuwissen M, Niccoli G, Piek JJ, Ribichini F, Samady H, Sapontis J, Seto AH, Sezer M, Sharp ASP, Singh J, Takashima H, Talwar S, Tanaka N, Tang K, Van Belle E, van Royen N, Vinhas H, Vrints CJ, Walters D, Yokoi H, Samuels B, Buller C, Patel MR, Serruys PW, Escaned J, Davies JE. Sex Differences in Instantaneous Wave-Free Ratio or Fractional Flow Reserve-Guided Revascularization Strategy. JACC Cardiovasc Interv 2020; 12:2035-2046. [PMID: 31648764 DOI: 10.1016/j.jcin.2019.06.035] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 06/04/2019] [Accepted: 06/11/2019] [Indexed: 01/10/2023]
Abstract
OBJECTIVES This study sought to evaluate sex differences in procedural characteristics and clinical outcomes of instantaneous wave-free ratio (iFR)- and fractional flow reserve (FFR)-guided revascularization strategies. BACKGROUND An iFR-guided strategy has shown a lower revascularization rate than an FFR-guided strategy, without differences in clinical outcomes. METHODS This is a post hoc analysis of the DEFINE-FLAIR (Functional Lesion Assessment of Intermediate stenosis to guide Revascularization) study, in which 601 women and 1,891 men were randomized to iFR- or FFR-guided strategy. The primary endpoint was 1-year major adverse cardiac events (MACE), a composite of all-cause death, nonfatal myocardial infarction, or unplanned revascularization. RESULTS Among the entire population, women had a lower number of functionally significant lesions per patient (0.31 ± 0.51 vs. 0.43 ± 0.59; p < 0.001) and less frequently underwent revascularization than men (42.1% vs. 53.1%; p < 0.001). There was no difference in mean iFR value according to sex (0.91 ± 0.09 vs. 0.91 ± 0.10; p = 0.442). However, the mean FFR value was lower in men than in women (0.83 ± 0.09 vs. 0.85 ± 0.10; p = 0.001). In men, an FFR-guided strategy was associated with a higher rate of revascularization than an iFR-guided strategy (57.1% vs. 49.3%; p = 0.001), but this difference was not observed in women (41.4% vs. 42.6%; p = 0.757). There was no difference in MACE rates between iFR- and FFR-guided strategies in both women (5.4% vs. 5.6%, adjusted hazard ratio: 1.10; 95% confidence interval: 0.50 to 2.43; p = 0.805) and men (6.6% vs. 7.0%, adjusted hazard ratio: 0.98; 95% confidence interval: 0.66 to 1.46; p = 0.919). CONCLUSIONS An FFR-guided strategy was associated with a higher rate of revascularization than iFR-guided strategy in men, but not in women. However, iFR- and FFR-guided strategies showed comparable clinical outcomes, regardless of sex. (Functional Lesion Assessment of Intermediate Stenosis to guide Revascularization [DEFINE-FLAIR]; NCT02053038).
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Affiliation(s)
- Chee Hae Kim
- Division of Cardiology, Department of Internal Medicine, VHS Medical Center, Seoul, South Korea
| | - Bon-Kwon Koo
- Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul National University, Seoul, South Korea; Institute on Aging, Seoul National University, Seoul, South Korea.
| | - Hakim-Moulay Dehbi
- Cancer Research UK and University College London Cancer Trials Centre, University College London, London, United Kingdom
| | - Joo Myung Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Joon-Hyung Doh
- Department of Medicine, Inje University Ilsan Paik Hospital, Daehwa-dong, South Korea
| | - Chang-Wook Nam
- Department of Medicine, Keimyung University Dongsan Medical Center, Daegu, South Korea
| | - Eun-Seok Shin
- Division of Cardiology, Department of Internal Medicine, Ulsan Medical Center, Ulsan Hospital, Ulsan, South Korea
| | | | - Rasha Al-Lamee
- Hammersmith Hospital, Imperial College London, London, United Kingdom
| | - Ricardo Petraco
- Hammersmith Hospital, Imperial College London, London, United Kingdom
| | - Sayan Sen
- Hammersmith Hospital, Imperial College London, London, United Kingdom
| | - Iqbal S Malik
- Hammersmith Hospital, Imperial College London, London, United Kingdom
| | | | - Hernán Mejía-Rentería
- Hospital Clínico San Carlos, Instituto de Investigación Sanitaria San Carlos, Universidad Complutense de Madrid, Madrid, Spain
| | | | - Ali Alghamdi
- King Abdulaziz Medical City Cardiac Center, Riyadh, Saudi Arabia
| | - John Altman
- Colorado Heart and Vascular, Lakewood, Colorado
| | | | | | - Waldemar Bojara
- Gemeinschaftsklinikum Mittelrhein, Kemperhof Koblenz, Koblenz, Germany
| | - Salvatore Brugaletta
- Cardiovascular Institute, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | | | - Carlo Di Mario
- Royal Brompton Hospital, Imperial College London, London, United Kingdom; University of Florence, Florence, Italy
| | - Andrejs Erglis
- Pauls Stradins Clinical University Hospital, Riga, Latvia
| | | | - Olaf Going
- Sana Klinikum Lichtenberg, Lichtenberg, Germany
| | - Tobias Härle
- Klinikum Oldenburg, European Medical School, Carl von Ossietzky University, Oldenburg, Germany
| | | | | | | | - Allen Jeremias
- Stony Brook University Medical Center, New York, New York
| | - Rajesh K Kharbanda
- John Radcliffe Hospital, Oxford University Hospitals Foundation Trust, Oxford, United Kingdom
| | | | | | | | - Mika Laine
- Helsinki University Hospital, Helsinki, Finland
| | | | | | | | | | - Jan J Piek
- AMC Heart Center, Academic Medical Center, Amsterdam, the Netherlands
| | | | | | | | - Arnold H Seto
- Veterans Affairs Long Beach Healthcare System, Long Beach, California
| | - Murat Sezer
- Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Andrew S P Sharp
- Royal Devon and Exeter Hospital, University of Exeter, Exeter, United Kingdom
| | - Jasvindar Singh
- Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | | | - Suneel Talwar
- Royal Bournemouth General Hospital, Bournemouth, United Kingdom
| | | | - Kare Tang
- Essex Cardiothoracic Centre, Basildon, United Kingdom; Anglia Ruskin University, Chelmsford, United Kingdom
| | - Eric Van Belle
- Institut Coeur Poumon, Lille University Hospital, Lille, France; UMR INSERM 1011, Centre Hospitalier Universitaire de Lille et de Institut Pasteur de Lille, Université de Lille, Lille, France
| | | | | | | | | | | | - Bruce Samuels
- Cedars-Sinai Heart Institute, Los Angeles, California
| | | | | | - Patrick W Serruys
- Hammersmith Hospital, Imperial College London, London, United Kingdom
| | - Javier Escaned
- Hospital Clínico San Carlos, Instituto de Investigación Sanitaria San Carlos, Universidad Complutense de Madrid, Madrid, Spain
| | - Justin E Davies
- Hammersmith Hospital, Imperial College London, London, United Kingdom
