1
|
Ghobrial M, Bawamia B, Cartlidge T, Purcell I, Bagnall A, Farag M, Alkhalil M. The role of gender in resting full-cycle ratio (RFR) guided coronary revascularization. Int J Cardiol 2024; 408:132159. [PMID: 38744341 DOI: 10.1016/j.ijcard.2024.132159] [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: 11/07/2023] [Revised: 04/05/2024] [Accepted: 05/10/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND Gender-based differences in clinical outcomes of patients undergoing fractional flow reserved (FFR) guided coronary revascularization is well documented. This study aimed to compare resting full-cycle ratio (RFR) values between men and women and whether this translated into difference in clinical outcomes in patients who underwent RFR-guided coronary revascularization. METHODS This was a retrospective single-centre study of consecutive patients who underwent RFR-guided revascularization for coronary lesions with intermediate degree of stenosis. The primary endpoint was a composite of all-cause mortality, myocardial infarction (MI), unplanned revascularization, and unstable angina requiring hospital admission at one year. RESULTS In 373 consecutive patients (510 lesions, 26% women) there was no statistically significant difference in RFR value between men and women (0.90 ± 10 versus 0.90 ± 11, P = 0.95). There was no statistically significant difference between men and women in the primary endpoint, even after adjustment to the imbalance between the two groups [3.7% vs. 3.0%; HR 1.43, 95% CI (0.46 to 4.43), P = 0.54]; or its individual components of death (1.1% vs 0.8%, P = 0.76), MI (1.9% vs 0.8%, P = 0.38) or unplanned revascularization, including unstable angina admissions (2.6% vs 2.3%, P = 0.82). The comparable clinical outcomes were consistent across all different subgroups, including clinical presentation, diabetes status, left ventricle systolic function, kidney function, and the interrogated coronary artery. CONCLUSION Our study suggests no significant gender-based difference in the value of RFR or 1-year clinical outcomes in patients undergoing resting physiology guided coronary revascularization.
Collapse
Affiliation(s)
- Mina Ghobrial
- Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne, UK
| | - Bilal Bawamia
- Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne, UK
| | | | - Ian Purcell
- Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne, UK
| | - Alan Bagnall
- Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne, UK
| | - Mohamed Farag
- Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne, UK
| | - Mohammad Alkhalil
- Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne, UK; Translational and Clinical Research Institute, Newcastle University, Newcastle-upon-Tyne, UK.
| |
Collapse
|
2
|
Kim MC, Ahn JH, Hyun DY, Lim Y, Lee SH, Oh S, Cho KH, Sim DS, Hong YJ, Kim JH, Jeong MH, Cho JH, Lee SR, Kang DO, Hwang JY, Youn YJ, Jeong YH, Park Y, Kim DB, Choo EH, Kim CJ, Kim W, Rhew JY, Lee JH, Yoo SY, Ahn Y. Timing of fractional flow reserve-guided complete revascularization in patients with ST-segment elevation myocardial infarction with multivessel disease: Rationale and design of the OPTION-STEMI trial. Am Heart J 2024; 273:35-43. [PMID: 38641031 DOI: 10.1016/j.ahj.2024.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 03/19/2024] [Accepted: 03/31/2024] [Indexed: 04/21/2024]
Abstract
BACKGROUND Current guidelines recommend complete revascularization (CR) in hemodynamically stable patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease (MVD). With regard to the timing of percutaneous coronary intervention (PCI) for non-infarct-related artery (non-IRA), recent randomized clinical trials have revealed that immediate CR was non-inferior to staged CR. However, the optimal timing of CR remains uncertain. The OPTION-STEMI trial compared immediate CR and in-hospital staged CR guided by fractional flow reserve (FFR) for intermediate stenosis of the non-IRA. METHODS The OPTION-STEMI is a multicenter, investigator-initiated, prospective, open-label, non-inferiority randomized clinical trial. The study included patients with at least 1 non-IRA lesion with ≥50% stenosis by visual estimation. Patients fulfilling the inclusion criteria were randomized into 2 groups at a 1:1 ratio: immediate CR (i.e., PCI for the non-IRA performed during primary angioplasty) or in-hospital staged CR. In the in-hospital staged CR group, PCI for non-IRA lesions was performed on another day during the index hospitalization. Non-IRA lesions with 50%-69% stenosis by visual estimation were evaluated by FFR, whereas those with ≥70% stenosis was revascularized without FFR. The primary endpoint was the composite of all-cause death, non-fatal myocardial infarction, and all unplanned revascularization at 1 year after randomization. Enrolment began in December 2019 and was completed in January 2024. The follow-up for the primary endpoint will be completed in January 2025, and primary results will be available in the middle of 2025. CONCLUSIONS The OPTION-STEMI is a multicenter, non-inferiority, randomized trial that evaluated the timing of in-hospital CR with the aid of FFR in patients with STEMI and MVD. TRIAL REGISTRATION URL: https://www. CLINICALTRIALS gov. Unique identifier: NCT04626882; and URL: https://cris.nih.go.kr. Unique identifier: KCT0004457.
