1
|
Spagnolo M, Occhipinti G, Laudani C, Greco A, Capodanno D. Periprocedural myocardial infarction and injury. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2024; 13:433-445. [PMID: 38323856 DOI: 10.1093/ehjacc/zuae014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 02/05/2024] [Accepted: 02/05/2024] [Indexed: 02/08/2024]
Abstract
Periprocedural myocardial infarction (PMI) and injury, pertinent to both cardiac and non-cardiac procedures, have gained increasing recognition in clinical practice. Over time, diverse definitions for diagnosing PMI have been developed and validated among patient populations undergoing coronary revascularization. However, this variety in definitions presents considerable challenges in clinical settings and complicates both the design and interpretation of clinical trials. The necessity to accurately diagnose PMI has spurred significant interest in establishing universally accepted and prognostically meaningful thresholds for cardiac biomarkers elevation and supportive ancillary criteria. In fact, elevations in cardiac biomarkers in line with the 4th Universal Definition of Myocardial Infarction, have been extensively confirmed to be associated with increased mortality and cardiovascular events. In the context of non-coronary cardiac procedures, such as Transcatheter Aortic Valve Implantation, there is a growing acknowledgment of both the high incidence rates and the adverse impact of PMI on patient outcomes. Similarly, emerging research underscores the significance of PMI and injury in non-cardiac surgery, highlighting the urgent need for effective prevention and risk management strategies in this domain.
Collapse
Affiliation(s)
- Marco Spagnolo
- Division of Cardiology, A.O.U. Policlinico 'G. Rodolico-San Marco', University of Catania, Via Santa Sofia 78, Catania - 95123, Italy
| | - Giovanni Occhipinti
- Division of Cardiology, A.O.U. Policlinico 'G. Rodolico-San Marco', University of Catania, Via Santa Sofia 78, Catania - 95123, Italy
| | - Claudio Laudani
- Division of Cardiology, A.O.U. Policlinico 'G. Rodolico-San Marco', University of Catania, Via Santa Sofia 78, Catania - 95123, Italy
| | - Antonio Greco
- Division of Cardiology, A.O.U. Policlinico 'G. Rodolico-San Marco', University of Catania, Via Santa Sofia 78, Catania - 95123, Italy
| | - Davide Capodanno
- Division of Cardiology, A.O.U. Policlinico 'G. Rodolico-San Marco', University of Catania, Via Santa Sofia 78, Catania - 95123, Italy
| |
Collapse
|
2
|
Mangiacapra F, Colaiori I, Di Gioia G, Pellicano M, Heyse A, Paolucci L, Peace A, Bartunek J, de Bruyne B, Barbato E. Effects of ticagrelor and prasugrel on coronary microcirculation in elective percutaneous coronary intervention. Heart 2023; 110:115-121. [PMID: 37316163 DOI: 10.1136/heartjnl-2022-321868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 05/29/2023] [Indexed: 06/16/2023] Open
Abstract
OBJECTIVE To compare the effects of ticagrelor and prasugrel on absolute coronary blood flow (Q) and microvascular resistance (R) in patients with stable coronary artery disease (CAD) treated with elective percutaneous coronary intervention (PCI) (NCT05643586). Besides being at least as effective as prasugrel in inhibiting platelet aggregation, ticagrelor has been shown to have additional properties potentially affecting coronary microcirculation. METHODS We randomly assigned 50 patients to ticagrelor (180 mg) or prasugrel (60 mg) at least 12 hours before intervention. Continuous thermodilution was used to measure Q and R before and after PCI. Platelet reactivity was measured before PCI. Troponin I was measured before, 8 and 24 hours after PCI. RESULTS At baseline, fractional flow reserve, Q and R were similar in two study groups. Patients in the ticagrelor group showed higher post-PCI Q (242±49 vs 205±53 mL/min, p=0.015) and lower R values (311 (263, 366) vs 362 (319, 382) mm Hg/L/min, p=0.032). Platelet reactivity showed a negative correlation with periprocedural variation of Q values (r=-0.582, p<0.001) and a positive correlation with periprocedural variation of R values (r=0.645, p<0.001). The periprocedural increase in high-sensitivity troponin I was significantly lower in the ticagrelor compared with the prasugrel group (5 (4, 9) ng/mL vs 14 (10, 24) ng/mL, p<0.001). CONCLUSIONS In patients with stable CAD undergoing PCI, pretreatment with a loading dose of ticagrelor compared with prasugrel improves post-procedural coronary flow and microvascular function and seems to reduce the related myocardial injury.
Collapse
Affiliation(s)
- Fabio Mangiacapra
- Research Unit of Cardiovascular Science, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
- Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Iginio Colaiori
- Cardiovasciular Research Center Aalst, OLV Hospital, Aalst, Belgium
| | | | | | - Alex Heyse
- Cardiovasciular Research Center Aalst, OLV Hospital, Aalst, Belgium
| | - Luca Paolucci
- Research Unit of Cardiovascular Science, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
- Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | | | - Jozef Bartunek
- Cardiovasciular Research Center Aalst, OLV Hospital, Aalst, Belgium
| | | | - Emanuele Barbato
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy
| |
Collapse
|
3
|
Chen W, Ni M, Huang H, Cong H, Fu X, Gao W, Yang Y, Yu M, Song X, Liu M, Yuan Z, Zhang B, Wang Z, Wang Y, Chen Y, Zhang C, Zhang Y. Chinese expert consensus on the diagnosis and treatment of coronary microvascular diseases (2023 Edition). MedComm (Beijing) 2023; 4:e438. [PMID: 38116064 PMCID: PMC10729292 DOI: 10.1002/mco2.438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 11/11/2023] [Accepted: 11/16/2023] [Indexed: 12/21/2023] Open
Abstract
Since the four working groups of the Chinese Society of Cardiology issued first expert consensus on coronary microvascular diseases (CMVD) in 2017, international consensus documents on CMVD have increased rapidly. Although some of these documents made preliminary recommendations for the diagnosis and treatment of CMVD, they did not provide classification of recommendations and levels of evidence. In order to summarize recent progress in the field of CMVD, standardize the methods and procedures of diagnosis and treatment, and identify the scientific questions for future research, the four working groups of the Chinese Society of Cardiology updated the 2017 version of the Chinese expert consensus on CMVD and adopted a series of measures to ensure the quality of this document. The current consensus has raised a new classification of CMVD, summarized new epidemiological findings for different types of CMVD, analyzed key pathological and molecular mechanisms, evaluated classical and novel diagnostic technologies, recommended diagnostic pathways and criteria, and therapeutic strategies and medications, for patients with CMVD. In view of the current progress and knowledge gaps of CMVD, future directions were proposed. It is hoped that this expert consensus will further expedite the research progress of CMVD in both basic and clinical scenarios.
Collapse
Affiliation(s)
- Wenqiang Chen
- The National Key Laboratory for Innovation and Transformation of Luobing TheoryThe Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical ScienceDepartment of CardiologyQilu Hospital of Shandong UniversityJinanShandongChina
| | - Mei Ni
- The National Key Laboratory for Innovation and Transformation of Luobing TheoryThe Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical ScienceDepartment of CardiologyQilu Hospital of Shandong UniversityJinanShandongChina
| | - He Huang
- Department of CardiologySir Run Run Shaw Hospital affiliated with Zhejiang University School of MedicineHangzhouChina
| | - Hongliang Cong
- Department of CardiologyTianjin Chest Hospital, Tianjin UniversityTianjinChina
| | - Xianghua Fu
- Department of CardiologyThe Second Hospital of Hebei Medical UniversityShijiazhuangHebeiChina
| | - Wei Gao
- Department of CardiologyPeking University Third HospitalBeijingChina
| | - Yuejin Yang
- Department of CardiologyFuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Mengyue Yu
- Department of CardiologyFuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Xiantao Song
- Department of CardiologyBeijing Anzhen Hospital, Capital Medical UniversityBeijingChina
| | - Meilin Liu
- Department of GeriatricsPeking University First HospitalBeijingChina
| | - Zuyi Yuan
- Department of CardiologyThe First Affiliated Hospital of Xian Jiaotong UniversityXianChina
| | - Bo Zhang
- Department of CardiologyFirst Affiliated Hospital, Dalian Medical UniversityDalianLiaoningChina
| | - Zhaohui Wang
- Department of CardiologyUnion Hospital, Tongji Medical College, Huazhong University of Science and TechnologyWuhanChina
| | - Yan Wang
- Department of CardiologyXiamen Cardiovascular Hospital, Xiamen UniversityXiamenChina
| | - Yundai Chen
- Senior Department of Cardiology, Sixth Medical Center of Chinese PLA General Hospital, Beijing, China; for the Basic Research Group, Atherosclerosis and Coronary Heart Disease Group, Interventional Cardiology Group, and Women's Heart Health Group of the Chinese Society of Cardiology
| | - Cheng Zhang
- The National Key Laboratory for Innovation and Transformation of Luobing TheoryThe Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical ScienceDepartment of CardiologyQilu Hospital of Shandong UniversityJinanShandongChina
| | - Yun Zhang
- The National Key Laboratory for Innovation and Transformation of Luobing TheoryThe Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical ScienceDepartment of CardiologyQilu Hospital of Shandong UniversityJinanShandongChina
| |
Collapse
|
4
|
Schweiger V, Gilhofer T, Fang R, Candreva A, Seifert B, Di Vece D, Wuerdinger M, Koleva I, Rajman K, Cieslik M, Gotschy A, Michel J, Stehli J, Niederseer D, Ryberg L, Ghadri J, Ruschitzka F, Stähli B, Cammann VL, Templin C. Coronary microvascular dysfunction in Takotsubo syndrome: an analysis using angiography-derived index of microcirculatory resistance. Clin Res Cardiol 2023:10.1007/s00392-023-02329-7. [PMID: 37985475 DOI: 10.1007/s00392-023-02329-7] [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: 08/29/2023] [Accepted: 10/18/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND Coronary microvascular dysfunction (CMD) has been proposed as a crucial factor in the pathophysiology of Takotsubo syndrome (TTS). The angiography-derived index of microcirculatory resistance (caIMR) offers an alternative to conventional hyperemic wire-based IMR to assess CMD. We aimed to evaluate CMD's prevalence, transience, and impact on in-hospital outcomes in TTS. METHODS All three coronary arteries of 96 patients with TTS were assessed for their coronary angiography derived Index of microcirculatory Resistance (caIMR) and compared to non-obstructed vessels of matched patients with ST-elevation myocardial infarction. Further, the association between caIMR and the TTS-specific combined in-hospital endpoint of death, cardiac arrest, ventricular arrhythmogenic events and cardiogenic shock was investigated. RESULTS Elevated IMR was present in all TTS patients, with significantly elevated caIMR values in all coronary arteries compared to controls. CaIMR did not differ between apical and midventricular TTS types. CaIMR normalized in TTS patients with follow-up angiographies performed at a median of 28 months (median caIMR at event vs follow-up: LAD 34.8 [29.9-41.1] vs 20.3 [16.0-25.3], p < 0.001; LCX: 38.7 [32.9-50.1] vs 23.7 [19.4-30.5], p < 0.001; RCA: 31.7 [25.0-39.1] vs 19.6 [17.1-24.0], p < 0.001). The extent of caIMR elevation significantly correlated with the combined in-hospital endpoint (p = 0.036). CONCLUSION TTS patients had evidence of elevated caIMR in at least one coronary artery with a trend towards higher LAD caIMR in apical type TTS and normalization after recovery. Furthermore, extent of caIMR elevation was associated with increased risk of in-hospital MACE of TTS patients.