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73
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Paul TK, Seto AH, White CJ. Nonhyperemic Pressure Ratios Versus Fractional Flow Reserve: What to Do With Discordant Results? J Am Heart Assoc 2020; 9:e018344. [PMID: 32914669 PMCID: PMC7726967 DOI: 10.1161/jaha.120.018344] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Timir K Paul
- Division of Cardiovascular Medicine East Tennessee State University Johnson City TN
| | | | - Christopher J White
- Department of Cardiovascular Diseases The Ochsner Clinical School University of Queensland, AU and the John Ochsner Heart & Vascular Institute Ochsner Medical Center New Orleans LA
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74
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Onishi K, Watanabe H, Kakehi K, Ikeda T, Takase T, Yamaji K, Ueno M, Kobuke K, Nakazawa G, Miyazaki S, Iwanaga Y. Determinants and prognostic implications of instantaneous wave-free ratio in patients with mild to intermediate coronary stenosis: Comparison with those of fractional flow reserve. PLoS One 2020; 15:e0237275. [PMID: 32760123 PMCID: PMC7410195 DOI: 10.1371/journal.pone.0237275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 07/22/2020] [Indexed: 01/10/2023] Open
Abstract
The instantaneous wave-free ratio (iFR) is used for assessing the hemodynamic severity of a lesion, as an alternative to the fractional flow reserve (FFR). We evaluated the relationship between iFR and FFR in detail and the clinical significance of iFR in patients with mild to intermediate coronary artery stenosis. We recruited consecutive 323 patients (421 lesions) with lesions exhibiting 30% to 80% diameter stenosis on angiography in whom FFR and iFR were measured. In the total lesions, mean diameter stenosis was 48.6% ± 9.0%, and physiological significance, defined by FFR of 0.80 or less or by iFR of 0.92 or less, was observed in 32.5% or 33.5%, respectively. Mismatch between iFR and FFR was observed in 18.1% of the lesions. Clinical factors did not predict FFR value; however, gender, diabetes mellitus, aortic stenosis, anemia, high-sensitivity CRP value, and renal function predicted iFR value. In multivariate logistic analysis after adjustment for FFR value, gender (p < 0.001), diabetes mellitus (p = 0.005), aortic stenosis (p = 0.016), high-sensitivity CRP (p < 0.001), and renal function (p = 0.003) were all independent predictors of iFR value. In Kaplan-Meier analysis, the baseline iFR predicted the subsequent major cardiovascular events (MACE) (hazard ratio, 2.40; 95% CI, 1.16–4.93; p = 0.018) and the results of the iFR-guided strategy for predicting rates of MACE and myocardial infarction/revascularization were superior to those of the FFR-guided strategy. In conclusion, significant clinical factors predicted iFR value, which affected the prognostic capacity. The iFR-guided strategy may be superior in patients with mild to intermediate stenosis.
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Affiliation(s)
- Kyohei Onishi
- Division of Cardiology, Department of Internal Medicine, Kindai University Faculty of Medicine, Osakasayama, Japan
| | - Heitaro Watanabe
- Division of Cardiology, Department of Internal Medicine, Kindai University Faculty of Medicine, Osakasayama, Japan
| | - Kazuyoshi Kakehi
- Division of Cardiology, Department of Internal Medicine, Kindai University Faculty of Medicine, Osakasayama, Japan
| | - Tomoyuki Ikeda
- Division of Cardiology, Department of Internal Medicine, Kindai University Faculty of Medicine, Osakasayama, Japan
| | - Toru Takase
- Division of Cardiology, Department of Internal Medicine, Kindai University Faculty of Medicine, Osakasayama, Japan
| | - Kenji Yamaji
- Division of Cardiology, Department of Internal Medicine, Kindai University Faculty of Medicine, Osakasayama, Japan
| | - Masafumi Ueno
- Division of Cardiology, Department of Internal Medicine, Kindai University Faculty of Medicine, Osakasayama, Japan
| | - Kazuhiro Kobuke
- Division of Cardiology, Department of Internal Medicine, Kindai University Faculty of Medicine, Osakasayama, Japan
| | - Gaku Nakazawa
- Division of Cardiology, Department of Internal Medicine, Kindai University Faculty of Medicine, Osakasayama, Japan
| | | | - Yoshitaka Iwanaga
- Division of Cardiology, Department of Internal Medicine, Kindai University Faculty of Medicine, Osakasayama, Japan
- * E-mail:
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75
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Mejía-Rentería H, Lee JM, van der Hoeven NW, Gonzalo N, Jiménez-Quevedo P, Nombela-Franco L, Núñez-Gil IJ, Salinas P, Del Trigo M, Cerrato E, van Royen N, Knaapen P, Koo BK, Macaya C, Fernández-Ortiz A, Escaned J. Coronary Microcirculation Downstream Non-Infarct-Related Arteries in the Subacute Phase of Myocardial Infarction: Implications for Physiology-Guided Revascularization. J Am Heart Assoc 2020; 8:e011534. [PMID: 31014181 PMCID: PMC6512122 DOI: 10.1161/jaha.118.011534] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background Concerns exist about reliability of pressure‐wire‐guided coronary revascularization of non‐infarct‐related arteries (non‐IRA). We investigated whether physiological assessment of non‐IRA during the subacute phase of myocardial infarction might be flawed by microcirculatory dysfunction. Methods and Results We analyzed non‐IRA that underwent fractional flow reserve, coronary flow reserve, and the index of microcirculatory resistance assessment. Microcirculation and hyperemic response were evaluated in 49 acute myocardial infarction patients (59 non‐IRA) and compared with a matched control group of 46 stable angina (SA) patients (59 vessels). Time between acute myocardial infarction to physiological interrogation was 5.9±2.4 days. Fractional flow reserve was similar in both groups (0.79±0.11 in non‐IRA versus 0.80±0.13 in SA vessels, P=0.527). Lower coronary flow reserve values were found in non‐IRA compared with SA vessels (1.77 [1.25–2.76] versus 2.44 [1.63–4.00], P=0.018), primarily driven by an increased baseline flow in non‐IRA (rest mean transit time 0.58 [0.32–0.83] versus 0.65 s [0.39–1.20], P=0.045), whereas the hyperemic flow was similar (hyperemic mean transit time 0.26 [0.20–0.42] versus 0.26 s [0.18–0.35], P=0.873). No differences were found regarding index of microcirculatory resistance (15.6 [10.4–21.8] in non‐IRA versus 16.7 [11.6–23.6] U in SA vessels, P=0.559). During adenosine infusion, the hyperemic response was similar in both groups (non‐IRA versus SA vessels) in terms of the resistive reserve ratio (3.1±2.1 versus 3.7±2.2, P=0.118). Conclusions In the subacute phase of myocardial infarction, non‐IRA show an increased baseline flow that may cause abnormal coronary flow reserve despite preserved hyperemic flow. In non‐IRA, microcirculatory resistance and adenosine‐induced hyperemic response are similar to those found in SA patients. From a physiological perspective, these findings support the use of fractional flow reserve to interrogate non‐IRA during the subacute phase of myocardial infarction. See Editorial Koh and Samady