Collapse
Affiliation(s)
- Min Chul Kim
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea
| | - Joon Ho Ahn
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea
| | - Dae Young Hyun
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea
| | - Yongwhan Lim
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea
| | - Seung Hun Lee
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea
| | - Seok Oh
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea
| | - Kyung Hoon Cho
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea
| | - Doo Sun Sim
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea
| | - Young Joon Hong
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea
| | - Ju Han Kim
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea
| | - Myung Ho Jeong
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea
| | | | - Sang-Rok Lee
- Division of Cardiology, Department of Internal Medicine, Jeonbuk National University Medical School, Jeonbuk National University Hospital, Jeonju, Korea
| | - Dong Oh Kang
- Cardiovascular Center, Department of Internal Medicine, Korea University College of Medicine, Korea University Guro Hospital, Seoul, Korea
| | - Jin-Yong Hwang
- Division of Cardiology, Department of Internal Medicine, Gyeongsang National University College of Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - Young Jin Youn
- Division of Cardiology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju Severance Christian Hospital, Wonju, Korea
| | - Young-Hoon Jeong
- CAU Thrombosis and Biomarker Center, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong, Korea and Division of Cardiology, Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Yongwhi Park
- Division of Cardiology, Department of Internal Medicine, Gyeongsang National University College of Medicine, Gyeongsang National University Changwon Hospital, Changwon, Korea
| | - Dong-Bin Kim
- Division of Cardiology, Department of Internal Medicine, The Catholic University of Korea, Bucheon St. Mary's Hospital, Bucheon, Korea
| | - Eun-Ho Choo
- Division of Cardiology, Department of Internal Medicine, The Catholic University of Korea, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Chan Joon Kim
- Division of Cardiology, Department of Internal Medicine, The Catholic University of Korea, Uijeongbu St. Mary's Hospital, Uijeongbu, Korea
| | - Weon Kim
- Division of Cardiology, Department of Internal Medicine, Kyung Hee University College of Medicine, Kyung Hee University Medical Center, Seoul, Korea
| | | | - Jung-Hee Lee
- Division of Cardiology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju Severance Christian Hospital, Wonju, Korea and Division of Cardiology, Yeungnam University College of Medicine, Yeungnam University Medical Center, Daegu, Korea
| | - Sang-Yong Yoo
- Good Morning Hospital, Pyeongtaek, Korea and Division of Cardiology, Department of Internal Medicine, University of Ulsan College of Medicine, Gangneung Asan Hospital, Gangneung, Korea
| | - Youngkeun Ahn
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea.
| |
Collapse
|
3
|
Warisawa T, Cook CM, Ahmad Y, Howard JP, Seligman H, Rajkumar C, Toya T, Doi S, Nakajima A, Nakayama M, Vera-Urquiza R, Yuasa S, Sato T, Kikuta Y, Kawase Y, Nishina H, Al-Lamee R, Sen S, Lerman A, Matsuo H, Akashi YJ, Escaned J, Davies JE. Physiological Assessment with iFR prior to FFR Measurement in Left Main Disease. Cardiovasc Interv Ther 2024; 39:241-251. [PMID: 38642290 PMCID: PMC11164744 DOI: 10.1007/s12928-024-00989-4] [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: 10/13/2023] [Accepted: 01/10/2024] [Indexed: 04/22/2024]
Abstract
Despite guideline-based recommendation of the interchangeable use of instantaneous wave-free ratio (iFR) and fractional flow reserve (FFR) to guide revascularization decision-making, iFR/FFR could demonstrate different physiological or clinical outcomes in some specific patient or lesion subsets. Therefore, we sought to investigate the impact of difference between iFR and FFR-guided revascularization decision-making on clinical outcomes in patients with left main disease (LMD). In this international multicenter registry of LMD with physiological interrogation, we identified 275 patients in whom physiological assessment was performed with both iFR/FFR. Major adverse cardiovascular event (MACE) was defined as a composite of death, non-fatal myocardial infarction, and ischemia-driven target lesion revascularization. The receiver-operating characteristic analysis was performed for both iFR/FFR to predict MACE in respective patients in whom revascularization was deferred and performed. In 153 patients of revascularization deferral, MACE occurred in 17.0% patients. The optimal cut-off values of iFR and FFR to predict MACE were 0.88 (specificity:0.74; sensitivity:0.65) and 0.76 (specificity:0.81; sensitivity:0.46), respectively. The area under the curve (AUC) was significantly higher for iFR than FFR (0.74; 95%CI 0.62-0.85 vs. 0.62; 95%CI 0.48-0.75; p = 0.012). In 122 patients of coronary revascularization, MACE occurred in 13.1% patients. The optimal cut-off values of iFR and FFR were 0.92 (specificity:0.93; sensitivity:0.25) and 0.81 (specificity:0.047; sensitivity:1.00), respectively. The AUCs were not significantly different between iFR and FFR (0.57; 95%CI 0.40-0.73 vs. 0.46; 95%CI 0.31-0.61; p = 0.43). While neither baseline iFR nor FFR was predictive of MACE in patients in whom revascularization was performed, iFR-guided deferral seemed to be safer than FFR-guided deferral.
Collapse
Affiliation(s)
- Takayuki Warisawa
- Department of Cardiology, St. Marianna University School of Medicine, 2-16-1 Sugao, Kawasaki, 216-8511, Japan.
- Department of Cardiology, NTT Medical Center Tokyo, Tokyo, Japan.