Collapse
Affiliation(s)
- Victor Schweiger
- Department of Cardiology, University Heart Centre, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Thomas Gilhofer
- Department of Cardiology, University Heart Centre, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Rick Fang
- Suzhou Rainmed Medical Technology Co., Ltd, Building 31, Northeast District, Nano City, No. 99 Jinji Lake Avenue, Suzhou Industrial Park, Suzhou, China
| | - Alessandro Candreva
- Department of Cardiology, University Heart Centre, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Burkhardt Seifert
- Division of Biostatistics, Epidemiology, Biostatistics, and Prevention Institute, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Davide Di Vece
- Department of Cardiology, University Heart Centre, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Michael Wuerdinger
- Department of Cardiology, University Heart Centre, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Iva Koleva
- Department of Cardiology, University Heart Centre, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Katja Rajman
- Department of Cardiology, University Heart Centre, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Maciej Cieslik
- Department of Cardiology, University Heart Centre, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Alexander Gotschy
- Department of Cardiology, University Heart Centre, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Jonathan Michel
- Department of Cardiology, University Heart Centre, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Julia Stehli
- Department of Cardiology, University Heart Centre, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - David Niederseer
- Department of Cardiology, University Heart Centre, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Linn Ryberg
- Department of Cardiology, University Heart Centre, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Jelena Ghadri
- Department of Cardiology, University Heart Centre, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Frank Ruschitzka
- Department of Cardiology, University Heart Centre, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Barbara Stähli
- Department of Cardiology, University Heart Centre, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Victoria Lucia Cammann
- Department of Cardiology, University Heart Centre, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Christian Templin
- Department of Cardiology, University Heart Centre, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.
| |
Collapse
|
5
|
Aldujeli A, Haq A, Tsai TY, Grabauskyte I, Tatarunas V, Briedis K, Rana S, Unikas R, Hamadeh A, Serruys PW, Brilakis ES. The impact of primary percutaneous coronary intervention strategies during ST-elevation myocardial infarction on the prevalence of coronary microvascular dysfunction. Sci Rep 2023; 13:20094. [PMID: 37973856 PMCID: PMC10654664 DOI: 10.1038/s41598-023-47343-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 11/12/2023] [Indexed: 11/19/2023] Open
Abstract
Coronary microvascular dysfunction (CMD) is a common complication of ST-segment elevation myocardial infarction (STEMI) and can lead to adverse cardiovascular events. This is a non-randomized, observational, prospective study of STEMI patients with multivessel disease who underwent primary PCI, grouped based on whether they underwent balloon pre-dilatation stenting or direct stenting of the culprit lesion. Coronary physiology measurements were performed 3 months post-PCI including coronary flow reserve (CFR) and index of microcirculatory resistance (IMR) measurements at the culprit vessel. The primary endpoint was the prevalence of CMD at 3 months, defined as IMR ≥ 25 or CFR < 2.0 with a normal fractional flow reserve. Secondary endpoints included major adverse cardiovascular events (MACE) at 12 months. Two hundred ten patients were enrolled; most were men, 125 (59.5%), with a median age of 65 years. One hundred twelve (53.2%) underwent balloon pre-dilatation before stenting, and 98 (46.7%) underwent direct stenting. The prevalence of CMD at 3 months was lower in the direct stenting group than in the balloon pre-dilatation stenting group (12.24% vs. 40.18%; p < 0.001). Aspiration thrombectomy and administration of intracoronary glycoprotein IIb/IIIa inhibitors were associated with lower odds of CMD (OR = 0.175, p = 0.001 and OR = 0.113, p = 0.001, respectively). Notably, MACE in patients who underwent direct stenting was lower than in those who underwent balloon pre-dilatation before stenting (14.29% vs. 26.79%; p = 0.040). In STEMI patients with multivessel disease, direct stenting of the culprit lesion, aspiration thrombectomy and administration of intracoronary glycoprotein IIb/IIIa inhibitors were associated with a lower prevalence of CMD at 3 months and lower incidence of MACE at 12 months compared with balloon pre-dilatation stenting.This trial is registered at https://ichgcp.net/clinical-trials-registry/NCT05406297 .
Collapse
Affiliation(s)
- Ali Aldujeli
- Lithuanian University of Health Sciences, Sukileliu pr. 15, 50161, Kaunas, Lithuania.
| | - Ayman Haq
- Abbott Northwestern Hospital/Minneapolis Heart Institute Foundation, Minneapolis, MN, USA
| | | | - Ingrida Grabauskyte
- Lithuanian University of Health Sciences, Sukileliu pr. 15, 50161, Kaunas, Lithuania
| | - Vacis Tatarunas
- Lithuanian University of Health Sciences, Sukileliu pr. 15, 50161, Kaunas, Lithuania
| | - Kasparas Briedis
- Lithuanian University of Health Sciences, Sukileliu pr. 15, 50161, Kaunas, Lithuania
| | - Sumit Rana
- Thorndale Medical Clinic, Dublin, Ireland
| | - Ramunas Unikas
- Lithuanian University of Health Sciences, Sukileliu pr. 15, 50161, Kaunas, Lithuania
| | - Anas Hamadeh
- Heart and Vascular Specialists of North Texas, Arlington, TX, USA
| | | | - Emmanouil S Brilakis
- Abbott Northwestern Hospital/Minneapolis Heart Institute Foundation, Minneapolis, MN, USA
| |
Collapse
|
6
|
Angiography-derived index of microvascular resistance in takotsubo syndrome. Int J Cardiovasc Imaging 2023; 39:233-244. [PMID: 36336756 PMCID: PMC9813145 DOI: 10.1007/s10554-022-02698-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 07/20/2022] [Indexed: 11/09/2022]
Abstract
Coronary microvascular dysfunction (CMD) has been proposed as a key driver in the etiopathogenesis of Takotsubo syndrome (TTS), likely related to an "adrenergic storm" upon a susceptible microvascular circulation. The aim of our manuscript was to assess CMD in patients with TTS through the computation of the angiography-derived index of microcirculatory resistance (IMR) and its correlation with clinical presentation. Coronary angiograms of 41 consecutive TTS patients were retrospectively analyzed to derive angiography-based indices of CMD. Three indices (NH-IMRangio, AngioIMR and A-IMR) were calculated based on quantitative flow ratio. CMD was defined as an IMRangio value ≥ 25 units. The correlation between CMD and clinical presentation was then assessed. Median age was 76 years, 85.7% were women and mean left ventricular ejection fraction (LVEF) at first echocardiogram was 41.2%. Angiography-derived IMR was higher in left anterior descending artery (LAD) than circumflex and right coronary artery with either NH-IMRangio (53.9 ± 19.8 vs 35.8 ± 15.4 vs 40.8 ± 18.5, p-value < 0.001), AngioIMR (47.2 ± 17.3 vs 31.8 ± 12.2 vs 37.3 ± 13.7, p-value < 0.001) or A-IMR (52.7 ± 19 vs 36.1 ± 14.1 vs 41.8 ± 16.1, p-value < 0.001). All patients presented CMD with angiography-derived IMR ≥ 25 in at least one territory with each formula. Angiography-derived IMR in LAD territory was significantly higher in patients presenting with LVEF impairment (≤ 40%) than in those with preserved ventricular global function (NH-IMRangio: 59.3 ± 18.1 vs 46.3 ± 16.0 p-value = 0.030; AngioIMR: 52.9 ± 17.8 vs 41.4 ± 14.2, p-value = 0.037; A-IMR: 59.2 ± 18.6 vs 46.3 ± 17.0, p-value = 0.035). CMD assessed with angiography-derived IMR is a common finding in TTS and it is inversely correlated with LV function. The available formulas have a substantial superimposable diagnostic performance in assessing coronary microvascular function.
Collapse
|
7
|
COlchicine to Prevent PeriprocEdural Myocardial Injury in Percutaneous Coronary Intervention (COPE-PCI): Coronary Microvascular Physiology Pilot Substudy. J Interv Cardiol 2022; 2022:1098429. [PMID: 35685430 PMCID: PMC9168184 DOI: 10.1155/2022/1098429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 04/22/2022] [Indexed: 11/18/2022] Open
Abstract
Aim In this randomized pilot trial, we aimed to assess the anti-inflammatory effect of preprocedural colchicine on coronary microvascular physiology measurements before and after PCI. Methods Patients undergoing PCI for stable angina (SA) or non-ST-elevation myocardial infarction (NSTEMI) were randomized to oral colchicine or placebo, 6- to 24-hours before the procedure. Strict prespecified inclusion/exclusion criteria were set to ensure all patients were given the study medication, had a PCI, and had pre- and post-PCI culprit vessel invasive coronary physiology measurements. Fractional flow reserve (FFR), Index of Microvascular Resistance (IMR), Coronary Flow Reserve (CFR), and Resistive Reserve Ratio (RRR) were measured immediately before and after PCI. CMVD was defined as any one of post-PCI IMR >32 or CFR <2 or RRR <2. High-sensitive-(hs)-troponin-I, hsCRP, and leucocyte count were measured before and 24 hours after PCI. Results A total of 50 patients were randomized and met the strict prespecified inclusion/exclusion criteria: 24-colchicine and 26-placebo. Pre-PCI coronary physiology measurements, hs-troponin-I, and hsCRP were similar between groups. Although numerically lower in patients given colchicine, the proportion of patients who developed CMVD was not significantly different between groups (colchicine: 10 (42%) vs placebo: 16 (62%), p=0.16). Colchicine patients had higher post-PCI CFR and RRR vs placebo (respectively: 3.25 vs 2.00, p=0.03 & 4.25 vs 2.75, p < 0.01). Neutrophil count was lower after PCI in the colchicine arm (p=0.02), and hsCRP post-PCI remained low in both treatment arms (1.0 mg/L vs 1.7 mg/L, p=0.97). Patients randomized to colchicine had significantly less PCI-related absolute hs-troponin-I change (46 ng/L vs 152 ng/L, p=0.01). Conclusion In this pilot randomized substudy, colchicine given 6 to 24 hours before PCI did not statistically impact the post-PCI CMVD definition used in this study, yet it did improve post-PCI RRR and CFR measurements, with less procedure-related troponin release and less inflammation.
Collapse
|
8
|
Abstract
Mechanical stress from haemodynamic perturbations or interventional manipulation of epicardial coronary atherosclerotic plaques with inflammatory destabilization can release particulate debris, thrombotic material and soluble substances into the coronary circulation. The physical material obstructs the coronary microcirculation, whereas the soluble substances induce endothelial dysfunction and facilitate vasoconstriction. Coronary microvascular obstruction and dysfunction result in patchy microinfarcts accompanied by an inflammatory reaction, both of which contribute to progressive myocardial contractile dysfunction. In clinical studies, the benefit of protection devices to retrieve atherothrombotic debris during percutaneous coronary interventions has been modest, and the treatment of microembolization has mostly relied on antiplatelet and vasodilator agents. The past 25 years have witnessed a relative proportional increase in non-ST-segment elevation myocardial infarction in the presentation of acute coronary syndromes. An associated increase in the incidence of plaque erosion rather than rupture has also been recognized as a key mechanism in the past decade. We propose that coronary microembolization is a decisive link between plaque erosion at the culprit lesion and the manifestation of non-ST-segment elevation myocardial infarction. In this Review, we characterize the features and mechanisms of coronary microembolization and discuss the clinical trials of drugs and devices for prevention and treatment.
Collapse
Affiliation(s)
- Petra Kleinbongard
- grid.5718.b0000 0001 2187 5445Institute for Pathophysiology, West German Heart and Vascular Center, University of Essen Medical School, Essen, Germany
| | - Gerd Heusch
- grid.5718.b0000 0001 2187 5445Institute for Pathophysiology, West German Heart and Vascular Center, University of Essen Medical School, Essen, Germany
| |
Collapse
|
9
|
Del Buono MG, Montone RA, Camilli M, Carbone S, Narula J, Lavie CJ, Niccoli G, Crea F. Coronary Microvascular Dysfunction Across the Spectrum of Cardiovascular Diseases: JACC State-of-the-Art Review. J Am Coll Cardiol 2021; 78:1352-1371. [PMID: 34556322 PMCID: PMC8528638 DOI: 10.1016/j.jacc.2021.07.042] [Citation(s) in RCA: 183] [Impact Index Per Article: 61.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 07/08/2021] [Accepted: 07/19/2021] [Indexed: 12/12/2022]
Abstract
Coronary microvascular dysfunction (CMD) encompasses several pathogenetic mechanisms involving coronary microcirculation and plays a major role in determining myocardial ischemia in patients with angina without obstructive coronary artery disease, as well as in several other conditions, including obstructive coronary artery disease, nonischemic cardiomyopathies, takotsubo syndrome, and heart failure, especially the phenotype associated with preserved ejection fraction. Unfortunately, despite the identified pathophysiological and prognostic role of CMD in several conditions, to date, there is no specific treatment for CMD. Due to the emerging role of CMD as common denominator in different clinical phenotypes, additional research in this area is warranted to provide personalized treatments in this "garden variety" of patients. The purpose of this review is to describe the pathophysiological mechanisms of CMD and its mechanistic and prognostic role across different cardiovascular diseases. We will also discuss diagnostic modalities and the potential therapeutic strategies resulting from recent clinical studies.
Collapse
Affiliation(s)
- Marco Giuseppe Del Buono
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy. https://twitter.com/marcodelbuono3
| | - Rocco A Montone
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
| | - Massimiliano Camilli
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Salvatore Carbone
- Department of Kinesiology and Health Sciences, College of Humanities and Sciences, Virginia Commonwealth University, Richmond, Virginia, USA; VCU Pauley Heart Center, Division of Cardiology, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Jagat Narula
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Carl J Lavie
- Department of Cardiovascular Diseases, Ochsner Clinical School, New Orleans, Louisiana, USA
| | | | - Filippo Crea
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy; Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| |
Collapse
|
10
|
Noirclerc N, Marliere S, Bakhti A, Mangin L, Cassar E, Vautrin E, Piliero N, Ormezzano O, Bouvaist H, Riou L, Vanzetto G, Belle L, Barone-Rochette G. Impact of a micro-net mesh technology covering stent on coronary microvascular dysfunction in patients with high thrombus burden. Catheter Cardiovasc Interv 2021; 99:397-404. [PMID: 34057279 DOI: 10.1002/ccd.29782] [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: 12/24/2020] [Revised: 04/26/2021] [Accepted: 05/10/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND Highly thrombotic coronary lesions continue to be a serious and clinically significant problem that is not effectively and completely addressed by current technology. OBJECTIVES We aimed to investigate whether a micro-net mesh (MNM) technology covering stent could preserve the index of microcirculatory resistance (IMR) after percutaneous coronary intervention (PCI) in patients with high thrombus burden. METHODS AND RESULTS Fifty-two patients with non-ST elevation myocardial infarction or ST Elevation Myocardial Infarction and high thrombus burden (TIMI thrombus grade ≥ 3) were randomized into two groups, PCI with a MNM covering stent (MNM group, n = 25) and PCI with any commercially available stent (DES group, n = 27). As the primary endpoint, IMR was measured immediately after PCI using a pressure-temperature sensor-tipped coronary wire. The secondary endpoint was left ventricular ejection fraction (LVEF) at 6 months of follow-up. The IMR in the MNM group was significantly lower in comparison to the DES group (33.2 [21.3, 48.9] vs. 57.2 [39.9, 98.0], p = 0.005). No significant differences were observed in baseline LVEF (54.5 ± 10.2% vs. 53.1 ± 6.87%, p = .57), while LVEF was significantly improved at follow-up in the MNM group (61.1 ± 7.1% vs. 53.9 ± 6.35%, p = .0001). CONCLUSION MNM technology significantly improved coronary microvascular dysfunction after PCI in patient with acute coronary syndrome and appears as a useful technological option for thrombus management.