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Affiliation(s)
- Hernán Mejía-Rentería
- 1 Hospital Clínico San Carlos IDISSC and Universidad Complutense de Madrid Madrid Spain
| | - Joo Myung Lee
- 2 Division of Cardiology Department of Internal Medicine Heart Vascular Stroke Institute Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Korea
| | | | - Nieves Gonzalo
- 1 Hospital Clínico San Carlos IDISSC and Universidad Complutense de Madrid Madrid Spain
| | - Pilar Jiménez-Quevedo
- 1 Hospital Clínico San Carlos IDISSC and Universidad Complutense de Madrid Madrid Spain
| | - Luis Nombela-Franco
- 1 Hospital Clínico San Carlos IDISSC and Universidad Complutense de Madrid Madrid Spain
| | - Iván J Núñez-Gil
- 1 Hospital Clínico San Carlos IDISSC and Universidad Complutense de Madrid Madrid Spain
| | - Pablo Salinas
- 1 Hospital Clínico San Carlos IDISSC and Universidad Complutense de Madrid Madrid Spain
| | - María Del Trigo
- 1 Hospital Clínico San Carlos IDISSC and Universidad Complutense de Madrid Madrid Spain
| | - Enrico Cerrato
- 4 Interventional Cardiology San Luigi Gonzaga University Hospital Orbassano and Rivoli Infermi Hospital Turin Italy
| | - Niels van Royen
- 3 Department of Cardiology VU University Medical Center Amsterdam The Netherlands
| | - Paul Knaapen
- 3 Department of Cardiology VU University Medical Center Amsterdam The Netherlands
| | - Bon-Kwon Koo
- 5 Department of Internal Medicine and Cardiovascular Center Seoul National University Hospital Seoul Korea.,6 Institute on Aging Seoul National University Seoul Korea
| | - Carlos Macaya
- 1 Hospital Clínico San Carlos IDISSC and Universidad Complutense de Madrid Madrid Spain
| | | | - Javier Escaned
- 1 Hospital Clínico San Carlos IDISSC and Universidad Complutense de Madrid Madrid Spain
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76
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van de Hoef TP, de Waard GA, Meuwissen M, Voskuil M, Chamuleau SAJ, van Royen N, Piek JJ. Invasive coronary physiology: a Dutch tradition. Neth Heart J 2020; 28:99-107. [PMID: 32780339 PMCID: PMC7419414 DOI: 10.1007/s12471-020-01461-7] [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] [Indexed: 01/10/2023] Open
Abstract
Invasive coronary physiology has been applied since the early days of percutaneous transluminal coronary angioplasty, and has become a rapidly emerging field of research. Many physiology indices have been developed, tested in clinical studies, and are now applied in daily clinical practice. Recent clinical practice guidelines further support the use of advanced invasive physiology methods to optimise the diagnosis and treatment of patients with acute and chronic coronary syndromes. This article provides a succinct review of the history of invasive coronary physiology, the basic concepts of currently available physiological parameters, and will particularly highlight the Dutch contribution to this field of invasive coronary physiology.
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Affiliation(s)
- T P van de Hoef
- Department of Clinical and Experimental Cardiology, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam, The Netherlands.
| | - G A de Waard
- Department of Clinical and Experimental Cardiology, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - M Meuwissen
- Department of Cardiology, Amphia Hospital, Breda, The Netherlands
| | - M Voskuil
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - S A J Chamuleau
- Department of Clinical and Experimental Cardiology, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - N van Royen
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - J J Piek
- Department of Clinical and Experimental Cardiology, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam, The Netherlands
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77
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Claessen BE, van Wijk DF. FFR in the Setting of ACS. JACC Cardiovasc Interv 2020; 13:1904-1906. [DOI: 10.1016/j.jcin.2020.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 06/08/2020] [Indexed: 11/16/2022]
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78
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Montone RA, Niccoli G, Crea F, Jang IK. Management of non-culprit coronary plaques in patients with acute coronary syndrome. Eur Heart J 2020; 41:3579-3586. [DOI: 10.1093/eurheartj/ehaa481] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 02/09/2020] [Accepted: 05/25/2020] [Indexed: 01/24/2023] Open
Abstract
Abstract
Approximately 50% of patients with ST-segment elevation myocardial infarction (STEMI) have multivessel coronary artery disease, a condition associated with an increased incidence of recurrent ischaemic events and higher mortality. Based on recent evidences, a strategy of staged percutaneous coronary intervention (PCI) of obstructive non-culprit lesions should be considered the gold standard for the management of these patients. However, several issues remain still unresolved. Indeed, what is the optimal timing of staged PCI is not completely defined. Moreover, assessment of intermediate non-culprit lesions represent still a clinical conundrum, as pressure-wire indexes do not seem able to correctly identify those patients in whom deferral is safe. Intracoronary imaging may help to identify untreated non-culprit lesions containing vulnerable plaques that may portend a higher risk of future cardiovascular events. However, there are hitherto no studies demonstrating that preventive PCI of vulnerable plaques or more intensive pharmacological treatment is associated with an improved clinical outcome. In this review, we discuss the recent evolving concepts about management of non-culprit plaques in STEMI patients, proposing a diagnostic and therapeutic algorithm to guide physicians in clinical practice. We also underscore the several knowledge gaps to address in future studies.