- National Heart and Lung Institute, Imperial College London, London, UK.
| | - Christopher M Cook
- The Essex Cardiothroacic Centre, Essex, UK
- Anglia Ruskin University, Essex, UK
| | - Yousif Ahmad
- Cardiovascular Medicine, Yale School of Medicine, New Haven, USA
| | - James P Howard
- National Heart and Lung Institute, Imperial College London, London, UK
- Cardiovascular Science, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Henry Seligman
- National Heart and Lung Institute, Imperial College London, London, UK
- Guys and St, Royal Brompton and Harefield Hospitals, Thomas NHS Foundation Trust, London, UK
| | - Christopher Rajkumar
- National Heart and Lung Institute, Imperial College London, London, UK
- Cardiovascular Science, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Takumi Toya
- Department of Cardiology, National Defense Medical College, Tokorozawa, Japan
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, USA
| | - Shunichi Doi
- Department of Cardiology, St. Marianna University School of Medicine, 2-16-1 Sugao, Kawasaki, 216-8511, Japan
| | - Akihiro Nakajima
- Department of Cardiovascular Medicine, New Tokyo Hospital, Matsudo, Japan
| | - Masafumi Nakayama
- Department of Cardiology, Tokyo D Tower Hospital, Tokyo, Japan
- Cardiovascular Center, Toda Central General Hospital, Toda, Japan
| | - Rafael Vera-Urquiza
- Hospital Clinico San Carlos IDISSC, Complutense University of Madrid, Madrid, Spain
| | - Sonoka Yuasa
- Hospital Clinico San Carlos IDISSC, Complutense University of Madrid, Madrid, Spain
| | - Takao Sato
- Department of Cardiology, Tachikawa General Hospital, Nagaoka, Japan
| | - Yuetsu Kikuta
- National Heart and Lung Institute, Imperial College London, London, UK
- Division of Cardiology, Fukuyama Cardiovascular Hospital, Fukuyama, Japan
| | - Yoshiaki Kawase
- Department of Cardiovascular Medicine, Gifu Heart Center, Gifu, Japan
| | - Hidetaka Nishina
- Department of Cardiology, Tsukuba Medical Center Hospital, Tsukuba, Japan
| | - Rasha Al-Lamee
- National Heart and Lung Institute, Imperial College London, London, UK
- Cardiovascular Science, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Sayan Sen
- National Heart and Lung Institute, Imperial College London, London, UK
- Cardiovascular Science, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Amir Lerman
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, USA
| | - Hitoshi Matsuo
- Department of Cardiovascular Medicine, Gifu Heart Center, Gifu, Japan
| | - Yoshihiro J Akashi
- Department of Cardiology, St. Marianna University School of Medicine, 2-16-1 Sugao, Kawasaki, 216-8511, Japan
| | - Javier Escaned
- Hospital Clinico San Carlos IDISSC, Complutense University of Madrid, Madrid, Spain
| | - Justin E Davies
- National Heart and Lung Institute, Imperial College London, London, UK
| |
Collapse
|
4
|
Shiely F, O Shea N, Murphy E, Eustace J. Registry-based randomised controlled trials: conduct, advantages and challenges-a systematic review. Trials 2024; 25:375. [PMID: 38863017 PMCID: PMC11165819 DOI: 10.1186/s13063-024-08209-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 05/29/2024] [Indexed: 06/13/2024] Open
Abstract
BACKGROUND Registry-based randomised controlled trials (rRCTs) have been described as pragmatic studies utilising patient data embedded in large-scale registries to facilitate key clinical trial procedures including recruitment, randomisation and the collection of outcome data. Whilst the practice of utilising registries to support the conduct of randomised trials is increasing, the use of the registries within rRCTs is inconsistent. The purpose of this systematic review is to explore the conduct of rRCTs using a patient registry to facilitate trial recruitment and the collection of outcome data, and to discuss the advantages and challenges of rRCTs. METHODS A systematic search of the literature was conducted using five databases from inception to June 2020: PubMed, Embase (through Ovid), CINAHL, Scopus and the Cochrane Controlled Register of Trials (CENTRAL). The search strategy comprised of MESH terms and key words related to rRCTs. Study selection was performed independently by two reviewers. A risk of bias for each study was completed. A narrative synthesis was conducted. RESULTS A total 47,862 titles were screened and 24 rRCTs were included. Eleven rRCTs (45.8%) used more than one registry to facilitate trial conduct. Six rRCTs (25%) randomised participants via a specific randomisation module embedded within a registry. Recruitment ranged between 209 to 106,000 participants. Advantages of rRCTs are recruitment efficiency, shorter trial times, cost effectiveness, outcome data completeness, smaller carbon footprint, lower participant burden and the ability to conduct multiple trials from the same registry. Challenges are data collection/management, quality assurance issues and the timing of informed consent. CONCLUSIONS Optimising the design of rRCTs is dependent on the capabilities of the registry. New registries should be designed and existing registries reviewed to enable the conduct of rRCTs. At all times, data management and quality assurance of all registry data should be given key consideration. We suggest the inclusion of the term 'registry-based' in the title of all rRCT manuscripts and a clear simple breakdown of the registry-based conduct of the trial in the abstract to facilitate indexing in the major databases.
Collapse
Affiliation(s)
- Frances Shiely
- Trials Research and Methodologies Unit, HRB Clinical Research Facility, University College Cork, 4th Floor Western Gateway Building, Western Road, Cork, Ireland.