Collapse
Affiliation(s)
| | | | - Akader Bakhti
- Department of Cardiology, Hospital Center, Annecy-Genevois, France
| | - Lionel Mangin
- Department of Cardiology, Hospital Center, Annecy-Genevois, France
| | - Emmanuel Cassar
- Department of Cardiology, Hospital Center, Annecy-Genevois, France
| | - Estelle Vautrin
- Department of Cardiology, University Hospital, Grenoble-Alpes, France
| | - Nicolas Piliero
- Department of Cardiology, University Hospital, Grenoble-Alpes, France
| | - Olivier Ormezzano
- Department of Cardiology, University Hospital, Grenoble-Alpes, France.,University Grenoble alpes, INSERM U1039, Bioclinic Radiopharmaceutics Laboratory, Grenoble, France
| | - Helene Bouvaist
- Department of Cardiology, University Hospital, Grenoble-Alpes, France
| | - Laurent Riou
- University Grenoble alpes, INSERM U1039, Bioclinic Radiopharmaceutics Laboratory, Grenoble, France
| | - Gerald Vanzetto
- Department of Cardiology, University Hospital, Grenoble-Alpes, France.,University Grenoble alpes, INSERM U1039, Bioclinic Radiopharmaceutics Laboratory, Grenoble, France.,French Alliance Clinical Trial, French Clinical Research Infrastructure Network, Paris, France
| | - Loic Belle
- Department of Cardiology, Hospital Center, Annecy-Genevois, France
| | - Gilles Barone-Rochette
- Department of Cardiology, University Hospital, Grenoble-Alpes, France.,University Grenoble alpes, INSERM U1039, Bioclinic Radiopharmaceutics Laboratory, Grenoble, France.,French Alliance Clinical Trial, French Clinical Research Infrastructure Network, Paris, France
| |
Collapse
|
11
|
Xu J, Lo S, Juergens CP, Leung DY. Impact of Targeted Therapies for Coronary Microvascular Dysfunction as Assessed by the Index of Microcirculatory Resistance. J Cardiovasc Transl Res 2020; 14:327-337. [PMID: 32710373 DOI: 10.1007/s12265-020-10062-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Accepted: 07/19/2020] [Indexed: 11/25/2022]
Abstract
Coronary microvascular dysfunction (CMD) has emerged as an important therapeutic target in the contemporary management of ischemic heart disease. However, due to a lack of a reliable traditional "gold standard" test for CMD, optimal treatment remains undefined. The index of microcirculatory resistance (IMR) is an intra-coronary wire-based technique that provides a more reliable and quantitative assessment of CMD and has been increasingly used as a preferred endpoint for evaluating CMD treatment strategies in recent studies. IMR can help diagnose CMD in angina patients with non-obstructive epicardial coronary disease, predict peri-procedural myocardial infarction in stable patients undergoing coronary stenting, and predict long-term prognosis after acute myocardial infarction. Studies of IMR in the setting of non-ST-elevation acute coronary syndromes are still lacking. This review critically appraises the current published literature evaluating targeted therapies for CMD using IMR as the assessment tool and provides insights into evidence gaps in this important field. The index of microcirculatory resistance has rapidly evolved from a research tool to being the new "gold standard" test for evaluating coronary microvascular dysfunction.
Collapse
Affiliation(s)
- James Xu
- Department of Cardiology, Liverpool Hospital, Sydney, NSW, 2170, Australia.
- South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia.
| | - Sidney Lo
- Department of Cardiology, Liverpool Hospital, Sydney, NSW, 2170, Australia
- South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Craig P Juergens
- Department of Cardiology, Liverpool Hospital, Sydney, NSW, 2170, Australia
- South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Dominic Y Leung
- Department of Cardiology, Liverpool Hospital, Sydney, NSW, 2170, Australia
- South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
| |
Collapse
|
12
|
Index of Microcirculatory Resistance Measured during Intracoronary Adenosine-Induced Hyperemia. J Interv Cardiol 2020; 2020:4829647. [PMID: 32508541 PMCID: PMC7243016 DOI: 10.1155/2020/4829647] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 03/09/2020] [Accepted: 03/19/2020] [Indexed: 11/24/2022] Open
Abstract
Background The index of microcirculatory resistance is an invasive measure of coronary microvascular function that has to be calculated during maximal hyperemia, classically achieved with intravenous adenosine (IV). The aim of this study was to evaluate the use of intracoronary (IC) adenosine for the calculation of IMR. Methods and Results 31 patients with stable coronary artery disease were included in the study. Coronary pressure and thermodilution measurements were obtained at rest and during maximal hyperemia using a pressure-temperature sensor-tipped coronary guidewire. Duplicate measurements were performed using first IC and then IV adenosine. Dispersion of transit times was comparable for IC and IV adenosine. IMR values based on IC vs IV adenosine showed a high level of agreement and an intraclass correlation coefficient of 0.90. Applying an upper normal limit of 25, misclassification of IMR using IC adenosine was seen in just one patient in whom IC adenosine resulted in a lower value. A simplified procedure based on a single bolus dose of saline did not change the level of agreement or the rate of misclassification. Conclusions We found an excellent agreement between IMR values measured during hyperemia induced by IC as compared to IV adenosine. The use of IC adenosine may facilitate invasive assessment of microvascular function and is potentially time- and cost-saving with less patient discomfort as compared to IV infusion. The trail is registered with NCT03369184.
Collapse
|
13
|
Periprocedural Myocardial Injury: Pathophysiology, Prognosis, and Prevention. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2020; 21:1041-1052. [PMID: 32586745 DOI: 10.1016/j.carrev.2020.04.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 04/08/2020] [Accepted: 04/09/2020] [Indexed: 01/27/2023]
Abstract
The definition and clinical implications of myocardial infarction occurring in the setting of percutaneous coronary intervention have been the subject of unresolved controversy. The definitions of periprocedural myocardial infarction (PMI) are many and have evolved over recent years. Additionally, the recent advancement of different imaging modalities has provided useful information on a patients' pre-procedural risk of myocardial infarction. Nonetheless, questions on the benefit of different approaches to prevent PMI and their practical implementation remain open. This review aims to address these questions and to provide a current and contemporary perspective.
Collapse
|
14
|
Mangiacapra F, Bressi E, Di Gioia G, Pellicano M, Di Serafino L, Peace AJ, Bartunek J, Morisco C, Wijns W, De Bruyne B, Barbato E. Coronary microcirculation and peri-procedural myocardial injury during elective percutaneous coronary intervention. Int J Cardiol 2020; 306:42-46. [DOI: 10.1016/j.ijcard.2019.12.042] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 12/02/2019] [Accepted: 12/23/2019] [Indexed: 10/25/2022]
|
15
|
Comparison of direct stenting with conventional strategy on myocardial impairments in ST-segment elevation myocardial infarction: a cardiac magnetic resonance imaging study. Int J Cardiovasc Imaging 2020; 36:1167-1175. [PMID: 32166507 DOI: 10.1007/s10554-020-01812-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 03/04/2020] [Indexed: 10/24/2022]
Abstract
Direct stenting (DS) without pre-dilatation of the culprit lesion might improve myocardial perfusion and prognosis in patients undergoing percutaneous coronary intervention for ST-elevation myocardial infarction (STEMI); however, some studies report conflicting results. We investigated whether DS provides incremental myocardial benefits over conventional stenting (CS) in STEMI patients based on cardiac magnetic resonance imaging (CMR) measures. Reperfused patients who underwent CMR examinations within 1 week of STEMI onset were selected from a multicenter CMR registry of STEMI (NCT: 03768453). Patients were stratified into either a DS or CS group. Each group comprised 137 patients after 1:1 propensity score matching. Major adverse events (MACEs), including death, myocardial re-infarction, re-admission for heart failure, and stroke were noted during a median period of 44 months (interquartile range 32-58 months). DS was associated with larger (p = 0.007) and shorter (p = 0.005) stent sizes than CS. DS and CS achieved comparable angiographic TIMI-3 flow grades (p = 0.86) and myocardial blush grades (p = 0.70). There were no group differences regarding the incidence of CMR manifestations of microvascular dysfunction, including microvascular obstruction (MVO) (p = 0.89) and intramyocardial hemorrhage (p = 0.47), the extent of MVO (p = 0.21), infarction size (p = 0.83), or left ventricular ejection fraction (p = 0.57). Kaplan-Meier analysis revealed similar risks of MACEs (log rank p = 0.909), which occurred in 23.4% of DS and 26.3% of CS patients (p = 0.576). DS did not show any incremental benefits over CS on myocardial impairments as evaluated using CMR.Clinical Trial Registration: Clinicaltrials.gov, NCT: 03768453.
Collapse
|
16
|
Changes in Index of Microcirculatory Resistance during PCI in the Left Anterior Descending Coronary Artery in Relation to Total Length of Implanted Stents. J Interv Cardiol 2019; 2019:1397895. [PMID: 31866770 PMCID: PMC6913317 DOI: 10.1155/2019/1397895] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 10/04/2019] [Accepted: 10/14/2019] [Indexed: 11/18/2022] Open
Abstract
Aim To investigate the relationship between stent length and changes in microvascular resistance during PCI in stable coronary artery disease (CAD). Methods and Results We measured fractional flow reserve (FFR), index of microcirculatory resistance (IMR), and coronary flow reserve (CFR) before and after stenting in 42 consecutive subjects with stable coronary artery undergoing PCI with stent in the LAD. Patients that had very long stent length (38–78 mm) had lower FFR before stenting than patients that had long (23–37 mm) and moderate (12–22 mm) stent length (0.59 (±0.16), 0.70 (±0.12), and 0.75 (±0.07); p=0.002). FFR improved after stenting and more so in subjects with very long stent length compared to long and moderate stent length (0.27 (s.d ± 16), 0.15 (s.d ± 0.12), and 0.12 (s.d ± 0.07); p for interaction = 0.013). Corrected IMR (IMRcorr) increased after stenting in subjects who had very long stent length, whereas IMRcorr was lower after stenting in subjects who had long or moderate stent length (4.6 (s.d. ± 10.7), −1.4 (s.d. ± 9,9), and −4.2 (s.d. ± 7.8); p for interaction = 0.009). Conclusions Changes in IMR during PCI in the LAD in stable CAD seem to be related to total length of stents implanted, possibly influencing post-PCI FFR. Larger studies are needed to confirm the relationship.
Collapse
|
17
|
Yang HM, Yoon MH, Lim HS, Seo KW, Choi BJ, Choi SY, Hwang GS, Tahk SJ. Lipid-Core Plaque Assessed by Near-Infrared Spectroscopy and Procedure Related Microvascular Injury. Korean Circ J 2019; 49:1010-1018. [PMID: 31456364 PMCID: PMC6813158 DOI: 10.4070/kcj.2019.0072] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 04/23/2019] [Accepted: 06/11/2019] [Indexed: 11/11/2022] Open
Abstract
Background and Objectives Microvascular damage due to distal embolization during percutaneous coronary intervention (PCI) is an important cause of periprocedural myocardial infarction. We assessed the lipid-core plaque using near-infrared spectroscopy (NIRS) and microvascular dysfunction invasively with the index of microcirculatory resistance (IMR) and evaluated their relationship. Methods This study is pilot retrospective observational study. We analyzed 39 patients who performed NIRS before and after PCI, while fractional flow reserve, thermo-dilution coronary flow reserve (CFR) and IMR were measured after PCI. The maximum value of lipid core burden index (LCBI) for any of the 4-mm segments at the culprit lesion (culprit LCBI4mm) was calculated at the culprit lesion. We divided the patients into 2 groups using a cutoff of culprit LCBI4mm ≥500. Results Mean pre-PCI LCBI was 333±196 and mean post-PCI IMR was 20±14 U. Post-PCI IMR was higher (15.6±7.3 vs. 42.6±17.6 U, p<0.001) and post-PCI CFR was lower (3.7±2.2 vs. 2.1±1.0, p=0.029) in the high LCBI group. Pre-PCI LCBI was positively correlated with post-PCI IMR (ρ=0.358, p=0.025) and negatively correlated with post-PCI CFR (ρ=−0.494, p=0.001). The incidence of microvascular dysfunction (IMR ≥25 U) was higher in the high LCBI group (9.4% vs. 85.7%, p<0.001). However, there were no significant differences in the incidences of creatine Kinase-MB (9.4% vs. 14.3%, p=0.563) and troponin-I elevation (12.5% vs. 14.3%, p=1.000). Conclusions A large lipid-core plaque at the ‘culprit’ lesion is observed higher incidence of post-PCI microvascular dysfunction after PCI. Prospective study with adequate subject numbers will be needed.