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Affiliation(s)
- Rocco A. Montone
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.go A. Gemelli, 1-00168 Rome, Italy
| | - Giampaolo Niccoli
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.go A. Gemelli, 1-00168 Rome, Italy
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Filippo Crea
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.go A. Gemelli, 1-00168 Rome, Italy
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Ik-Kyung Jang
- Cardiology Division, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, GRB 800, Boston, MA 02114, USA
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79
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Kogame N, Ono M, Kawashima H, Tomaniak M, Hara H, Leipsic J, Andreini D, Collet C, Patel MR, Tu S, Xu B, Bourantas CV, Lerman A, Piek JJ, Davies JE, Escaned J, Wijns W, Onuma Y, Serruys PW. The Impact of Coronary Physiology on Contemporary Clinical Decision Making. JACC Cardiovasc Interv 2020; 13:1617-1638. [DOI: 10.1016/j.jcin.2020.04.040] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 04/13/2020] [Accepted: 04/21/2020] [Indexed: 01/10/2023]
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80
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Scarsini R, Terentes-Printzios D, De Maria GL, Ribichini F, Banning A. Why, When and How Should Clinicians Use Physiology in Patients with Acute Coronary Syndromes? ACTA ACUST UNITED AC 2020; 15:e05. [PMID: 32577130 PMCID: PMC7301203 DOI: 10.15420/icr.2019.26] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 01/13/2020] [Indexed: 12/14/2022]
Abstract
Current data support the use of coronary physiology in patients with acute coronary syndrome (ACS). In patients with ST-elevation MI, the extent of myocardial damage and microvascular dysfunction create a complex conundrum to assimilate when considering clinical management and risk stratification. In this setting, the index of microcirculatory resistance emerged as an accurate tool to identify patients at risk of suboptimal myocardial reperfusion after primary percutaneous coronary intervention who may benefit from novel adjunctive therapies. In the context of non-ST-elevation ACS, coronary physiology should be carefully interpreted and often integrated with intracoronary imaging, especially in cases of ambiguous culprit lesion. Conversely, the functional assessment of bystander coronary disease is favoured by the available evidence, aiming to achieve complete revascularisation. Based on everyday clinical scenarios, the authors illustrate the available evidence and provide recommendations for the functional assessment of infarct-related artery and non-culprit lesions in patients with ACS.
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Affiliation(s)
- Roberto Scarsini
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals Oxford, UK.,Division of Cardiology, Department of Medicine, University of Verona Verona, Italy
| | | | - Giovanni Luigi De Maria
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals Oxford, UK
| | - Flavio Ribichini
- Division of Cardiology, Department of Medicine, University of Verona Verona, Italy
| | - Adrian Banning
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals Oxford, UK.,Division of Cardiovascular Medicine, BHF Centre of Research Excellence, University of Oxford Oxford, UK
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81
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Non-hyperaemic coronary pressure measurements to guide coronary interventions. Nat Rev Cardiol 2020; 17:629-640. [DOI: 10.1038/s41569-020-0374-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/31/2020] [Indexed: 01/11/2023]
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82
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Stone GW. Deferred Revascularization of Intermediate Left Main Lesions: No Room for Error. JACC Cardiovasc Interv 2020; 13:1665-1668. [PMID: 32417090 DOI: 10.1016/j.jcin.2020.03.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 03/24/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Gregg W Stone
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai and the Cardiovascular Research Foundation, New York, New York.
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83
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Anderson HV“S. Acute Coronary Physiology. JACC Cardiovasc Interv 2020; 13:1168-1170. [DOI: 10.1016/j.jcin.2020.03.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 03/26/2020] [Indexed: 11/15/2022]
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84
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Fractional Flow Reserve in Patients With Acute Coronary Syndrome. JACC Cardiovasc Interv 2020; 13:962-964. [DOI: 10.1016/j.jcin.2020.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 03/17/2020] [Indexed: 11/21/2022]
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85
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Chowdhury M, Osborn EA. Physiological Assessment of Coronary Lesions in 2020. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2020; 22:2. [PMID: 31938934 DOI: 10.1007/s11936-020-0803-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
PURPOSE OF REVIEW Physiological assessment of coronary artery disease (CAD) is an essential component of the interventional cardiology toolbox. However, despite long-term data demonstrating improved outcomes, physiology-guided percutaneous coronary intervention (PCI) remains underutilized in current practice. This review outlines the indications and technical aspects involved in evaluating coronary stenosis physiology, focusing on the latest developments in the field. RECENT FINDINGS Beyond fractional flow reserve (FFR), non-hyperemic pressure ratios (NHPR) that assess coronary physiology at rest without hyperemia now abound. Additional advances in other alternative FFR approaches, including non-invasive coronary CT (FFRCT), invasive angiography (FFRangio), and optical coherence tomography (FFROCT), are being realized. Artificial intelligence algorithms and robust tools that enable detailed pre-procedure "virtual" intervention are also emerging. The benefits of coronary physiological assessment to determine lesion functional significance are well established. In addition to stable CAD, coronary physiology can be especially helpful in clinical scenarios such as left main and multivessel CAD, serial lesions, non-infarct-related arteries in acute coronary syndromes, and residual ischemia post-PCI. Today, coronary physiological assessment remains an indispensable tool in the catheterization laboratory, with an exciting technological future that will further refine clinical practice and improve patient care.