- School of Public Health, University College Cork, 4th Floor Western Gateway Building, Western Road, Cork, Ireland.
| | - Niamh O Shea
- Trials Research and Methodologies Unit, HRB Clinical Research Facility, University College Cork, 4th Floor Western Gateway Building, Western Road, Cork, Ireland
- Health Research Board, Trials Methodology Research Network, University College Cork, Cork, Ireland
| | - Ellen Murphy
- Trials Research and Methodologies Unit, HRB Clinical Research Facility, University College Cork, 4th Floor Western Gateway Building, Western Road, Cork, Ireland
- Health Research Board, Trials Methodology Research Network, University College Cork, Cork, Ireland
| | - Joseph Eustace
- Department of Renal Medicine, Cork University Hospital, Cork, Ireland
| |
Collapse
|
5
|
Altstidl JM, Achenbach S, Feyrer J, Nazli JB, Marwan M, Gaede L, Möllmann H, Giesler T, Rittger H, Pauschinger M, Rudolph TK, Moshage W, Brück M, Tröbs M. Use of coronary physiology to guide revascularization in clinical practice: results of the F(FR) 2 registry. Clin Res Cardiol 2024:10.1007/s00392-024-02463-w. [PMID: 38832995 DOI: 10.1007/s00392-024-02463-w] [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: 02/22/2024] [Accepted: 05/15/2024] [Indexed: 06/06/2024]
Abstract
BACKGROUND Despite the recommendation of coronary physiology to guide revascularization in angiographically intermediate stenoses without established correlation to ischemia, its uptake in clinical practice is slow. AIMS This study aimed to analyze the use of coronary physiology in clinical practice. METHODS Based on a multicenter registry (Fractional Flow Reserve Fax Registry, F(FR)2, ClinicalTrials.gov identifier NCT03055910), clinical use, consequences, and complications of coronary physiology were systematically analyzed. RESULTS F(FR)2 enrolled 2,000 patients with 3,378 intracoronary pressure measurements. Most measurements (96.8%) were performed in angiographically intermediate stenoses. Out of 3,238 lesions in which coronary physiology was used to guide revascularization, revascularization was deferred in 2,643 (78.2%) cases. Fractional flow reserve (FFR) was the most common pressure index used (87.6%), with hyperemia induced by an intracoronary bolus of adenosine in 2,556 lesions (86.4%) and intravenous adenosine used for 384 measurements (13.0%). The route of adenosine administration did not influence FFR results (change-in-estimate -3.1% for regression model predicting FFR from diameter stenosis). Agreement with the subsequent revascularization decision was 93.4% for intravenous and 95.0% for intracoronary adenosine (p = 0.261). Coronary artery occlusion caused by the pressure wire was reported in two cases (0.1%) and dissection in three cases (0.2%), which was fatal once (0.1%). CONCLUSIONS In clinical practice, intracoronary pressure measurements are mostly used to guide revascularization decisions in angiographically intermediate stenoses. Intracoronary and intravenous administration of adenosine seem equally suited. While the rate of serious complications of wire-based intracoronary pressure measurements in clinical practice seems to be low, it is not negligible.
Collapse
Affiliation(s)
- J Michael Altstidl
- Department of Medicine 2 - Cardiology and Angiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Ulmenweg 18, 91054, Erlangen, Germany
| | - Stephan Achenbach
- Department of Medicine 2 - Cardiology and Angiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Ulmenweg 18, 91054, Erlangen, Germany
| | - Johannes Feyrer
- Department of Medicine 2 - Cardiology and Angiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Ulmenweg 18, 91054, Erlangen, Germany
| | - J Benedikt Nazli
- Department of Medicine 2 - Cardiology and Angiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Ulmenweg 18, 91054, Erlangen, Germany
| | - Mohamed Marwan
- Department of Medicine 2 - Cardiology and Angiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Ulmenweg 18, 91054, Erlangen, Germany
| | - Luise Gaede
- Department of Medicine 2 - Cardiology and Angiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Ulmenweg 18, 91054, Erlangen, Germany
| | - Helge Möllmann
- Department of Medicine 1 - Cardiology, Nephrology, Intensive Care and Rhythmology, St. Johannes Hospital Dortmund, Dortmund, Germany
| | - Tom Giesler
- Department of Cardiology, Helios Klinik Jerichower Land, Burg, Germany
| | - Harald Rittger
- Department of Cardiology and Pulmonology, Hospital Fürth, Fürth, Germany
| | - Matthias Pauschinger
- Department of Medicine 8 - Cardiology, Nuremberg Hospital South, Nuremberg, Germany
| | - Tanja K Rudolph
- Department of General and Interventional Cardiology, Heart and Diabetes Center NRW, Bad Oeynhausen, Germany
| | - Werner Moshage
- Department of Cardiology, Hospital Traunstein, Traunstein, Germany
| | - Martin Brück
- Department of Medicine 1, Hospital Wetzlar, Wetzlar, Germany
| | - Monique Tröbs
- Department of Medicine 2 - Cardiology and Angiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Ulmenweg 18, 91054, Erlangen, Germany.