Collapse
Affiliation(s)
- Hyoung Mo Yang
- Department of Cardiology, Ajou University School of Medicine, Suwon, Korea
| | - Myeong Ho Yoon
- Department of Cardiology, Ajou University School of Medicine, Suwon, Korea.
| | - Hong Seok Lim
- Department of Cardiology, Ajou University School of Medicine, Suwon, Korea
| | - Kyoung Woo Seo
- Department of Cardiology, Ajou University School of Medicine, Suwon, Korea
| | - Byoung Joo Choi
- Department of Cardiology, Ajou University School of Medicine, Suwon, Korea
| | - So Yeon Choi
- Department of Cardiology, Ajou University School of Medicine, Suwon, Korea
| | - Gyo Seung Hwang
- Department of Cardiology, Ajou University School of Medicine, Suwon, Korea
| | - Seung Jea Tahk
- Department of Cardiology, Ajou University School of Medicine, Suwon, Korea
| |
Collapse
|
18
|
Rampat R, Williams T, Hildick-Smith D, Cockburn J. The effect of elective implantation of the ABSORB bioresorbable vascular scaffold on coronary microcirculation: Serial assessment using the index of microcirculatory resistance. Microcirculation 2019; 26:e12521. [PMID: 30561875 DOI: 10.1111/micc.12521] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 12/10/2018] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Stenting with metal stents can affect microcirculatory function. The impact of BVS on the microvascular network has not been studied. METHODS A total of 30 patients with bifurcation disease of Medina (X,X,0) scheduled for elective PCI with the ABSORB BVS were studied. Pressure wire studies were performed before and after scaffold implantation and at a mean follow-up of 9 months. At each time point, FFR, IMR, and CFR were calculated using the thermodilution method. RESULTS Following scaffold implantation, FFR change from pre-PCI, post-PCI and follow-up was 0.76, 0.92 and 0.91, respectively (P < 0.001 from pre to post-PCI and P = 0.91 from post-PCI to follow-up). There was a statistically significant improvement between pre- and post-procedural IMR (median 27.7 to 17.9, P = 0.02) and CFR (median 2.2 to 2.9, P = 0.02). Median IMR at follow-up (23.6) remained numerically lower than pre-procedure but this was not statistically significant (P = 0.05). Similarly, while median CFR at follow-up remained at post-procedural level (2.9), this effect did not reach statistical significance (P = 0.06). CONCLUSION There is an immediate reduction in microvascular resistance after elective BVS implantation but this effect is not sustained long term.
Collapse
Affiliation(s)
- Rajiv Rampat
- Sussex Cardiac Centre, Brighton and Sussex University Hospitals, Brighton, UK.,Brighton and Sussex Medical School, Brighton, UK
| | - Timothy Williams
- Sussex Cardiac Centre, Brighton and Sussex University Hospitals, Brighton, UK.,Brighton and Sussex Medical School, Brighton, UK
| | - David Hildick-Smith
- Sussex Cardiac Centre, Brighton and Sussex University Hospitals, Brighton, UK
| | - James Cockburn
- Sussex Cardiac Centre, Brighton and Sussex University Hospitals, Brighton, UK
| |
Collapse
|
19
|
Verma B, Singh A, Saxena AK, Kumar M. Deflated Balloon-Facilitated Direct Stenting in Primary Angioplasty (The DBDS Technique): A Pilot Study. Cardiol Res 2018; 9:284-292. [PMID: 30344826 PMCID: PMC6188044 DOI: 10.14740/cr770w] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 09/27/2018] [Indexed: 01/06/2023] Open
Abstract
Background Several studies and meta-analyses have shown that direct stenting (DS) may improve clinical outcomes in patients with acute ST-elevation myocardial infarction (STEMI). But in most cases, the thrombolysis in myocardial infarction (TIMI) flow remains ≤ 1 after wire placement. We used deflated balloon to facilitate DS in patients with totally occluded culprit arteries. The aim of this study was to evaluate the feasibility, safety and outcomes of this novel technique in patients with STEMI in real-world clinical practice. Methods This was a prospective, observational, single-center pilot study. From September 2016 to June 2018, 454 patients were enrolled in the study. DS was performed when the culprit vessel was visualized with at least TIMI flow grade 1. Patients with complete occlusion of the vessel after wire placement were subjected to deflated balloon-facilitated DS technique (DBDS technique) and DS was done wherever possible. Results DS was done in 74% (n = 336) of the patients and 26% (n = 118) patients received stenting after pre-dilatation (PD). DBDS technique to facilitate DS was successful in 68% patients (211/309). Final TIMI 3 flow was achieved more frequently in the DS group as compared to PD group (96.7% versus 92.3%, P = 0.04). The procedural complications were also significantly lower in DS group (0.6% versus 7.6%, P < 0.001). DS group had significantly lower procedure time (33 ± 19 min versus 41 ± 17 min, P < 0.001), fluoroscopy time (6.2 ± 3.4 min versus 7.8 ± 32 min, P < 0.001), required lesser contrast volume (112 ± 16 mL versus 123 ± 18 mL, P < 0.001) and had lower procedural cost (310 ± 45$ versus 402 ± 56$, P < 0.001). ST-segment resolution > 50% after percutaneous coronary intervention (PCI) were significantly higher in the DS group (85.7% versus 71.1%, P < 0.001). At 30 days, the major adverse cardiac event (MACE) rate was significantly lower in the DS group (2.4% versus 9.3%, P = 0.02), mainly driven by lower rates of target lesion revascularization (TLR) (0.9% versus 4.2%, P = 0.01). Conclusion This cost-effective technique appears to be simple, feasible and safe and is associated with superior clinical outcomes. It helps in maximizing DS and could offer an alternative to PD and aspiration thrombectomy in total occlusion. However, larger studies with longer follow up are required before a wider application of this technique.
Collapse
Affiliation(s)
- Bhupendra Verma
- Department of Cardiology, Shree Krishna Hospital, Kashipur, UK, India
| | - Amrita Singh
- Department of Cardiology, Shree Krishna Hospital, Kashipur, UK, India
| | - Ashwani K Saxena
- Department of Cardiology, Shree Krishna Hospital, Kashipur, UK, India
| | - Manu Kumar
- Department of Cardiology, Shree Krishna Hospital, Kashipur, UK, India
| |
Collapse
|
20
|
Mangiacapra F, Pellicano M, Di Serafino L, Bressi E, Peace AJ, Di Gioia G, Morisco C, Bartunek J, Wijns W, Bruyne BD, Barbato E. Platelet reactivity and coronary microvascular impairment after percutaneous revascularization in stable patients receiving clopidogrel or prasugrel. Atherosclerosis 2018; 278:23-28. [PMID: 30236867 DOI: 10.1016/j.atherosclerosis.2018.08.044] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 07/15/2018] [Accepted: 08/29/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND AIMS Increased platelet reactivity (PR) associated with variable degree of coronary microvascular impairment has been reported in patients on clopidogrel after elective percutaneous coronary intervention (PCI). Prasugrel provides more potent platelet inhibition than clopidogrel, though it is unknown whether it might also prevent PCI-related platelet activation. In stable patients undergoing elective PCI, we compared: (1) the effects of prasugrel vs. clopidogrel on peri-procedural variations of PR and (2) the correlation of platelet inhibition potency with PCI-induced coronary microvascular impairment. METHODS Forty thienopyridine-naive patients were randomly assigned to a loading dose of either prasugrel 60 mg (n = 20) or clopidogrel 600 mg (n = 20) at least 12 h before PCI. At the time of PCI, we assessed adenosine diphosphate (ADP)-induced PR with the Multiplate Analyzer, and the pressure-derived index of microvascular resistance (IMR) in the treated coronary, both at baseline and post-procedure. RESULTS ADP-induced PR was significantly lower in the prasugrel compared with clopidogrel group both at baseline (16.0 ± 8.7 vs. 33.9 ± 18.0 aggregation units [AU], p < 0.001) and post-procedure (16.2 ± 9.0 vs. 39.0 ± 18.6 AU, p < 0.001). A significant peri-procedural increase in PR was observed in the clopidogrel group (p = 0.008), but not in the prasugrel group (p = 0.822). A significant correlation was found between IMR and PR both at baseline (r = 0.458, p = 0.003) and post-PCI (r = 0.487, p = 0.001). CONCLUSIONS A loading dose of prasugrel compared with clopidogrel is able to attenuate PCI-related increase in PR in patients with stable CAD undergoing PCI, which might contribute to the beneficial effect of this drug on peri-procedural coronary microvascular function.
Collapse
Affiliation(s)
- Fabio Mangiacapra
- Cardiovascular Research Center Aalst, OLV Clinic, Aalst, Belgium; Unit of Cardiovascular Science, Department of Medicine, Campus Bio-Medico University, Rome, Italy
| | | | | | - Edoardo Bressi
- Unit of Cardiovascular Science, Department of Medicine, Campus Bio-Medico University, Rome, Italy
| | - Aaron J Peace
- Cardiovascular Research Center Aalst, OLV Clinic, Aalst, Belgium; Altnagelvin Hospital, WHSCT, Londonderry, Northern Ireland, United Kingdom
| | | | - Carmine Morisco
- Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | - Jozef Bartunek
- Cardiovascular Research Center Aalst, OLV Clinic, Aalst, Belgium
| | - William Wijns
- Cardiovascular Research Center Aalst, OLV Clinic, Aalst, Belgium; The Lambe Institute for Translational Medicine and Curam, National University of Ireland, Galway, Ireland; Saolta University Healthcare Group, Galway, Ireland
| | | | - Emanuele Barbato
- Cardiovascular Research Center Aalst, OLV Clinic, Aalst, Belgium; Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy.
| |
Collapse
|
21
|
Fearon WF, Dash R. Index of Microcirculatory Resistance and Infarct Size. JACC Cardiovasc Imaging 2018; 12:849-851. [PMID: 29680353 DOI: 10.1016/j.jcmg.2018.04.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 04/04/2018] [Accepted: 04/05/2018] [Indexed: 11/25/2022]
Affiliation(s)
- William F Fearon
- Division of Cardiovascular Medicine and Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California.
| | - Rajesh Dash
- Division of Cardiovascular Medicine and Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California
| |
Collapse
|
22
|
Abstract
Traditionally, invasive coronary physiological assessment has focused on the epicardial coronary artery. More recently, appreciation of the importance of the coronary microvasculature in determining patient outcomes has grown. Several invasive modalities for interrogating microvascular function have been proposed. Angiographic techniques have been limited by their qualitative and subjective nature. Doppler wire-derived coronary flow reserve has been applied in research studies, but its clinical role has been limited by its lack of reproducibility, its lack of a clear normal value, and the fact that it is not specific for the microvasculature but interrogates the entire coronary circulation. The index of microcirculatory resistance—a thermodilution-derived measure of the minimum achievable microvascular resistance—is relatively easy to measure, more reproducible, has a clearer normal value, and is independent of epicardial coronary artery stenosis. The index of microcirculatory resistance has been shown to have prognostic value in patients with ST-segment–elevation myocardial infarction and cardiac allograft vasculopathy after heart transplantation. Emerging data demonstrate its role in evaluating patients with chest pain and nonobstructive coronary artery disease. Increasingly, the index of microcirculatory resistance is used as a reference standard for invasively assessing the microvasculature in clinical trials.
Collapse
Affiliation(s)
- William F. Fearon
- From the Division of Cardiovascular Medicine, Stanford University, CA
| | - Yuhei Kobayashi
- From the Division of Cardiovascular Medicine, Stanford University, CA
| |
Collapse
|
23
|
Kanaji Y, Murai T, Yonetsu T, Usui E, Araki M, Matsuda J, Hoshino M, Yamaguchi M, Niida T, Hada M, Ichijyo S, Hamaya R, Kanno Y, Isobe M, Kakuta T. Effect of Elective Percutaneous Coronary Intervention on Hyperemic Absolute Coronary Blood Flow Volume and Microvascular Resistance. Circ Cardiovasc Interv 2017; 10:CIRCINTERVENTIONS.117.005073. [DOI: 10.1161/circinterventions.117.005073] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 08/23/2017] [Indexed: 11/16/2022]
Affiliation(s)
- Yoshihisa Kanaji
- From the Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Japan (Y.K., T.M., T.Y., E.U., M.A., J.M., M.H., M.Y., T.N., M.H., S.I., R.H., Y.K., T.K.) and Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Japan (M.I.)
| | - Tadashi Murai
- From the Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Japan (Y.K., T.M., T.Y., E.U., M.A., J.M., M.H., M.Y., T.N., M.H., S.I., R.H., Y.K., T.K.) and Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Japan (M.I.)
| | - Taishi Yonetsu
- From the Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Japan (Y.K., T.M., T.Y., E.U., M.A., J.M., M.H., M.Y., T.N., M.H., S.I., R.H., Y.K., T.K.) and Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Japan (M.I.)
| | - Eisuke Usui
- From the Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Japan (Y.K., T.M., T.Y., E.U., M.A., J.M., M.H., M.Y., T.N., M.H., S.I., R.H., Y.K., T.K.) and Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Japan (M.I.)
| | - Makoto Araki
- From the Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Japan (Y.K., T.M., T.Y., E.U., M.A., J.M., M.H., M.Y., T.N., M.H., S.I., R.H., Y.K., T.K.) and Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Japan (M.I.)
| | - Junji Matsuda
- From the Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Japan (Y.K., T.M., T.Y., E.U., M.A., J.M., M.H., M.Y., T.N., M.H., S.I., R.H., Y.K., T.K.) and Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Japan (M.I.)
| | - Masahiro Hoshino
- From the Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Japan (Y.K., T.M., T.Y., E.U., M.A., J.M., M.H., M.Y., T.N., M.H., S.I., R.H., Y.K., T.K.) and Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Japan (M.I.)
| | - Masao Yamaguchi
- From the Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Japan (Y.K., T.M., T.Y., E.U., M.A., J.M., M.H., M.Y., T.N., M.H., S.I., R.H., Y.K., T.K.) and Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Japan (M.I.)