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Affiliation(s)
- Mohsin Chowdhury
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 185 Pilgrim Road, Baker 4, Boston, MA, 02215, USA
| | - Eric A Osborn
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 185 Pilgrim Road, Baker 4, Boston, MA, 02215, USA.
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86
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[Coronary physiology in the catheter laboratory]. Herz 2020; 46:15-23. [PMID: 31938804 DOI: 10.1007/s00059-019-04878-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 11/21/2019] [Accepted: 12/06/2019] [Indexed: 01/10/2023]
Abstract
The regulation of coronary flow is mainly located in the resistance vessels of the microcirculation, so that the functional relevance of a coronary stenosis arises from the interaction between the epicardial stenosis and the downstream microcirculation. These complex interactions are precisely detectable by physiological measurements, such as the instantaneous wave-free ratio (iwFR) or the fractional flow reserve (FFR). In contrast, the purely visual assessment of the coronary anatomy could lead to misinterpretation and possibly to incorrect revascularization decisions. Consequently, in the current guidelines on myocardial revascularization of the European Society of Cardiology (ESC) the measurement of iwFR and FFR has a class IA indication in intermediate stenoses with unclear hemodynamic relevance. Despite this clear recommendation, physiological measurements are not yet regularly used in the clinical routine. Besides the purely hemodynamic assessment, novel methods such as co-registration and coronary mapping can be used for virtual planning of percutaneous coronary interventions, especially in vessels with diffuse lesions and serial stenoses. Furthermore, invasive flow measurements are also helpful for risk stratification between conservative and interventional treatment of patients with acute coronary syndrome, where additional factors of flow limitation, such as coronary spasm, thrombus and acute disturbance of the microcirculation play an important role.
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87
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Opportunities for enhancing the care of older patients with ST-elevation myocardial infarction presenting for primary percutaneous coronary intervention: Rationale and design of the SAFE-STEMI for Seniors trial. Am Heart J 2019; 218:84-91. [PMID: 31715434 DOI: 10.1016/j.ahj.2019.09.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 09/18/2019] [Indexed: 11/21/2022]
Abstract
Advanced age is directly related to worse outcomes following ST-elevation myocardial infarction (STEMI) and higher complication rates from antithrombotic therapies and primary percutaneous coronary intervention (PCI). Often excluded from clinical trials, seniors presenting with STEMI remain an understudied population despite contributing to 140,000 hospital admissions annually. The SAFE-STEMI for Seniors study is a prospective, multicenter, unblinded, randomized clinical trial designed to examine the efficacy and safety of instantaneous wave-free ratio-guided complete revascularization in multivessel disease, while also investigating other components of STEMI care for patients ≥60 years including the efficacy and safety of zotarolimus-eluting stents for primary PCI and transradial PCI with the Glidesheath Slender and TR band. The SAFE-STEMI trial represents North America's first and only prospective randomized investigational device exemption study to use a Coordinated Registry Network infrastructure with collaborative partnering across industry manufacturers, promoting both efficiency and reduced cost of evidence development for regulatory decisions related to both diagnostic and therapeutic technologies in a single study design. The study has been powered to evaluate 2 independent co-primary end points in a population of older patients with STEMI: (1) third-generation drug-eluting stents for primary PCI and (2) instantaneous wave-free ratio-guided complete revascularization versus infarct-related artery-only revascularization.
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88
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Ihdayhid AR, Koh JS, Ramzy J, Kumar A, Michail M, Brown A, Samady H. The Role of Fractional Flow Reserve and Instantaneous Wave-Free Ratio Measurements in Patients with Acute Coronary Syndrome. Curr Cardiol Rep 2019; 21:159. [PMID: 31768835 DOI: 10.1007/s11886-019-1233-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
PURPOSE OF REVIEW The role of fractional flow reserve to guide revascularization in patients with stable angina is well established. The instantaneous wave-free ratio (iFR) is an emerging adenosine-free resting index that is non-inferior to FFR and has potential to streamline the functional evaluation of coronary artery disease. The feasibility and utility of intracoronary physiology in patients with acute coronary syndrome (ACS) is unclear. This review will discuss the physiological principles and validity of using FFR and iFR in patients presenting with ACS. We will also provide an overview of the available evidence for their role in guiding revascularization in this patient group. RECENT FINDINGS The use of intracoronary physiology in culprit lesions of patients presenting with STEMI is not recommended and its accuracy is uncertain in patients with NSTEMI. In contrast, the physiological assessment of non-culprit vessels with FFR and IFR is a reliable measure of lesion-specific ischemia. Recent studies have demonstrated that FFR-guided revascularization of non-culprit lesions improves clinical outcomes although the role of iFR in this patient cohort is unknown. Physiology-guided revascularization of non-culprit ACS lesions improves clinical outcomes. Future studies investigating the complementary role of plaque morphology, biomechanics, and systemic inflammation may provide clinicians with a more comprehensive framework to guide treatment decisions.
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Affiliation(s)
- Abdul Rahman Ihdayhid
- Monash Cardiovascular Research Centre and MonashHeart, Monash University and Monash Health, Melbourne, Australia
| | - Jin-Sin Koh
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, Republic of Korea.,Andreas Gruentzig Cardiovascular Center, Division of Cardiology, Department of Medicine, Emory University School of Medicine, 1364 Clifton Road, Suite F606, Atlanta, GA, 30322, USA
| | - John Ramzy
- Monash Cardiovascular Research Centre and MonashHeart, Monash University and Monash Health, Melbourne, Australia
| | - Arnav Kumar
- Andreas Gruentzig Cardiovascular Center, Division of Cardiology, Department of Medicine, Emory University School of Medicine, 1364 Clifton Road, Suite F606, Atlanta, GA, 30322, USA
| | - Michael Michail
- Monash Cardiovascular Research Centre and MonashHeart, Monash University and Monash Health, Melbourne, Australia.,Institute of Cardiovascular Science, University College London, London, UK
| | - Adam Brown
- Monash Cardiovascular Research Centre and MonashHeart, Monash University and Monash Health, Melbourne, Australia
| | - Habib Samady
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, Republic of Korea. .,Andreas Gruentzig Cardiovascular Center, Division of Cardiology, Department of Medicine, Emory University School of Medicine, 1364 Clifton Road, Suite F606, Atlanta, GA, 30322, USA.