| |
Collapse
|
6
|
d'Entremont MA, Tiong D, Sadeghirad B, McGrath BP, Cioffi GM, Garni TA, Cheema ZM, Layland J, Revaiah PC, Serruys PW, Stone GW, Jolly SS. Assessment of Coronary Stenoses for Percutaneous Coronary Intervention: A Systematic Review and Network Meta-Analysis of Randomized Trials. Am J Cardiol 2024; 223:29-39. [PMID: 38768846 DOI: 10.1016/j.amjcard.2024.05.019] [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: 03/21/2024] [Revised: 05/14/2024] [Accepted: 05/15/2024] [Indexed: 05/22/2024]
Abstract
Evidence regarding the comparative efficacy of the different methods to determine the significance of coronary stenoses in the catheterization laboratory is lacking. We aimed to compare all available methods guiding the decision to perform percutaneous coronary intervention (PCI). We searched Medline, Embase, and CENTRAL until October 5, 2023. We included trials that randomized patients with greater than 30% stenoses who were considered for PCI and reported major adverse cardiovascular events (MACE). We performed a frequentist random-effects network meta-analysis and assessed the certainty of evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. We included 15 trials with 16,333 participants with a mean weighted follow-up of 34 months. The trials contained a median of 49.3% (interquartile range: 32.6%, 100%) acute coronary syndrome participants. Quantitative flow ratio (QFR) was associated with a decreased risk of MACE compared with coronary angiography (CA) (risk ratio [RR] 0.68, 95% confidence interval [CI] 0.56 to 0.82, high certainty), fractional flow reserve (FFR) (RR 0.73, 95% CI 0.58 to 0.92, moderate certainty), and instantaneous wave-free ratio (iFR) (RR 0.63, 95% CI 0.49 to 0.82, moderate certainty), and ranked first for MACE (88.1% probability of being the best). FFR (RR 0.93, 95% CI 0.82 to 1.06, moderate certainty) and iFR (RR 1.07, 95% CI 0.90 to 1.28, moderate certainty) likely did not decrease the risk of MACE compared with CA. Intravascular imaging may not be associated with a significant decrease in MACE compared with CA (RR 0.85, 95% CI 0.62 to 1.17, low certainty) when used to guide the decision to perform PCI. In conclusion, a decision to perform PCI based on QFR was associated with a decreased risk of MACE compared with CA, FFR, and iFR in a mixed stable coronary disease and acute coronary syndrome population. These hypothesis-generating findings should be validated in large, randomized, head-to-head trials.
Collapse
Affiliation(s)
- Marc-André d'Entremont
- Population Health Research Institute, Hamilton, Ontario, Canada; Hamilton Health Sciences, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Centre Hospitalier Universitaire de Sherbrooke (CHUS), Sherbrooke, Quebec, Canada
| | - Denise Tiong
- Hamilton Health Sciences, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Behnam Sadeghirad
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
| | - Brian P McGrath
- Hamilton Health Sciences, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Giacomo Maria Cioffi
- Hamilton Health Sciences, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Turki Al Garni
- Hamilton Health Sciences, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Zain M Cheema
- Hamilton Health Sciences, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | - Pruthvi C Revaiah
- CORRIB Research Centre for Advanced Imaging and Core Laboratory, University of Galway, Galway, Ireland
| | - Patrick W Serruys
- CORRIB Research Centre for Advanced Imaging and Core Laboratory, University of Galway, Galway, Ireland
| | - Gregg W Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York
| | - Sanjit S Jolly
- Population Health Research Institute, Hamilton, Ontario, Canada; Hamilton Health Sciences, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
| |
Collapse
|
7
|
Kelsey MD, Kelsey AM. Diagnosing Coronary Artery Disease in the Patient Presenting with Stable Ischemic Heart Disease: The Role of Anatomic versus Functional Testing. Med Clin North Am 2024; 108:427-439. [PMID: 38548455 DOI: 10.1016/j.mcna.2023.11.002] [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] [Indexed: 04/02/2024]
Abstract
There are unique advantages and disadvantages to functional versus anatomic testing in the work-up of patients who present with symptoms suggestive of obstructive coronary artery disease. Evaluation of these individuals starts with an assessment of pre-test probability, which guides subsequent testing decisions. The choice between anatomic and functional testing depends on this pre-test probability. In general, anatomic testing has particular utility among younger individuals and women; while functional testing can be helpful to rule-in ischemia and guide revascularization decisions. Ultimately, selection of the most appropriate test should be individualized to the patient and clinical scenario.
Collapse
Affiliation(s)
- Michelle D Kelsey
- Division of Cardiology, Department of Medicine, Duke University, 2301 Erwin Road, Durham, NC 27710, USA; Duke Clinical Research Institute, 300 West Morgan Street, Durham, NC 27701, USA.