| | - Takayuki Niida
- From the Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Japan (Y.K., T.M., T.Y., E.U., M.A., J.M., M.H., M.Y., T.N., M.H., S.I., R.H., Y.K., T.K.) and Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Japan (M.I.)
| | - Masahiro Hada
- From the Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Japan (Y.K., T.M., T.Y., E.U., M.A., J.M., M.H., M.Y., T.N., M.H., S.I., R.H., Y.K., T.K.) and Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Japan (M.I.)
| | - Sadamitsu Ichijyo
- From the Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Japan (Y.K., T.M., T.Y., E.U., M.A., J.M., M.H., M.Y., T.N., M.H., S.I., R.H., Y.K., T.K.) and Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Japan (M.I.)
| | - Rikuta Hamaya
- From the Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Japan (Y.K., T.M., T.Y., E.U., M.A., J.M., M.H., M.Y., T.N., M.H., S.I., R.H., Y.K., T.K.) and Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Japan (M.I.)
| | - Yoshinori Kanno
- From the Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Japan (Y.K., T.M., T.Y., E.U., M.A., J.M., M.H., M.Y., T.N., M.H., S.I., R.H., Y.K., T.K.) and Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Japan (M.I.)
| | - Mitsuaki Isobe
- From the Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Japan (Y.K., T.M., T.Y., E.U., M.A., J.M., M.H., M.Y., T.N., M.H., S.I., R.H., Y.K., T.K.) and Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Japan (M.I.)
| | - Tsunekazu Kakuta
- From the Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Japan (Y.K., T.M., T.Y., E.U., M.A., J.M., M.H., M.Y., T.N., M.H., S.I., R.H., Y.K., T.K.) and Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Japan (M.I.)
| |
Collapse
|
24
|
Magalhaes MA, Minha S, Lhermusier T, Pendyala L, Escarcega RO, Baker NC, Torguson R, Satler LF, Pichard A, Waksman R. Does direct stenting with drug-eluting stents improve outcome? A meta-analysis of 10,900 patients. Catheter Cardiovasc Interv 2017; 90:213-222. [PMID: 27862877 DOI: 10.1002/ccd.26861] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 10/04/2016] [Accepted: 10/16/2016] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The aim of this study is to summarize the outcomes of patients undergoing direct stenting (DS) with drug-eluting stents (DES) compared to those who underwent balloon predilatation. BACKGROUND DS has been associated with improved outcomes in the bare-metal stent era. Although DS with DES implantation has been increasingly adopted in clinical practice, its safety and effectiveness remain controversial. METHODS The search criteria identified 546 studies in the Medline/PubMed, Cochrane, and EMBASE databases from 2001 to July 2014. From these, seven studies totaling 10,900 patients were selected. Summarized estimates [odds ratio (OR) and 95% confidence intervals] were obtained using a random-effects model. The primary outcomes were a composite of major adverse cardiac events (MACE), including all-cause death, myocardial infarction (MI), and repeat revascularization. The secondary outcomes included a composite of death and MI and the rates of target lesion revascularization (TLR). RESULTS Overall, 4101 (38%) and 6799 (62%) patients underwent DS with DES and balloon pre-dilatation, respectively. DS with DES reduced the likelihood of MACE (OR: 0.81 [0.71-0.93]). Additionally, DS with DES was associated with reduced rates of death/MI (OR: 0.76 [0.62-0.92]), and TLR (OR: 0.66 [0.44-0.98]). CONCLUSIONS DS with DES is safe and may be associated with better outcomes in selected patients. © 2016 Wiley Periodicals, Inc.
Collapse
Affiliation(s)
- Marco A Magalhaes
- Department of Internal Medicine, MedStar Washington Hospital Center, Washington, DC.,Division of Cardiology, MedStar Washington Hospital Center, Washington, DC.,Department of Cardiology/Division of Interventional Cardiology, Hospital Alemão Oswaldo Cruz, Sao Paulo, Brazil
| | - Sa'ar Minha
- Department of Internal Medicine, MedStar Washington Hospital Center, Washington, DC.,Division of Cardiology, MedStar Washington Hospital Center, Washington, DC
| | - Thibault Lhermusier
- Department of Internal Medicine, MedStar Washington Hospital Center, Washington, DC.,Division of Cardiology, MedStar Washington Hospital Center, Washington, DC
| | - Lakshmana Pendyala
- Department of Internal Medicine, MedStar Washington Hospital Center, Washington, DC.,Division of Cardiology, MedStar Washington Hospital Center, Washington, DC
| | - Ricardo O Escarcega
- Department of Internal Medicine, MedStar Washington Hospital Center, Washington, DC.,Division of Cardiology, MedStar Washington Hospital Center, Washington, DC
| | - Nevin C Baker
- Department of Internal Medicine, MedStar Washington Hospital Center, Washington, DC.,Division of Cardiology, MedStar Washington Hospital Center, Washington, DC
| | - Rebecca Torguson
- Department of Internal Medicine, MedStar Washington Hospital Center, Washington, DC.,Division of Cardiology, MedStar Washington Hospital Center, Washington, DC
| | - Lowell F Satler
- Department of Internal Medicine, MedStar Washington Hospital Center, Washington, DC.,Division of Cardiology, MedStar Washington Hospital Center, Washington, DC
| | - Augusto Pichard
- Department of Internal Medicine, MedStar Washington Hospital Center, Washington, DC.,Division of Cardiology, MedStar Washington Hospital Center, Washington, DC
| | - Ron Waksman
- Department of Internal Medicine, MedStar Washington Hospital Center, Washington, DC.,Division of Cardiology, MedStar Washington Hospital Center, Washington, DC
| |
Collapse
|
25
|
Outcomes of direct stenting in patients with ST-elevated myocardial infarction. Herz 2017; 43:447-454. [DOI: 10.1007/s00059-017-4581-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Revised: 05/14/2017] [Accepted: 05/14/2017] [Indexed: 11/26/2022]
|
26
|
Cerrato E, Quirós A, Echavarría-Pinto M, Mejia-Renteria H, Aldazabal A, Ryan N, Gonzalo N, Jimenez-Quevedo P, Nombela-Franco L, Salinas P, Núñez-Gil IJ, Rumoroso JR, Fernández-Ortiz A, Macaya C, Escaned J. PRotective Effect on the coronary microcirculation of patients with DIabetes by Clopidogrel or Ticagrelor (PREDICT): study rationale and design. A randomized multicenter clinical trial using intracoronary multimodal physiology. Cardiovasc Diabetol 2017; 16:68. [PMID: 28526024 PMCID: PMC5438565 DOI: 10.1186/s12933-017-0543-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 04/28/2017] [Indexed: 12/25/2022] Open
Abstract
Background In diabetic patients a predisposed coronary microcirculation along with a higher risk of distal particulate embolization during primary percutaneous intervention (PCI) increases the risk of peri-procedural microcirculatory damage. However, new antiplatelet agents, in particular Ticagrelor, may protect the microcirculation through its adenosine-mediated vasodilatory effects. Methods PREDICT is an original, prospective, randomized, multicenter controlled study designed to investigate the protective effect of Ticagrelor on the microcirculation during PCI in patient with diabetes mellitus type 2 or pre-diabetic status. The primary endpoints of this study aim to test (i) the decrease in microcirculatory resistance with antiplatelet therapy (Ticagrelor > Clopidogrel; mechanistic effect) and (ii) the relative microcirculatory protection of Ticagrelor compared to Clopidogrel during PCI (Ticagrelor < Clopidogrel; protective effect). Conclusions PREDICT will be the first multicentre clinical trial to test the adenosine-mediated vasodilatory effect of Ticagrelor on the microcirculation during PCI in diabetic patients. The results will provide important insights into the prospective beneficial effect of this drug in preventing microvascular impairment related to PCI (http://www.clinicaltrials.gov No. NCT02698618). Electronic supplementary material The online version of this article (doi:10.1186/s12933-017-0543-5) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Enrico Cerrato
- Unidad de Cardiología Intervencionista, Hospital Clínico San Carlos, 28040, Madrid, Spain. .,Interventional Cardiology Unit, San Luigi Gonzaga University Hospital, Orbassano and Infermi Hospital, Rivoli, Turin, Italy.
| | - Alicia Quirós
- Unidad de Cardiología Intervencionista, Hospital Clínico San Carlos, 28040, Madrid, Spain
| | - Mauro Echavarría-Pinto
- Unidad de Cardiología Intervencionista, Hospital Clínico San Carlos, 28040, Madrid, Spain
| | - Hernan Mejia-Renteria
- Unidad de Cardiología Intervencionista, Hospital Clínico San Carlos, 28040, Madrid, Spain
| | - Andres Aldazabal
- Unidad de Cardiología Intervencionista, Hospital Clínico San Carlos, 28040, Madrid, Spain
| | - Nicola Ryan
- Unidad de Cardiología Intervencionista, Hospital Clínico San Carlos, 28040, Madrid, Spain
| | - Nieves Gonzalo
- Unidad de Cardiología Intervencionista, Hospital Clínico San Carlos, 28040, Madrid, Spain
| | - Pilar Jimenez-Quevedo
- Unidad de Cardiología Intervencionista, Hospital Clínico San Carlos, 28040, Madrid, Spain
| | - Luis Nombela-Franco
- Unidad de Cardiología Intervencionista, Hospital Clínico San Carlos, 28040, Madrid, Spain
| | - Pablo Salinas
- Unidad de Cardiología Intervencionista, Hospital Clínico San Carlos, 28040, Madrid, Spain
| | - Iván J Núñez-Gil
- Unidad de Cardiología Intervencionista, Hospital Clínico San Carlos, 28040, Madrid, Spain
| | | | | | - Carlos Macaya
- Unidad de Cardiología Intervencionista, Hospital Clínico San Carlos, 28040, Madrid, Spain
| | - Javier Escaned
- Unidad de Cardiología Intervencionista, Hospital Clínico San Carlos, 28040, Madrid, Spain
| |
Collapse
|
27
|
He GX, Xie J, Jiang H, Tan W, Xu B. Effects of Qishen Yiqi Dripping Pills (芪参益气滴丸) in Reducing Myocardial Injury and Preserving Microvascular Function in Patients Undergoing Elective Percutaneous Coronary Intervention: A Pilot Randomized Study. Chin J Integr Med 2017; 24:193-199. [DOI: 10.1007/s11655-017-2955-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Indexed: 10/19/2022]
|
28
|
Carrick D, Haig C, Ahmed N, Carberry J, Yue May VT, McEntegart M, Petrie MC, Eteiba H, Lindsay M, Hood S, Watkins S, Davie A, Mahrous A, Mordi I, Ford I, Radjenovic A, Oldroyd KG, Berry C. Comparative Prognostic Utility of Indexes of Microvascular Function Alone or in Combination in Patients With an Acute ST-Segment-Elevation Myocardial Infarction. Circulation 2016; 134:1833-1847. [PMID: 27803036 PMCID: PMC5131697 DOI: 10.1161/circulationaha.116.022603] [Citation(s) in RCA: 121] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Accepted: 10/05/2016] [Indexed: 01/11/2023]
Abstract
Supplemental Digital Content is available in the text. Background: Primary percutaneous coronary intervention is frequently successful at restoring coronary artery blood flow in patients with acute ST-segment–elevation myocardial infarction; however, failed myocardial reperfusion commonly passes undetected in up to half of these patients. The index of microvascular resistance (IMR) is a novel invasive measure of coronary microvascular function. We aimed to investigate the pathological and prognostic significance of an IMR>40, alone or in combination with a coronary flow reserve (CFR≤2.0), in the culprit artery after emergency percutaneous coronary intervention for acute ST-segment–elevation myocardial infarction. Methods: Patients with acute ST-segment–elevation myocardial infarction were prospectively enrolled during emergency percutaneous coronary intervention and categorized according to IMR (≤40 or >40) and CFR (≤2.0 or >2.0). Cardiac magnetic resonance imaging was acquired 2 days and 6 months after myocardial infarction. All-cause death or first heart failure hospitalization was a prespecified outcome (median follow-up, 845 days). Results: IMR and CFR were measured in the culprit artery at the end of percutaneous coronary intervention in 283 patients with ST-segment–elevation myocardial infarction (mean±SD age, 60±12 years; 73% male). The median IMR and CFR were 25 (interquartile range, 15–48) and 1.6 (interquartile range, 1.1–2.1), respectively. An IMR>40 was a multivariable associate of myocardial hemorrhage (odds ratio, 2.10; 95% confidence interval, 1.03–4.27; P=0.042). An IMR>40 was closely associated with microvascular obstruction. Symptom-to-reperfusion time, TIMI (Thrombolysis in Myocardial Infarction) blush grade, and no (≤30%) ST-segment resolution were not associated with these pathologies. An IMR>40 was a multivariable associate of the changes in left ventricular ejection fraction (coefficient, −2.12; 95% confidence interval, −4.02 to −0.23; P=0.028) and left ventricular end-diastolic volume (coefficient, 7.85; 95% confidence interval, 0.41–15.29; P=0.039) at 6 months independently of infarct size. An IMR>40 (odds ratio, 4.36; 95% confidence interval, 2.10–9.06; P<0.001) was a multivariable associate of all-cause death or heart failure. Compared with an IMR>40, the combination of IMR>40 and CFR≤2.0 did not have incremental prognostic value. Conclusions: An IMR>40 is a multivariable associate of left ventricular and clinical outcomes after ST-segment–elevation myocardial infarction independently of the infarction size. Compared with standard clinical measures of the efficacy of myocardial reperfusion, including the ischemic time, ST-segment elevation, angiographic blush grade, and CFR, IMR has superior clinical value for risk stratification and may be considered a reference test for failed myocardial reperfusion. Clinical Trial Registration: URL: https//www.clinicaltrials.gov. Unique identifier: NCT02072850.