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89
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Kubo T, Shiono Y. Prognostic Relevance of Discordant Results Between Fractional Flow Reserve and Resting Indices. Circ J 2019; 83:2203-2204. [PMID: 31511441 DOI: 10.1253/circj.cj-19-0769] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Takashi Kubo
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Yasutsugu Shiono
- Department of Cardiovascular Medicine, Wakayama Medical University
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90
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Lee SH, Choi KH, Lee JM, Hwang D, Rhee TM, Park J, Kim HK, Cho YK, Yoon HJ, Park J, Song YB, Hahn JY, Doh JH, Nam CW, Shin ES, Hur SH, Koo BK. Physiologic Characteristics and Clinical Outcomes of Patients With Discordance Between FFR and iFR. JACC Cardiovasc Interv 2019; 12:2018-2031. [PMID: 31563683 DOI: 10.1016/j.jcin.2019.06.044] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 06/12/2019] [Accepted: 06/18/2019] [Indexed: 01/10/2023]
Abstract
OBJECTIVES This study evaluated the physiologic characteristics of discordant lesions between instantaneous wave-free ratio (iFR) and fractional flow reserve (FFR) and the prognosis at 5 years. BACKGROUND FFR or iFR have been standard methods for assessing the functional significance of coronary artery stenosis. However, limited data exist about the physiologic characteristics of discordant lesions and the prognostic implications resulting from these lesions. METHODS A total of 840 vessels from 596 patients were classified according to iFR and FFR; high iFR-high FFR (n = 580), low iFR-high FFR (n = 40), high iFR-low FFR (n = 69), and low iFR-low FFR (n = 128) groups, which were compared with a control group (n = 23). The differences in coronary circulatory indices including the coronary flow reserve (CFR), index of microcirculatory resistance (IMR), and resistance reserve ratio (RRR) (resting distal arterial pressure × mean transit time / hyperemic distal arterial pressure × hyperemic mean transit time), which reflect the vasodilatory capacity of coronary microcirculation, were compared. Patient-oriented composite outcomes (POCO) at 5 years including all-cause death, any myocardial infarction, and any revascularization were compared among patients with deferred lesions. RESULTS In the low iFR-high FFR group, CFR, RRR, and IMR measurements were similar to the low iFR-low FFR group: CFR 2.71 versus 2.43 (p = 0.144), RRR 3.36 versus 3.68 (p = 0.241), and IMR 18.51 versus 17.38 (p = 0.476). In the high iFR-low FFR group, the CFR, RRR, and IMR measurements were similar to the control group: CFR 2.95 versus 3.29 (p = 0.160), RRR 4.28 versus 4.00 (p = 0.414), and IMR 17.44 versus 17.06 (p = 0.818). Among the 4 groups, classified by iFR and FFR, CFR and RRR were all significantly different, except for IMR. However, there were no significant differences in the rates of POCO, regardless of discordance between the iFR and FFR. Only the low iFR-low FFR group had a higher POCO rate compared with the high iFR-high FFR group (adjusted hazard ratio: 2.46; 95% confidence interval: 1.17 to 5.16; p = 0.018). CONCLUSIONS Differences in coronary circulatory function were found, especially in the vasodilatory capacity between the low iFR-high FFR and high iFR-low FFR groups. FFR-iFR discordance was not related to an increased risk of POCO among patients with deferred lesions at 5 years. (Clinical, Physiological and Prognostic Implication of Microvascular Status;NCT02186093; Physiologic Assessment of Microvascular Function in Heart Transplant Patients; NCT02798731).
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Affiliation(s)
- Seung Hun Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan 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.
| | - Doyeon Hwang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Tae-Min Rhee
- 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; Department of Internal Medicine, Naju National Hospital, Ministry of Health and Welfare, Naju, Korea
| | - Hyun Kuk Kim
- Department of Internal Medicine and Cardiovascular Center, Chosun University Hospital, University of Chosun College of Medicine, Gwangju, Korea
| | - Yun-Kyeong Cho
- Department of Medicine, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Hyuck-Jun Yoon
- Department of Medicine, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Jinhyoung Park
- Department of Biomedical Engineering, Sungkyunkwan University, Suwon, Korea
| | - Young Bin Song
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joo-Yong Hahn
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joon-Hyung Doh
- Department of Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Chang-Wook Nam
- Department of Medicine, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Eun-Seok Shin
- Division of Cardiology, Ulsan Hospital, Ulsan, Korea; Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Seung-Ho Hur
- Department of Medicine, Keimyung University Dongsan Medical Center, Daegu, 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
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91
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Díez-Delhoyo F, Gutiérrez-Ibañes E, Fernández-Avilés F. Functional disorders in non-culprit coronary arteries and their implications in patients with acute myocardial infarction. Trends Cardiovasc Med 2019; 30:346-352. [PMID: 31547950 DOI: 10.1016/j.tcm.2019.08.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 08/17/2019] [Accepted: 08/31/2019] [Indexed: 11/29/2022]
Abstract
Approximately 30-50% of patients with ST-segment elevation acute myocardial infarction have multivessel disease. The physiology of the non-culprit artery (NCA) is complex and represents a challenge to physicians as, while these plaques are presumably stable, clinical data show that they frequently lead to major adverse cardiovascular events. In addition the presence of microvascular and endothelial dysfunction may have prognostic implications and interfere with current physiological indices for stenosis severity assessment. In this review we aim to summarize current methods to study the microcirculation, discuss the evidence available regarding the endothelium and the microvascular compartment of the NCA; the best strategies to perform a complete revascularization based on proven ischemia; real limitations associated to hyperemic stenosis indices; and the potential role of novel resting-indices in this specific acute context.