| | - Anita M Kelsey
- Division of Cardiology, Department of Medicine, Duke University, 2301 Erwin Road, Durham, NC 27710, USA. https://twitter.com/AnitaKelseyMD
| |
Collapse
|
8
|
Jo HH, Kang DY, Lee JM, Lim SM, Park YS, Choi Y, Kim H, Lee J, Ahn JM, Park DW, Park SJ. Evaluation of Instantaneous Wave-Free Ratio and Fractional Flow Reserve in Severe Aortic Valve Stenosis. Circ Cardiovasc Interv 2024; 17:e013237. [PMID: 38629298 DOI: 10.1161/circinterventions.123.013237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 02/08/2024] [Indexed: 04/30/2024]
Abstract
BACKGROUND The optimal functional evaluation of coronary artery stenosis in patients with severe aortic stenosis (AS) has not been established. The objective of the study was to evaluate the instantaneous wave-free ratio (iFR) and fractional flow reserve (FFR) in patients with and without severe AS. METHODS We retrospectively investigated 395 lesions in 293 patients with severe AS and 2257 lesions in 1882 patients without severe AS between 2010 and 2022 from a subgroup of the Interventional Cardiology Research In-Cooperation Society FFR Registry. All patients had FFR values, and iFR was analyzed post hoc using dedicated software only in lesions with adequate resting pressure curves (311 lesions in patients with severe AS and 2257 lesions in patients with nonsevere AS). RESULTS The incidence of iFR ≤0.89 was 66.6% and 31.8% (P<0.001), while the incidence of FFR ≤0.80 was 45.3% and 43.9% (P=0.60) in the severe AS group and the nonsevere AS group, respectively. In the severe AS group, most lesions (95.2%) with iFR >0.89 had FFR >0.80, while 36.2% of lesions with iFR ≤0.89 had FFR >0.80. During a median follow-up of 2 years, FFR ≤0.80 was significantly associated with deferred lesion failure (adjusted hazard ratio, 2.71 [95% CI, 1.08-6.80]; P=0.034), while iFR ≤0.89 showed no prognostic value (adjusted hazard ratio, 1.31 [95% CI, 0.47-3.60]; P=0.60) in the severe AS group. Lesions with iFR ≤0.89 and FFR >0.80, in particular, were not associated with a higher rate of deferred lesion failure at 3 years compared with lesions with iFR >0.89 (15.4% versus 17.0%; P=0.58). CONCLUSIONS This study suggested that FFR appears to be less affected by the presence of severe AS and is more associated with prognosis. iFR may overestimate the functional severity of coronary artery disease without prognostic significance, yet it can be useful for excluding significant stenosis in patients with severe AS.
Collapse
Affiliation(s)
- Ha Hye Jo
- Division of Cardiology, Heart Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Do-Yoon Kang
- Division of Cardiology, Heart Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Joong Min Lee
- Division of Cardiology, Heart Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - So-Min Lim
- Division of Cardiology, Heart Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Young-Sun Park
- Division of Cardiology, Heart Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Yeonwoo Choi
- Division of Cardiology, Heart Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Hoyun Kim
- Division of Cardiology, Heart Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jinho Lee
- Division of Cardiology, Heart Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jung-Min Ahn
- Division of Cardiology, Heart Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Duk-Woo Park
- Division of Cardiology, Heart Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Seung-Jung Park
- Division of Cardiology, Heart Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| |
Collapse
|
9
|
Belyayev L, Stock EM, Hattler B, Bakaeen FG, Kinlay S, Quin JA, Haime M, Biswas K, Zenati MA. Complete Coronary Revascularization and Outcomes in Patients Who Underwent Coronary Artery Bypass Grafting: Insights from The REGROUP Trial. Am J Cardiol 2024; 217:127-135. [PMID: 38266796 DOI: 10.1016/j.amjcard.2024.01.015] [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: 10/01/2023] [Revised: 12/19/2023] [Accepted: 01/15/2024] [Indexed: 01/26/2024]
Abstract
There is growing evidence in support of coronary complete revascularization (CR). Nonetheless, there is no universally accepted definition of CR in patients who undergo coronary bypass grafting surgery (CABG). We sought to investigate the outcomes of CR, defined as surgical revascularization of any territory supplied by a suitable coronary artery with ≥50% stenosis. We performed a preplanned subanalysis in the Randomized Trial of Endoscopic or Open Saphenous Vein Graft Harvesting (REGROUP) clinical trial cohort. Of 1,147 patients who underwent CABG, 810 (70.6%) received CR. The primary outcome was a composite of major adverse cardiac events (MACEs), including death from any cause, nonfatal myocardial infarction, or repeat revascularization over a median 4.7 years of follow-up. MACE occurred in 175 patients (21.6%) in the CR group and 86 patients (25.5%) in the incomplete revascularization (IR) group (hazard ratio [HR] 0.87, 95% confidence interval [CI] 0.67 to 1.13, p = 0.29). A total of 97 patients (12.0%) in the CR group and 48 patients (14.2%) in the IR group died (HR 0.93, 95% CI 0.65 to 1.32, p = 0.67); nonfatal myocardial infarction occurred in 49 patients (6.0%) in the CR group and 30 patients (8.9%) in the IR group (HR 0.76, 95% CI 0.48 to 1.2, p = 0.24), and repeat revascularization occurred in 62 patients (7.7%) in the CR group and 39 patients (11.6%) in the IR group (HR 0.64; 95% CI 0.42 to 0.95, p = 0.027). In conclusion, in patients with a great burden of co-morbidities who underwent CABG in the REGROUP trial over a median follow-up period of a median 4.7 years, CR was associated with similar MACE rates but a reduced risk of repeat revascularization. Longer-term follow-up is warranted.