Collapse
Affiliation(s)
- David Carrick
- From BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences (D.C., N.A., J.C., V.T.Y.M., M.M., M.C.P., I.M., A.R., K.G.O., C.B.), and Robertson Centre for Biostatistics (C.H., I.F.), University of Glasgow, Glasgow, UK; and West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, UK (D.C., N.A., J.C., V.T.Y.M., M.M., M.C.P., H.E., M.L., S.H.., S.W., A.D., A.M., I.M., K.G.O., C.B.)
| | - Caroline Haig
- From BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences (D.C., N.A., J.C., V.T.Y.M., M.M., M.C.P., I.M., A.R., K.G.O., C.B.), and Robertson Centre for Biostatistics (C.H., I.F.), University of Glasgow, Glasgow, UK; and West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, UK (D.C., N.A., J.C., V.T.Y.M., M.M., M.C.P., H.E., M.L., S.H.., S.W., A.D., A.M., I.M., K.G.O., C.B.)
| | - Nadeem Ahmed
- From BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences (D.C., N.A., J.C., V.T.Y.M., M.M., M.C.P., I.M., A.R., K.G.O., C.B.), and Robertson Centre for Biostatistics (C.H., I.F.), University of Glasgow, Glasgow, UK; and West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, UK (D.C., N.A., J.C., V.T.Y.M., M.M., M.C.P., H.E., M.L., S.H.., S.W., A.D., A.M., I.M., K.G.O., C.B.)
| | - Jaclyn Carberry
- From BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences (D.C., N.A., J.C., V.T.Y.M., M.M., M.C.P., I.M., A.R., K.G.O., C.B.), and Robertson Centre for Biostatistics (C.H., I.F.), University of Glasgow, Glasgow, UK; and West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, UK (D.C., N.A., J.C., V.T.Y.M., M.M., M.C.P., H.E., M.L., S.H.., S.W., A.D., A.M., I.M., K.G.O., C.B.)
| | - Vannesa Teng Yue May
- From BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences (D.C., N.A., J.C., V.T.Y.M., M.M., M.C.P., I.M., A.R., K.G.O., C.B.), and Robertson Centre for Biostatistics (C.H., I.F.), University of Glasgow, Glasgow, UK; and West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, UK (D.C., N.A., J.C., V.T.Y.M., M.M., M.C.P., H.E., M.L., S.H.., S.W., A.D., A.M., I.M., K.G.O., C.B.)
| | - Margaret McEntegart
- From BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences (D.C., N.A., J.C., V.T.Y.M., M.M., M.C.P., I.M., A.R., K.G.O., C.B.), and Robertson Centre for Biostatistics (C.H., I.F.), University of Glasgow, Glasgow, UK; and West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, UK (D.C., N.A., J.C., V.T.Y.M., M.M., M.C.P., H.E., M.L., S.H.., S.W., A.D., A.M., I.M., K.G.O., C.B.)
| | - Mark C Petrie
- From BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences (D.C., N.A., J.C., V.T.Y.M., M.M., M.C.P., I.M., A.R., K.G.O., C.B.), and Robertson Centre for Biostatistics (C.H., I.F.), University of Glasgow, Glasgow, UK; and West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, UK (D.C., N.A., J.C., V.T.Y.M., M.M., M.C.P., H.E., M.L., S.H.., S.W., A.D., A.M., I.M., K.G.O., C.B.)
| | - Hany Eteiba
- From BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences (D.C., N.A., J.C., V.T.Y.M., M.M., M.C.P., I.M., A.R., K.G.O., C.B.), and Robertson Centre for Biostatistics (C.H., I.F.), University of Glasgow, Glasgow, UK; and West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, UK (D.C., N.A., J.C., V.T.Y.M., M.M., M.C.P., H.E., M.L., S.H.., S.W., A.D., A.M., I.M., K.G.O., C.B.)
| | - Mitchell Lindsay
- From BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences (D.C., N.A., J.C., V.T.Y.M., M.M., M.C.P., I.M., A.R., K.G.O., C.B.), and Robertson Centre for Biostatistics (C.H., I.F.), University of Glasgow, Glasgow, UK; and West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, UK (D.C., N.A., J.C., V.T.Y.M., M.M., M.C.P., H.E., M.L., S.H.., S.W., A.D., A.M., I.M., K.G.O., C.B.)
| | - Stuart Hood
- From BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences (D.C., N.A., J.C., V.T.Y.M., M.M., M.C.P., I.M., A.R., K.G.O., C.B.), and Robertson Centre for Biostatistics (C.H., I.F.), University of Glasgow, Glasgow, UK; and West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, UK (D.C., N.A., J.C., V.T.Y.M., M.M., M.C.P., H.E., M.L., S.H.., S.W., A.D., A.M., I.M., K.G.O., C.B.)
| | - Stuart Watkins
- From BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences (D.C., N.A., J.C., V.T.Y.M., M.M., M.C.P., I.M., A.R., K.G.O., C.B.), and Robertson Centre for Biostatistics (C.H., I.F.), University of Glasgow, Glasgow, UK; and West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, UK (D.C., N.A., J.C., V.T.Y.M., M.M., M.C.P., H.E., M.L., S.H.., S.W., A.D., A.M., I.M., K.G.O., C.B.)
| | - Andrew Davie
- From BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences (D.C., N.A., J.C., V.T.Y.M., M.M., M.C.P., I.M., A.R., K.G.O., C.B.), and Robertson Centre for Biostatistics (C.H., I.F.), University of Glasgow, Glasgow, UK; and West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, UK (D.C., N.A., J.C., V.T.Y.M., M.M., M.C.P., H.E., M.L., S.H.., S.W., A.D., A.M., I.M., K.G.O., C.B.)
| | - Ahmed Mahrous
- From BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences (D.C., N.A., J.C., V.T.Y.M., M.M., M.C.P., I.M., A.R., K.G.O., C.B.), and Robertson Centre for Biostatistics (C.H., I.F.), University of Glasgow, Glasgow, UK; and West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, UK (D.C., N.A., J.C., V.T.Y.M., M.M., M.C.P., H.E., M.L., S.H.., S.W., A.D., A.M., I.M., K.G.O., C.B.)
| | - Ify Mordi
- From BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences (D.C., N.A., J.C., V.T.Y.M., M.M., M.C.P., I.M., A.R., K.G.O., C.B.), and Robertson Centre for Biostatistics (C.H., I.F.), University of Glasgow, Glasgow, UK; and West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, UK (D.C., N.A., J.C., V.T.Y.M., M.M., M.C.P., H.E., M.L., S.H.., S.W., A.D., A.M., I.M., K.G.O., C.B.)
| | - Ian Ford
- From BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences (D.C., N.A., J.C., V.T.Y.M., M.M., M.C.P., I.M., A.R., K.G.O., C.B.), and Robertson Centre for Biostatistics (C.H., I.F.), University of Glasgow, Glasgow, UK; and West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, UK (D.C., N.A., J.C., V.T.Y.M., M.M., M.C.P., H.E., M.L., S.H.., S.W., A.D., A.M., I.M., K.G.O., C.B.)
| | - Aleksandra Radjenovic
- From BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences (D.C., N.A., J.C., V.T.Y.M., M.M., M.C.P., I.M., A.R., K.G.O., C.B.), and Robertson Centre for Biostatistics (C.H., I.F.), University of Glasgow, Glasgow, UK; and West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, UK (D.C., N.A., J.C., V.T.Y.M., M.M., M.C.P., H.E., M.L., S.H.., S.W., A.D., A.M., I.M., K.G.O., C.B.)
| | - Keith G Oldroyd
- From BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences (D.C., N.A., J.C., V.T.Y.M., M.M., M.C.P., I.M., A.R., K.G.O., C.B.), and Robertson Centre for Biostatistics (C.H., I.F.), University of Glasgow, Glasgow, UK; and West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, UK (D.C., N.A., J.C., V.T.Y.M., M.M., M.C.P., H.E., M.L., S.H.., S.W., A.D., A.M., I.M., K.G.O., C.B.)
| | - Colin Berry
- From BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences (D.C., N.A., J.C., V.T.Y.M., M.M., M.C.P., I.M., A.R., K.G.O., C.B.), and Robertson Centre for Biostatistics (C.H., I.F.), University of Glasgow, Glasgow, UK; and West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, UK (D.C., N.A., J.C., V.T.Y.M., M.M., M.C.P., H.E., M.L., S.H.., S.W., A.D., A.M., I.M., K.G.O., C.B.).
| |
Collapse
|
29
|
Murai T, Lee T, Kanaji Y, Matsuda J, Usui E, Araki M, Niida T, Hishikari K, Ichijyo S, Hamaya R, Yonetsu T, Isobe M, Kakuta T. The influence of elective percutaneous coronary intervention on microvascular resistance: a serial assessment using the index of microcirculatory resistance. Am J Physiol Heart Circ Physiol 2016; 311:H520-31. [DOI: 10.1152/ajpheart.00837.2015] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 06/23/2016] [Indexed: 12/31/2022]
Abstract
This study investigates whether hyperemic microvascular resistance (MR) is influenced by elective percutaneous coronary intervention (PCI) by using the index of microcirculatory resistance (IMR). Seventy-one consecutive patients with stable angina pectoris undergoing elective PCI were prospectively studied. The IMR was measured before and after PCI and at the 10-mo follow-up. The IMR significantly decreased until follow-up; the pre-PCI, post-PCI, and follow-up IMRs had a median of 19.8 (interquartile range, 14.6–28.9), 16.2 (11.8–22.1), and 14.8 (11.8–18.7), respectively ( P < 0.001). The pre-PCI IMR was significantly correlated with the change in IMR between pre- and post-PCI ( r = 0.84, P < 0.001) and between pre-PCI and follow-up ( r = 0.93, P < 0.001). Pre-PCI IMR values were significantly higher in territories with decreases in IMR than in those with increases in IMR [pre-PCI IMR: 25.4 (18.4–35.5) vs. 12.5 (9.4–16.8), P < 0.001]. At follow-up, IMR values in territories showing decreases in IMR were significantly lower than those with increases in IMR [IMR at follow-up: 13.9 (10.9–17.6) vs. 16.6 (14.0–21.4), P = 0.013]. The IMR decrease was significantly associated with a greater shortening of mean transit time, indicating increases in coronary flow ( P < 0.001). The optimal cut-off values of pre-PCI IMR to predict a decrease in IMR after PCI and at follow-up were 16.8 and 17.0, respectively. In conclusion, elective PCI affected hyperemic MR and its change was associated with pre-PCI MR, resulting in showing a wide distribution. Overall hyperemic MR significantly decreased until follow-up. The modified hyperemic MR introduced by PCI may affect post-PCI coronary flow.
Collapse
Affiliation(s)
- Tadashi Murai
- Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan; and
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tetsumin Lee
- Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan; and
| | - Yoshihisa Kanaji
- Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan; and
| | - Junji Matsuda
- Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan; and
| | - Eisuke Usui
- Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan; and
| | - Makoto Araki
- Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan; and
| | - Takayuki Niida
- Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan; and
| | - Keiichi Hishikari
- Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan; and
| | - Sadamitsu Ichijyo
- Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan; and
| | - Rikuta Hamaya
- Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan; and
| | - Taishi Yonetsu
- Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan; and
| | - Mitsuaki Isobe
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tsunekazu Kakuta
- Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan; and
| |
Collapse
|
30
|
The index of microcirculatory resistance in the physiologic assessment of the coronary microcirculation. Coron Artery Dis 2016; 26 Suppl 1:e15-26. [PMID: 26247265 DOI: 10.1097/mca.0000000000000213] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The coronary microcirculation plays a critical role in normal cardiac physiology as well as in many disease states. However, methods to evaluate the function of the coronary microvessels have been limited by technical and theoretical issues. Recently, the index of microcirculatory resistance (IMR) has been proposed and validated as a simple and specific invasive method of assessing the coronary microcirculation. By relying on the thermodilution theory and using a pressure-temperature sensor guidewire, IMR provides a measurement of the minimum achievable microcirculatory resistance in a target coronary artery territory, enabling a quantitative assessment of the microvascular integrity. Unlike indices such as coronary flow reserve, IMR is highly reproducible and independent of hemodynamic changes. In ST-elevation myocardial infarction, IMR predicts myocardial recovery and long-term mortality, whereas in patients with stable coronary artery disease, preintervention IMR predicts the occurrence of periprocedural myocardial infarction. Increasingly, research has focused on IMR-guided interventions of the microcirculation, with the aim of preventing and/or treating the microcirculatory dysfunction that commonly accompanies the epicardial coronary disease. In the present review, we will discuss the theoretical and practical basis for IMR, the clinical studies supporting it, and the future lines of research using this novel tool.
Collapse
|
31
|
Hwang D, Lee JM, Koo BK. Physiologic Assessment of Coronary Artery Disease: Focus on Fractional Flow Reserve. Korean J Radiol 2016; 17:307-20. [PMID: 27134520 PMCID: PMC4842851 DOI: 10.3348/kjr.2016.17.3.307] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 02/29/2016] [Indexed: 01/10/2023] Open
Abstract
The presence of myocardial ischemia is the most important prognostic factor in patients with ischemic heart disease. Fractional flow reserve (FFR) is a gold standard invasive method used to detect the stenosis-specific myocardial ischemia. FFR-guided revascularization strategy is superior to angiography-guided strategy. The recently developed hyperemia-free index, instantaneous wave free ratio is being actively investigated. A non-invasive FFR derived from coronary CT angiography is now used in clinical practice. Due to rapid expansion of invasive and non-invasive physiologic assessment, comprehensive understanding of the role and potential pitfalls of each modality are required for its application. In this review, we focus on the basic and clinical aspects of physiologic assessment in ischemic heart disease.