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Affiliation(s)
- Felipe Díez-Delhoyo
- Department of Cardiology, Instituto de Investigación Sanitaria Gregorio Marañon, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Centro de Investigación en Red en Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain.
| | - Enrique Gutiérrez-Ibañes
- Department of Cardiology, Instituto de Investigación Sanitaria Gregorio Marañon, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Centro de Investigación en Red en Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain; Department of Bioengineering and Aerospace Engineering, Universidad Carlos III, Madrid, Spain
| | - Francisco Fernández-Avilés
- Department of Cardiology, Instituto de Investigación Sanitaria Gregorio Marañon, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Centro de Investigación en Red en Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain; Department of Medicine, Universidad Complutense, Madrid, Spain
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92
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Lee JM, Rhee TM, Choi KH, Park J, Hwang D, Kim J, Park J, Kim HY, Jung HW, Cho YK, Yoon HJ, Song YB, Hahn JY, Nam CW, Shin ES, Doh JH, Hur SH, Koo BK. Clinical Outcome of Lesions With Discordant Results Among Different Invasive Physiologic Indices - Resting Distal Coronary to Aortic Pressure Ratio, Resting Full-Cycle Ratio, Diastolic Pressure Ratio, Instantaneous Wave-Free Ratio, and Fractional Flow Reserve. Circ J 2019; 83:2210-2221. [PMID: 31484836 DOI: 10.1253/circj.cj-19-0230] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND We evaluated the 2-year clinical outcomes of deferred lesions with discordant results between resting and hyperemic pressure-derived physiologic indices, including resting distal to aortic coronary pressure (resting Pd/Pa), instantaneous wave-free ratio (iFR), resting full-cycle ratio (RFR), diastolic pressure ratio (dPR), and fractional flow reserve (FFR).Methods and Results:The 2-year clinical outcomes of 1,024 vessels (435 patients) with available resting Pd/Pa, iFR, RFR, dPR, and FFR data were analyzed according to a 4-group classification using known cutoff values (resting Pd/Pa ≤0.92, iFR/RFR/dPR ≤0.89, and FFR ≤0.80): Group 1 (concordant normal), Group 2 (high resting index and low FFR), Group 3 (low resting index and high FFR), and Group 4 (concordance abnormal). The primary outcome was vessel-oriented composite outcomes (VOCO) in deferred vessels at 2 years. In the comparison of VOCO risk among 4 groups classified according to FFR and 4 resting physiologic indices, Group 4 consistently showed a significantly higher risk of VOCO than Group 1. Comparison of VOCO risk among 4 groups classified according to iFR and other resting physiologic indices also showed the same results. The presence of discordance, either between hyperemic and resting indices or among resting indices, was not an independent predictor for VOCO. CONCLUSIONS Discordant results between resting physiologic indices and FFR and among the resting indices were not associated with increased risk of VOCO in deferred lesions.
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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
| | - Tae-Min Rhee
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital
| | - Ki Hong Choi
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Jonghanne Park
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital.,Department of Internal Medicine, Naju National Hospital, Ministry of Health and Welfare
| | - Doyeon Hwang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital
| | - Jinseob Kim
- Department of Epidemiology, School of Public Health, Seoul National University
| | - Jinhyoung Park
- Department of Biomedical Engineering, Sungkyunkwan University
| | - Hyung Yoon Kim
- Department of Cardiovascular Medicine, Chonnam National University Hospital
| | - Hae Won Jung
- Department of Cardiology, Daegu Catholic University Medical Center
| | - Yun-Kyeong Cho
- Department of Medicine, Keimyung University Dongsan Medical Center
| | - Hyuck-Jun Yoon
- Department of Medicine, Keimyung University Dongsan Medical Center
| | - Young Bin Song
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Joo-Yong Hahn
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Chang-Wook Nam
- Department of Medicine, Keimyung University Dongsan Medical Center
| | - Eun-Seok Shin
- Division of Cardiology, Ulsan Hospital.,Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine
| | - Joon-Hyung Doh
- Department of Medicine, Inje University Ilsan Paik Hospital
| | - Seung-Ho Hur
- Department of Medicine, Keimyung University Dongsan Medical Center
| | - Bon-Kwon Koo
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital.,Institute on Aging, Seoul National University
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93
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Discordance of intracoronary pressure-based indices in severe angiographic stenosis: are we missing the flow? Cardiovasc Interv Ther 2019; 35:304-305. [PMID: 31388970 DOI: 10.1007/s12928-019-00609-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 08/02/2019] [Indexed: 01/09/2023]
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94
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Lee JM, Hwang D, Choi KH, Kim CH, Bang JI, Suh M, Paeng JC, Cheon GJ, Koo BK. Diagnostic Performance of Nonhyperemic Pressure Ratios Assessed by 13N-Ammonium Positron Emission Tomography. JACC Cardiovasc Interv 2019; 12:1517-1518. [DOI: 10.1016/j.jcin.2019.04.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 04/11/2019] [Indexed: 10/26/2022]
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95
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Chinnaiyan KM, Safian RD, Gallagher ML, George J, Dixon SR, Bilolikar AN, Abbas AE, Shoukfeh M, Brodsky M, Stewart J, Cami E, Forst D, Timmis S, Crile J, Raff GL. Clinical Use of CT-Derived Fractional Flow Reserve in the Emergency Department. JACC Cardiovasc Imaging 2019; 13:452-461. [PMID: 31326487 DOI: 10.1016/j.jcmg.2019.05.025] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 04/30/2019] [Accepted: 05/08/2019] [Indexed: 12/13/2022]
Abstract
OBJECTIVES This study sought to examine the feasibility, safety, clinical outcomes, and costs associated with computed tomography-derived fractional flow reserve (FFRCT) in acute chest pain (ACP) patients in a coronary computed tomography angiography (CTA)-based triage program. BACKGROUND FFRCT is useful in determining lesion-specific ischemia in patients with stable ischemic heart disease, but its utility in ACP has not been studied. METHODS ACP patients with no known coronary artery disease undergoing coronary CTA and coronary CTA with FFRCT were studied. FFRCT ≤0.80 was considered positive for hemodynamically significant stenosis. RESULTS Among 555 patients, 297 underwent coronary CTA and FFRCT (196 negative, 101 positive), whereas 258 had coronary CTA only. The rejection rate for FFRCT was 1.6%. At 90 days, there was no difference in major adverse cardiac events (including death, nonfatal myocardial infarction, and unexpected revascularization after the index visit) between the coronary CTA and FFRCT groups (4.3% vs. 2.7%; p = 0.310). Diagnostic failure, defined as discordance between the coronary CTA or FFRCT results with invasive findings, did not differ between the groups (1.9% vs. 1.68%; p = NS). No deaths or myocardial infarction occurred with negative FFRCT when revascularization was deferred. Negative FFRCT was associated with higher nonobstructive disease on invasive coronary angiography (56.5%) than positive FFRCT (8.0%) and coronary CTA (22.9%) (p < 0.001). There was no difference in overall costs between the coronary CTA and FFRCT groups ($8,582 vs. $8,048; p = 0.550). CONCLUSIONS In ACP, FFRCT is feasible, with no difference in major adverse cardiac events and costs compared with coronary CTA alone. Deferral of revascularization is safe with negative FFRCT, which is associated with higher nonobstructive disease on invasive angiography.