Collapse
Affiliation(s)
- Leonid Belyayev
- Division of Thoracic and Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts.
| | - Eileen M Stock
- Cooperative Studies Program Coordinating Center, Office of Research and Development, US Department of Veterans Affairs, Perry Point, Maryland
| | - Brack Hattler
- Division of Cardiology, Eastern Colorado Veterans Affairs Healthcare System and University of Colorado, Aurora, Colorado
| | - Faisal G Bakaeen
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Scott Kinlay
- Divisions of Cardiology, Veterans Affairs Boston Healthcare System, and Harvard Medical School, Boston, Massachusetts
| | - Jacqueline A Quin
- Cardiac Surgery, Veterans Affairs Boston Healthcare System, and Harvard Medical School, Boston, Massachusetts
| | - Miguel Haime
- Cardiac Surgery, Veterans Affairs Boston Healthcare System, and Harvard Medical School, Boston, Massachusetts
| | - Kousick Biswas
- Cooperative Studies Program Coordinating Center, Office of Research and Development, US Department of Veterans Affairs, Perry Point, Maryland
| | - Marco A Zenati
- Division of Thoracic and Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts; Cardiac Surgery, Veterans Affairs Boston Healthcare System, and Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
10
|
Kitabata H. Editorial: Can QFR be beyond pressure-wire based physiological indices? CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024; 61:42-43. [PMID: 38036406 DOI: 10.1016/j.carrev.2023.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 11/22/2023] [Indexed: 12/02/2023]
Affiliation(s)
- Hironori Kitabata
- Department of Cardiovascular Medicine, Wakayama Medical University, Japan.
| |
Collapse
|
11
|
Dahdal J, Bakker F, Svanerud J, Danad I, Driessen RS, Raijmakers PG, Harms HJ, Lammertsma AA, van de Hoef TP, Appelman Y, van Royen N, Knaapen P, de Waard GA. Validation of resting full-cycle ratio and diastolic pressure ratio with [ 15O]H 2O positron emission tomography myocardial perfusion. Heart Vessels 2024; 39:299-309. [PMID: 38367040 PMCID: PMC10920410 DOI: 10.1007/s00380-023-02356-4] [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: 06/13/2023] [Accepted: 10/18/2023] [Indexed: 02/19/2024]
Abstract
Fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) are invasive techniques used to evaluate the hemodynamic significance of coronary artery stenosis. These methods have been validated through perfusion imaging and clinical trials. New invasive pressure ratios that do not require hyperemia have recently emerged, and it is essential to confirm their diagnostic efficacy. The aim of this study was to validate the resting full-cycle ratio (RFR) and the diastolic pressure ratio (dPR), against [15O]H2O positron emission tomography (PET) imaging. A total of 129 symptomatic patients with an intermediate risk of coronary artery disease (CAD) were included. All patients underwent cardiac [15O]H2O PET with quantitative assessment of resting and hyperemic myocardial perfusion. Within a 2 week period, coronary angiography was performed. Intracoronary pressure measurements were obtained in 320 vessels and RFR, dPR, and FFR were computed. PET derived regional hyperemic myocardial blood flow (hMBF) and myocardial perfusion reserve (MPR) served as reference standards. In coronary arteries with stenoses (43%, 136 of 320), the overall diagnostic accuracies of RFR, dPR, and FFR did not differ when PET hyperemic MBF < 2.3 ml min-1 (69.9%, 70.6%, and 77.1%, respectively) and PET MPR < 2.5 (70.6%, 71.3%, and 66.9%, respectively) were considered as the reference for myocardial ischemia. Non-significant differences between the areas under the receiver operating characteristic (ROC) curve were found between the different indices. Furthermore, the integration of FFR with RFR (or dPR) does not enhance the diagnostic information already achieved by FFR in the characterization of ischemia via PET perfusion. In conclusion, the novel non-hyperemic pressure ratios, RFR and dPR, have a diagnostic performance comparable to FFR in assessing regional myocardial ischemia. These findings suggest that RFR and dPR may be considered as an FFR alternative for invasively guiding revascularization treatment in symptomatic patients with CAD.
Collapse
Affiliation(s)
- Jorge Dahdal
- Department of Cardiology, Amsterdam University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
- Department of Cardiology, Hospital Del Salvador, Salvador 364, 7500922, Santiago, Chile
| | - Frank Bakker
- Department of Cardiology, Amsterdam University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Johan Svanerud
- Coroventis Research AB, Ulls Väg 29A, 75651, Uppsala, Sweden
| | - Ibrahim Danad
- Utrecht University Medical Center, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Roel S Driessen
- Department of Cardiology, Amsterdam University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Pieter G Raijmakers
- Department of Radiology and Nuclear Medicine, VU University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Hendrik J Harms
- Clinical Institute, Aarhus University, Palle Juul-Jensens Blvd. 82, 8200, Aarhus, Denmark
| | - Adriaan A Lammertsma
- Department of Radiology and Nuclear Medicine, VU University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Tim P van de Hoef
- Utrecht University Medical Center, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Yolande Appelman
- Department of Cardiology, Amsterdam University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Niels van Royen
- Department of Cardiology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - Paul Knaapen
- Department of Cardiology, Amsterdam University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Guus A de Waard
- Department of Cardiology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands.