Collapse
Affiliation(s)
- Doyeon Hwang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul 03080, Korea
| | - Joo Myung Lee
- Department of Internal Medicine and Cardiovascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Bon-Kwon Koo
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul 03080, Korea
- Institute of Aging, Seoul National University, Seoul 03087, Korea
| |
Collapse
|
32
|
Geir Solberg O, Aaberge L, Ragnarsson A, Aas M, Endresen K, Šaltytė Benth J, Gullestad L, Stavem K. Comparison of simplified and comprehensive methods for assessing the index of microvascular resistance in heart transplant recipients. Catheter Cardiovasc Interv 2016; 87:283-90. [PMID: 26525162 DOI: 10.1002/ccd.26283] [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: 03/31/2015] [Revised: 08/06/2015] [Accepted: 10/03/2015] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The objectives of the present study were to compare a simplified and a comprehensive method of estimating the index of microvascular resistance (IMR) and assess the changes from 7-11 weeks to 1 year after heart transplant (HTx). BACKGROUND he IMR is specific to the microvasculature and reflects the status of the microcirculation in cardiac patients and can be estimated via a simplified method (IMR(s)) or a comprehensive method (IMR(c)). The calculation for the latter includes coronary wedge pressure and central venous pressure. METHODS Consecutively transplanted patients (n = 48) underwent left and right heart catheterization including physiological evaluation at two time points post-HTx. The agreement between the values of IMR obtained using the IMR(s) and IMR(c) methods were assessed using Bland-Altman analysis. The agreements and differences were assessed using mixed model analysis. RESULTS The mean bias between IMRs and IMRc was 1.3 mm Hg·s (95% limits of agreement: -1.2, 3.8 mm Hg). Between 7-11 weeks and 1 year post-HTx there was a significant decline in IMR(s) values (P = 0.03) but a smaller and statistically nonsignificant decline in IMR(c) values (P = 0.13). The significant difference (P = 0.04) between IMR(c) and IMR(s) 7-11 weeks post-HTx was no longer present at 1 year (P = 0.24). CONCLUSIONS The IMR(s) method resulted in slightly higher IMR estimates and exhibited a somewhat larger change over the 10-month follow-up period than the IMR(c) method. However, the differences between the methods were small and unlikely to be of clinical importance.
Collapse
Affiliation(s)
- Ole Geir Solberg
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway.,Institue of Clinical Medicine, Faculty of Medicine, University of Oslo, Norway
| | - Lars Aaberge
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Asgrimur Ragnarsson
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Marit Aas
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Knut Endresen
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Jūratė Šaltytė Benth
- Institute of Clinical Medicine, Campus Ahus, University of Oslo, Oslo, Norway.,HØKH, Research Centre, Akershus University Hospital, Lørenskog, Norway
| | - Lars Gullestad
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway.,K.G. Jebsen Cardiac Research Centre and Centre for Heart Failure Research, Faculty of Medicine, University of Oslo, Norway
| | - Knut Stavem
- Institute of Clinical Medicine, Campus Ahus, University of Oslo, Oslo, Norway.,HØKH, Research Centre, Akershus University Hospital, Lørenskog, Norway.,Department of Pulmonary Medicine, Akershus University Hospital, Lørenskog, Norway
| |
Collapse
|
33
|
Tebaldi M, Biscaglia S, Fineschi M, Manari A, Menozzi M, Secco GG, Di Lorenzo E, D'Ascenzo F, Fabbian F, Tumscitz C, Ferrari R, Campo G. Fractional Flow Reserve Evaluation and Chronic Kidney Disease: Analysis From a Multicenter Italian Registry (the FREAK Study). Catheter Cardiovasc Interv 2015; 88:555-562. [PMID: 26717890 DOI: 10.1002/ccd.26364] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Revised: 11/03/2015] [Accepted: 11/22/2015] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To establish if the presence of chronic kidney disease (CKD) influences fractional flow reserve (FFR) value in patients with intermediate coronary stenosis. BACKGROUND FFR-guided coronary revascularization reduces cardiac adverse events in patients with coronary artery disease. CKD impairs microcirculation and increases cardiovascular risk. Whether CKD presence may limit FFR accuracy is unknown. METHODS We used data from a multicenter prospective registry enrolling 1.004 patients undergoing FFR evaluation for intermediate stenosis. We assessed the relationship between clinical and angiographic variables and FFR measurement. CKD was defined as CrCl value ≤45 ml/min. FFR value was considered potentially flow-limiting, and therefore positive, if ≤0.80. The index of microcirculatory resistance (IMR) was calculated in 20 patients stratified according CrCl value (single-center substudy). RESULTS FFR measurement was positive in 395 (39%) patients. Overall, 131 (13%) patients had CKD. Patients with CrCl ≤45 ml/min showed significantly higher FFR values as compared to the others (0.84 ± 0.07 vs. 0.81 ± 0.08, p < 0.001). Positive FFR occurrence was lower in patients with CrCl ≤45 ml/min (27% vs. 41%, p < 0.01). After multivariable analysis, diabetes (HR 1.07, 95%CI 1.008-1.13, p = 0.03), left anterior descending (HR 1.35, 95%CI 1.27-1.43, p < 0.001) and CrCl ≤45 ml/min (HR 0.92, 95%CI 0.87-0.97, p = 0.005) emerged as independent predictors of FFR measurement. Accordingly, IMR values were higher in patients with CrCl ≤45 ml/min (32 U [28245] vs. 16 U [11220], p < 0.01). CONCLUSIONS FFR and IMR measurements differ between CKD patients and those with normal renal function. Flow-limiting FFR is less frequent in patients with CrCl ≤45 ml/min. © 2015 Wiley Periodicals, Inc.
Collapse
Affiliation(s)
- Matteo Tebaldi
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria Di Ferrara, Cona, Ferrara, Italy.
| | - Simone Biscaglia
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria Di Ferrara, Cona, Ferrara, Italy
| | - Massimo Fineschi
- Department of Cardiology, University Medical Hospital of Siena, Siena, Italy
| | - Antonio Manari
- Department of Cardiology, Santa Maria Nuova Hospital, Reggio-Emilia, Italy
| | - Mila Menozzi
- Department of Cardiology, Ospedale Degli Infermi, Rimini
| | - Gioel Gabrio Secco
- Division of Cardiology, "Santi Antonio E Biagio E Cesare Arrigo" Hospital, Alessandria, Italy
| | - Emilio Di Lorenzo
- Department of Heart and Vessels, S.G. Moscati Hospital, Avellino, Italy
| | - Fabrizio D'Ascenzo
- Division of Cardiology Città Della Salute E Della Scienza, Hospital University of Turin, Turin, Italy
| | - Fabio Fabbian
- Clinica Medica, Departement of Medical Science, University of Ferrara, Cona, Ferrara, Italy
| | - Carlo Tumscitz
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria Di Ferrara, Cona, Ferrara, Italy
| | - Roberto Ferrari
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria Di Ferrara, Cona, Ferrara, Italy.,Maria Cecilia Hospital, GVM Care & Research, E.S. Health Science Foundation, Cotignola, Italy
| | - Gianluca Campo
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria Di Ferrara, Cona, Ferrara, Italy.,Laboratorio per Le Tecnologie Delle Terapie Avanzate (LTTA) Center, Ferrara, Italy
| |
Collapse
|
34
|
Broyd CJ, Echavarria-Pinto M, Cerrato E, Escaned J. Evaluation of Microvascular Disease and Clinical Outcomes. Interv Cardiol Clin 2015; 4:443-457. [PMID: 28581931 DOI: 10.1016/j.iccl.2015.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Although coronary microcirculatory dysfunction occurs in numerous cardiac conditions and influences prognosis, it has been largely ignored in clinical practice due to the lack of adequate methods for its assessment. Microcirculatory dysfuntion may result from a variety of causes, including structural remodelling (arterioles or capillaries), dysregulation (paradoxical arteriolar vasoconstriction), hypersensitivity to vasoactive factors or adrenergic drive, and extravascular compression of collapsable elements. Thus, the selection of a method to interrogate coronary microcirculation should be based on the suspected cause of dysfunction. This article reviews such assessment tools and their prognostic information.
Collapse
Affiliation(s)
| | | | - Enrico Cerrato
- Cardiovascular Institute, Hospital Clínico San Carlos, Madrid 28040, Spain
| | - Javier Escaned
- Cardiovascular Institute, Hospital Clínico San Carlos, Madrid 28040, Spain.
| |
Collapse
|
35
|
Abstract
Intracoronary hemodynamic assessment of the physiologic significance of coronary lesions improves clinical outcomes in patients with coronary artery disease. Coronary flow velocity reserve, fractional flow reserve, instantaneous wave-free ratio, and index of microcirculatory resistance utilize sensor-mounted guidewires to approximate coronary flow. Coronary flow velocity reserve and fractional flow reserve rely on pharmacologic administration of adenosine to achieve hyperemia and diagnose epicardial lesion severity. As an adenosine-free index, the instantaneous wave-free ratio utilizes a wave-free period in the mid-late diastole during which resistance is constant and low to assess lesion significance. The index of microcirculatory resistance combines hyperemic pressure measurements with thermodilution to quantify microvascular resistance. We review the physiology, clinical trials, and clinical applications of these invasive hemodynamic assessments.
Collapse
|
36
|
Miyazaki T, Ashikaga T, Ohigashi H, Komura M, Kobayashi K, Isobe M. Impact of smoking on coronary microcirculatory resistance in patients with coronary artery disease. Int Heart J 2014; 56:29-36. [PMID: 25503655 DOI: 10.1536/ihj.14-189] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The aim of this study was to investigate the relationship between coronary microvascular function and smoking using the 3 parameters fractional flow reserve (FFR), coronary flow reserve (CFR(thermo)), and index of microcirculatory resistance (IMR) in patients with coronary artery disease (CAD). A total of 97 CAD patients with 148 intermediate stenotic lesions were divided into two groups: current and former smokers (Smokers: n = 54), and those who had never smoked (Non-smokers: n = 43). Coronary physiology measurements were made following coronary angiography at rest and during hyperemia induced with intravenous adenosine triphosphate. If a patient had several intermediate lesions, the lesion producing the largest IMR value and minimum FFR(myo) and CFR(thermo) value was selected. Averaged over all patients, the FFR(myo), CFR(thermo), and IMR values were 0.86 ± 0.10, 2.66 ± 1.50, and 20.8 ± 10.7, respectively. There was no significant correlation between FFR(myo) and IMR. There were no significant differences between smokers and non-smokers in FFR(myo) value (median: 0.85 [IQR: 0.74-0.90] versus 0.87 [IQR: 0.83-0.90], P = 0.15) and CFR(thermo) value (median: 1.90 [IQR: 1.56-3.16] versus 2.10 [IQR: 1.50-2.67] U, P = 0.95). The IMR value was significantly greater in smokers (median: 24.2 [IQR: 16.8-32.5] U versus 18.5 [IQR: 15.4-27.0] U, P = 0.04). In multivariate analysis, smoking was an independent predictor of increased IMR. Smoking appears to have a detrimental effect on coronary microvascular function as measured by IMR.
Collapse
Affiliation(s)
- Toru Miyazaki
- Department of Cardiovascular Medicine, Kashiwa Municipal, Chiba; Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | | | | | | | | | | |
Collapse
|
37
|
Facing the complexity of ischaemic heart disease with intracoronary pressure and flow measurements. Curr Opin Cardiol 2014; 29:564-70. [DOI: 10.1097/hco.0000000000000110] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
|
38
|
Camici PG, d'Amati G, Rimoldi O. Coronary microvascular dysfunction: mechanisms and functional assessment. Nat Rev Cardiol 2014; 12:48-62. [DOI: 10.1038/nrcardio.2014.160] [Citation(s) in RCA: 290] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
|
39
|
Hirohata A, Yamamoto K, Hirose E, Kobayashi Y, Takafuji H, Sano F, Matsumoto K, Ohara M, Yoshioka R, Takinami H, Ohe T. Nicorandil prevents microvascular dysfunction resulting from PCI in patients with stable angina pectoris: a randomised study. EUROINTERVENTION 2014; 9:1050-6. [PMID: 24457276 DOI: 10.4244/eijv9i9a178] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS Nicorandil, an ATP sensitive potassium channel opener, may reduce the incidence of microvascular dysfunction after percutaneous coronary intervention (PCI) by dilating coronary resistance vessels. The aim of the study was evaluation of the impact of the administration of intravenous nicorandil on measuring the index of microcirculatory resistance (IMR) in PCI to patients with stable angina pectoris (SAP). METHODS AND RESULTS Intravascular ultrasound (IVUS), fractional flow reserve (FFR), IMR and blood examination (CK-MB), cardiac troponin I (cTnI) immediately post-PCI (and 24 hours later) were performed in 62 consecutive patients with SAP undergoing PCI. FFR and IMR were measured simultaneously with a single coronary pressure wire. IMR was defined as Pd/coronary flow (or Pd* mean transit time) at peak hyperaemia. Patients were randomised to the control (n=29), or nicorandil group (n=33). In the nicorandil group, nicorandil was intravenously administered as a 6 mg bolus injection just before PCI and as a constant infusion at 6 mg/hour for 24 hours thereafter. All volumetric IVUS parameters and FFR were similar between the two groups both pre- and post-PCI. However, IMR immediately post-PCI and cTnI 24 hours post-PCI were significantly higher in the control group compared to the nicorandil group (IMR: 25.4±12.1 vs. 17.9±9.1 units, and cTnI: 0.21±0.13 vs. 0.12±0.08 ng/mL, for control vs. nicorandil). The incidence for cTnI elevation more than fivefold the normal range (>0.20 ng/mL) was significantly larger in the control group than in the nicorandil group (41% vs. 12%, p<0.01). Additionally, the control group showed a closer correlation between plaque volume reduction during stenting as assessed by volumetric IVUS, and cTnI elevation than the nicorandil group (r=0.55 vs. 0.42, p<0.001 for control vs. nicorandil). CONCLUSIONS In patients undergoing successful coronary stenting for stable angina, administration of nicorandil is associated with reduced microvascular dysfunction induced by PCI.