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Affiliation(s)
| | - Robert D Safian
- Department of Cardiovascular Medicine, Beaumont Health, Royal Oak, Michigan
| | | | - Julie George
- Department of Cardiovascular Medicine, Beaumont Health, Royal Oak, Michigan
| | - Simon R Dixon
- Department of Cardiovascular Medicine, Beaumont Health, Royal Oak, Michigan
| | - Abhay N Bilolikar
- Department of Cardiovascular Medicine, Beaumont Health, Royal Oak, Michigan
| | - Amr E Abbas
- Department of Cardiovascular Medicine, Beaumont Health, Royal Oak, Michigan
| | - Mazen Shoukfeh
- Department of Cardiovascular Medicine, Beaumont Health, Royal Oak, Michigan
| | - Marc Brodsky
- Department of Cardiovascular Medicine, Beaumont Health, Royal Oak, Michigan
| | - James Stewart
- Department of Cardiovascular Medicine, Beaumont Health, Royal Oak, Michigan
| | - Elvis Cami
- Department of Cardiovascular Medicine, Beaumont Health, Royal Oak, Michigan
| | - David Forst
- Department of Cardiovascular Medicine, Beaumont Health, Royal Oak, Michigan
| | - Steven Timmis
- Department of Cardiovascular Medicine, Beaumont Health, Royal Oak, Michigan
| | - Jason Crile
- Department of Cardiovascular Medicine, Beaumont Health, Royal Oak, Michigan
| | - Gilbert L Raff
- Department of Cardiovascular Medicine, Beaumont Health, Royal Oak, Michigan
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96
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Serruys PW, Kogame N, Katagiri Y, Modolo R, Buszman PE, Íñiguez-Romo A, Goicolea J, Hildick-Smith D, Ochala A, Dudek D, Piek JJ, Wykrzykowska JJ, Escaned J, Banning AP, Farooq V, Onuma Y. Clinical outcomes of state-of-the-art percutaneous coronary revascularisation in patients with three-vessel disease: two-year follow-up of the SYNTAX II study. EUROINTERVENTION 2019; 15:e244-e252. [DOI: 10.4244/eij-d-18-00980] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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97
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Koh J, Samady H. Robustness of Fractional Flow Reserve for Lesion Assessment in Non-Infarct-Related Arteries of Patients With Myocardial Infarction. J Am Heart Assoc 2019; 8:e012456. [PMID: 31014179 PMCID: PMC6512129 DOI: 10.1161/jaha.119.012456] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
See Article Mejía-Rentería et al.
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Affiliation(s)
- Jin‐Sin Koh
- Division of CardiologyDepartment of Internal MedicineGyeongsang National University School of Medicine and Gyeongsang National University HospitalJinjuRepublic of Korea
- Division of CardiologyDepartment of MedicineAndreas Gruentzig Cardiovascular CenterEmory University School of MedicineAtlantaGA
| | - Habib Samady
- Division of CardiologyDepartment of MedicineAndreas Gruentzig Cardiovascular CenterEmory University School of MedicineAtlantaGA
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Abstract
Background: Calculation of fractional flow reserve (FFR) using computed tomography (CT)-based 3D anatomical models and computational fluid dynamics (CFD) has become a common method to non-invasively assess the functional severity of atherosclerotic narrowing in coronary arteries. We examined the impact of various inflow boundary conditions on computation of FFR to shed light on the requirements for inflow boundary conditions to ensure model representation. Methods: Three-dimensional anatomical models of coronary arteries for four patients with mild to severe stenosis were reconstructed from CT images. FFR and its commonly-used alternatives were derived using the models and CFD. A combination of four types of inflow boundary conditions (BC) was employed: pulsatile, steady, patient-specific and population average. Results: The maximum difference of FFR between pulsatile and steady inflow conditions was 0.02 (2.4%), approximately at a level similar to a reported uncertainty level of clinical FFR measurement (3–4%). The flow with steady BC appeared to represent well the diastolic phase of pulsatile flow, where FFR is measured. Though the difference between patient-specific and population average BCs affected the flow more, the maximum discrepancy of FFR was 0.07 (8.3%), despite the patient-specific inflow of one patient being nearly twice as the population average. Conclusions: In the patients investigated, the type of inflow boundary condition, especially flow pulsatility, does not have a significant impact on computed FFRs in narrowed coronary arteries.
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99
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Davies RE, Abbott JD. Percutaneous Coronary Intervention: Developments in the Last 12 Months. US CARDIOLOGY REVIEW 2019. [DOI: 10.15420/usc.2019.1.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
In 2018, there were several studies that significantly added to the field of interventional cardiology. Research was focused on understanding the role of percutaneous coronary intervention (PCI) in various clinical syndromes, optimizing outcomes for high-risk lesion subsets, and building an evidence base for greater adoption of PCI guided by physiology and intracoronary imaging. In the area of innovation, novel and iterative developments in drug-eluting stents (DES) and scaffold platforms were compared with current generation DES. This article summarizes the research from last year which has had the most impact on PCI techniques and clinical care.
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Affiliation(s)
- Rhian E Davies
- Division of Cardiology, Rhode Island Hospital, Brown Medical School, Providence, RI
| | - J Dawn Abbott
- Division of Cardiology, Rhode Island Hospital, Brown Medical School, Providence, RI
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