Collapse
|
40
|
van Lavieren MA, van de Hoef TP, Piek JJ. Coronary wedge pressure and collateral flow contribution: not a dichotomy! EUROINTERVENTION 2014; 9:1485-8. [PMID: 24755391 DOI: 10.4244/eijv9i12a250] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Martijn A van Lavieren
- AMC Heart Center, Academic Medical Center - University of Amsterdam, Amsterdam, The Netherlands
| | | | | |
Collapse
|
41
|
Nolte F, van de Hoef TP, Meuwissen M, Voskuil M, Chamuleau SAJ, Henriques JPS, Verberne HJ, van Eck-Smit BLF, Koch KT, de Winter RJ, Spaan JAE, Tijssen JGP, Siebes M, Piek JJ. Increased hyperaemic coronary microvascular resistance adds to the presence of myocardial ischaemia. EUROINTERVENTION 2014; 9:1423-31. [PMID: 24755383 DOI: 10.4244/eijv9i12a240] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS It has been argued that hyperaemic microvascular resistance (HMR), defined as the ratio of mean distal coronary pressure to flow velocity, is overestimated in the presence of a coronary stenosis compared to actual microvascular resistance (MR), due to neglecting collateral flow. We aimed to test the hypothesis that HMR allows accurate identification of microvascular functional abnormalities by evaluating the association between high or low HMR and the presence of myocardial ischaemia on non-invasive stress testing. METHODS AND RESULTS Myocardial perfusion scintigraphy was performed in 228 patients, with 299 lesions to identify reversible myocardial ischaemia. Intracoronary distal pressure and flow velocity were assessed during adenosine-induced hyperaemia (20-40 µg, intracoronary) to determine hyperaemic stenosis resistance (HSR) and HMR. HMR >1.9 mmHg/cm/s was defined as high. The diagnostic odds ratio (OR) for myocardial ischaemia for lesions associated with high compared to low HMR was 2.6 (95% confidence interval [CI]: 1.5-4.4; p<0.001) overall, 3.3 (95% CI: 1.2-9.0; p=0.02) for lesions with HSR >0.8 mmHg/cm/s, and 1.3 (95% CI: 0.6-2.9; p=0.52) for lesions with HSR ≤0.8 mmHg/cm/s. CONCLUSIONS The increased risk of myocardial ischaemia in the presence of high HMR, uncorrected for collateral flow, demonstrates that HMR is reflective of an increase in actual MR, identifying pertinent pathophysiological alterations in the microvasculature.
Collapse
Affiliation(s)
- Froukje Nolte
- Department of Biomedical Engineering and Physics, University of Amsterdam, Amsterdam, The Netherlands
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
42
|
McCormick LM, Brown AJ, Ring LS, Gajendragadkar PR, Dockrill SJ, Hansom SP, Giblett JP, Gilbert TJ, Hoole SP, West NEJ. Direct stenting is an independent predictor of improved survival in patients undergoing primary percutaneous coronary intervention for ST elevation myocardial infarction. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2014; 3:340-6. [DOI: 10.1177/2048872614530864] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
| | | | - Liam S Ring
- Department of Cardiology, Papworth Hospital, UK
| | | | - Seth J Dockrill
- Department of Cardiology, Norfolk and Norwich University Hospital, UK
| | - Simon P Hansom
- Department of Cardiology, Norfolk and Norwich University Hospital, UK
| | | | - Timothy J Gilbert
- Department of Cardiology, Norfolk and Norwich University Hospital, UK
| | | | | |
Collapse
|
43
|
Affiliation(s)
- Yuhei Kobayashi
- Division of Cardiovascular Medicine, Stanford University Medical Center
| | - William F Fearon
- Division of Cardiovascular Medicine, Stanford University Medical Center
| |
Collapse
|
44
|
Pagonas N, Gross CM, Li M, Bondke A, Klauss V, Buschmann EE. Influence of epicardial stenosis severity and central venous pressure on the index of microcirculatory resistance in a follow-up study. EUROINTERVENTION 2014; 9:1063-8. [DOI: 10.4244/eijv9i9a180] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
|
45
|
Solberg OG, Ragnarsson A, Kvarsnes A, Endresen K, Kongsgård E, Aakhus S, Gullestad L, Stavem K, Aaberge L. Reference interval for the index of coronary microvascular resistance. EUROINTERVENTION 2014; 9:1069-75. [DOI: 10.4244/eijv9i9a181] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
|
46
|
He GX, Tan W. High-dose atorvastatin pretreatment could diminishes microvascular impairment in patients undergoing elective percutaneous coronary intervention. J Geriatr Cardiol 2013; 10:355-60. [PMID: 24454329 PMCID: PMC3888918 DOI: 10.3969/j.issn.1671-5411.2013.04.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Revised: 12/08/2013] [Accepted: 12/15/2013] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES High-dose statins pretreatment is reasonable before percutaneous coronary intervention (PCI) to reduce the risk of periprocedural myocardial injury. However, the mechanism underlying this protective effect has not been elucidated. The aim of this study is to evaluate the effects of high-dose atorvastatin pretreatment on microvascular function and myocardial injury after elective PCI. METHODS Eighty four patients underwent elective PCI were randomly assigned to high-dose atorvastatin (40 mg/d) and low-dose atorvastatin (20 mg/d) treatment for 7 days before PCI. The index of microcirculatory resistance (IMR) was measured by an intracoronary ressure/temperature sensor-tipped guidewire at maximal hyperemia after PCI. Fractional flow reserve (FFR) was measured before and after procedure. Troponin I levels were obtained at baseline and 20-24 h after procedure. RESULTS IMR values were significantly lower in high-dose group when compared to low-dose group (16.5 ± 6.1 vs. 31.2 ± 16.0, P < 0.001). Pre-PCI troponin I levels between the two groups were similar (0.028 ± 0.05 vs. 0.022 ± 0.04, P = 0.55). However, post-PCI troponin I levels in high-dose group were significantly lower than low-dose group (0.11 ± 0.02 vs. 0.16 ± 0.09, P < 0.001). Multivariate analysis identified maximum inflation pressure > 20 atm as an independent predictor of IMR > 32 (Odds ratio (OR): 3.3, 95% confidence intervals (95%CI): 1.3-8.5, P = 0.02). High-dose atorvastatin was the only independent protective factor of IMR > 32 (OR: 0.29, 95%CI: 0.11-0.74, P = 0.01). CONCLUSIONS The present study confirmed that diminishing microvascular impairment is one of the mechanism underlying protecting effect of high-dose statins pretreatment from myocardial injury during PCI. These suggest that high-dose statin pretreatment is reasonable in patients undergoing elective PCI.
Collapse
Affiliation(s)
- Gui-Xin He
- Department of Cardiology, the First Affiliated Hospital of Guangxi University of Chinese Medicine, 89-9 Dongge Road, Qingxiu District, Nanning 530023, Guangxi Province, China
| | - Wei Tan
- Department of Cardiology, the First Affiliated Hospital of Guangxi University of Chinese Medicine, 89-9 Dongge Road, Qingxiu District, Nanning 530023, Guangxi Province, China
| |
Collapse
|
47
|
Safety and effectiveness of drug-eluting stents versus bare-metal stents in elderly patients with small coronary vessel disease. Arch Cardiovasc Dis 2013; 106:554-61. [DOI: 10.1016/j.acvd.2013.06.056] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2013] [Revised: 06/23/2013] [Accepted: 06/25/2013] [Indexed: 11/21/2022]
|
48
|
Layland J, Judkins C, Palmer S, Whitbourn R, Wilson-O'Brien A, MacIsaac A, Wilson A. The resting status of the coronary microcirculation is a predictor of microcirculatory function following elective PCI for stable angina. Int J Cardiol 2013; 169:121-5. [DOI: 10.1016/j.ijcard.2013.08.092] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Revised: 08/12/2013] [Accepted: 08/29/2013] [Indexed: 11/24/2022]
|
49
|
Nijjer SS, Sen S, Petraco R, Sachdeva R, Cuculi F, Escaned J, Broyd C, Foin N, Hadjiloizou N, Foale RA, Malik I, Mikhail GW, Sethi AS, Al-Bustami M, Kaprielian RR, Khan MA, Baker CS, Bellamy MF, Hughes AD, Mayet J, Kharbanda RK, Di Mario C, Davies JE. Improvement in coronary haemodynamics after percutaneous coronary intervention: assessment using instantaneous wave-free ratio. Heart 2013; 99:1740-8. [PMID: 24047640 PMCID: PMC3841762 DOI: 10.1136/heartjnl-2013-304387] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Objective To determine whether the instantaneous wave-free ratio (iFR) can detect improvement in stenosis significance after percutaneous coronary intervention (PCI) and compare this with fractional flow reserve (FFR) and whole cycle Pd/Pa. Design A prospective observational study was undertaken in elective patients scheduled for PCI with FFR ≤0.80. Intracoronary pressures were measured at rest and during adenosine-mediated vasodilatation, before and after PCI. iFR, Pd/Pa and FFR values were calculated using the validated fully automated algorithms. Setting Coronary catheter laboratories in two UK centres and one in the USA. Patients 120 coronary stenoses in 112 patients were assessed. The mean age was 63±10 years, while 84% were male; 39% smokers; 33% with diabetes. Mean diameter stenosis was 68±16% by quantitative coronary angiography. Results Pre-PCI, mean FFR was 0.66±0.14, mean iFR was 0.75±0.21 and mean Pd/Pa 0.83±0.16. PCI increased all indices significantly (FFR 0.89±0.07, p<0.001; iFR 0.94±0.05, p<0.001; Pd/Pa 0.96±0.04, p<0.001). The change in iFR after intervention (0.20±0.21) was similar to ΔFFR 0.22±0.15 (p=0.25). ΔFFR and ΔiFR were significantly larger than resting ΔPd/Pa (0.13±0.16, both p<0.001). Similar incremental changes occurred in patients with a higher prevalence of risk factors for microcirculatory disease such as diabetes and hypertension. Conclusions iFR and FFR detect the changes in coronary haemodynamics elicited by PCI. FFR and iFR have a significantly larger dynamic range than resting Pd/Pa. iFR might be used to objectively document improvement in coronary haemodynamics following PCI in a similar manner to FFR.
Collapse
|
50
|
Yong AS, Layland J, Fearon WF, Ho M, Shah MG, Daniels D, Whitbourn R, Macisaac A, Kritharides L, Wilson A, Ng MK. Calculation of the index of microcirculatory resistance without coronary wedge pressure measurement in the presence of epicardial stenosis. JACC Cardiovasc Interv 2013; 6:53-8. [PMID: 23347861 DOI: 10.1016/j.jcin.2012.08.019] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2012] [Revised: 06/26/2012] [Accepted: 08/16/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVES This study sought to investigate a novel method to calculate the index of microcirculatory resistance (IMR) in the presence of significant epicardial stenosis without the need for balloon dilation to measure the coronary wedge pressure (P(w)). BACKGROUND The IMR provides a quantitative measure of coronary microvasculature status. However, in the presence of significant epicardial stenosis, IMR calculation requires incorporation of the coronary fractional flow reserve (FFR(cor)), which requires balloon dilation within the coronary artery for P(w) measurement. METHODS A method to calculate IMR by estimating FFR(cor) from myocardial FFR (FFR(myo)), which does not require P(w) measurement, was developed from a derivation cohort of 50 patients from a single institution. This method to calculate IMR was then validated in a cohort of 72 patients from 2 other different institutions. Physiology measurements were obtained with a pressure-temperature sensor wire before coronary intervention in both cohorts. RESULTS From the derivation cohort, a strong linear relationship was found between FFR(cor) and FFR(myo) (FFR(cor) = 1.34 × FFR(myo) - 0.32, r(2) = 0.87, p < 0.001) by regression analysis. With this equation to estimate FFR(cor) in the validation cohort, there was no significant difference between IMR calculated from estimated FFR(cor) and measured FFR(cor) (21.2 ± 12.9 U vs. 20.4 ± 13.6 U, p = 0.161). There was good correlation (r = 0.93, p < 0.001) and agreement by Bland-Altman analysis between calculated and measured IMR. CONCLUSIONS The FFR(cor), and, by extension, microcirculatory resistance can be derived without the need for P(w). This method enables assessment of coronary microcirculatory status before or without balloon inflation, in the presence of epicardial stenosis.
Collapse
Affiliation(s)
- Andy S Yong
- Department of Cardiovascular Medicine, Stanford University Medical Center, Stanford, California, USA
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|