| |
Collapse
|
12
|
Kiyohara Y, Kishino Y, Ueyama HA, Takahashi T, Kobayashi Y, Takagi H, Wiley J, Kuno T. Comparison among various physiology and angiography-guided strategies for deferring percutaneous coronary intervention: A network meta-analysis. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024; 61:35-41. [PMID: 37891055 DOI: 10.1016/j.carrev.2023.10.015] [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: 08/23/2023] [Revised: 10/16/2023] [Accepted: 10/18/2023] [Indexed: 10/29/2023]
Abstract
BACKGROUND/PURPOSE It is unclear whether coronary physiology or coronary angiography (CA)-guided strategy is the more preferable approach for deferring percutaneous coronary intervention (PCI). We sought to evaluate the clinical efficacy of various PCI strategies through a network meta-analysis of randomized controlled trials (RCTs). METHODS/MATERIALS We searched multiple databases for RCTs investigating the impact of the following strategies for the purpose of determining whether or not to defer PCI: fractional flow reserve, instantaneous wave-free ratio, quantitative flow ratio (QFR), and CA. We conducted a network meta-analysis for trial-defined major adverse cardiovascular events (MACE), all-cause death, cardiovascular death, myocardial infarction (MI), target lesion revascularization (TLR), and stent thrombosis. We performed a subgroup analysis for those with acute coronary syndrome (ACS). RESULTS Our search identified 12 eligible RCTs including a total of 13,177 patients. QFR-guided PCI was associated with reduced MACE, MI, and TLR compared with CA-guided PCI (relative risk (RR) 0.68; 95 % confidence interval (CI] [0.49 to 0.94], RR 0.58; 95 % CI [0.36 to 0.96], and RR 0.58; 95 % CI [0.38 to 0.91], respectively). There were no significant differences in any pairs for all-cause death, cardiovascular death, or stent thrombosis. QFR was ranked the best in most outcomes. In the subgroup analysis of the ACS cohort, there were no significant differences in MACE between any comparisons. CONCLUSIONS QFR was associated with reduced MACE, MI, and TLR compared with CA, and ranked the best in most outcomes. However, this was not applied in the ACS cohort.
Collapse
Affiliation(s)
- Yuko Kiyohara
- Department of Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Yoshikazu Kishino
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | | | | | - Yuhei Kobayashi
- Division of Cardiology, NewYork-Presbyterian Brooklyn Methodist Hospital, NY, USA
| | - Hisato Takagi
- Department of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan
| | - Jose Wiley
- Section of Cardiology, Department of Medicine, Tulane University School of Medicine, LA, USA
| | - Toshiki Kuno
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, NY, USA; Division of Cardiology, Jacobi Medical Center, Albert Einstein College of Medicine, NY, USA.
| |
Collapse
|
13
|
Sasaki S, Kawamori H, Toba T, Takeshige R, Fukuyama Y, Hiromasa T, Fujii H, Hamana T, Osumi Y, Iwane S, Yamamoto T, Naniwa S, Sakamoto Y, Matsuhama K, Fukuishi Y, Shinke T, Hirata KI, Otake H. Diagnostic Accuracy of Pre-Transcatheter Aortic Valve Replacement Nitroglycerin-Free Fractional Flow Reserve-Computed Tomography-Based Physiological Assessment in Patients With Severe Aortic Stenosis for Predicting Post-Transcatheter Aortic Valve Replacement Ischemia. Circ J 2024; 88:501-509. [PMID: 37813600 DOI: 10.1253/circj.cj-23-0312] [Citation(s) in RCA: 2] [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] [Indexed: 10/11/2023]
Abstract
BACKGROUND Fractional flow reserve-computed tomography (FFRCT) has not been validated in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR) for coronary artery disease due to theoretical difficulties in using nitroglycerin for such patients.Methods and Results: In this single-center study, we prospectively enrolled 21 patients (34 vessels) and performed pre-TAVR FFRCTwithout nitroglycerin, pre-TAVR invasive instantaneous wave-free ratio (iFR) measurements, and post-TAVR FFR measurements using a pressure wire. The diagnostic accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of pre-TAVR FFRCT≤0.80 to predict post-TAVR invasive FFR ≤0.80 were 82%, 83%, 82%, 71%, and 90%, respectively. A receiver operating characteristic analysis demonstrated an optimal cutoff of 0.78 for pre-TAVR FFRCTto indicate post-TAVR FFR ≤0.80, with an area under the curve (AUC) of 0.84, and the counterpart cutoff of pre-TAVR iFR was 0.89 with an AUC of 0.86. CONCLUSIONS FFRCTwithout nitroglycerin could be a useful non-invasive imaging modality for assessing the severity of coronary artery lesions in patients with severe AS.
Collapse
Affiliation(s)
- Satoru Sasaki
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine
| | - Hiroyuki Kawamori
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine
| | - Takayoshi Toba
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine
| | - Ryo Takeshige
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine
| | - Yusuke Fukuyama
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine
| | - Takashi Hiromasa
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine
| | - Hiroyuki Fujii
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine
| | - Tomoyo Hamana
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine
| | - Yuto Osumi
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine
| | - Seigo Iwane
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine
| | - Tetsuya Yamamoto
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine
| | - Shota Naniwa
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine
| | - Yuki Sakamoto
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine
| | - Koshi Matsuhama
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine
| | - Yuta Fukuishi
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine
| | - Toshiro Shinke
- Division of Cardiology, Showa University School of Medicine
| | - Ken-Ichi Hirata
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine
| | - Hiromasa Otake
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine
| |
Collapse
|
14
|
Abbasciano RG, Layton GR, Torre S, Abbaker N, Copperwheat A, Lucarelli C, Bhandari S, Nijjer S, Mikhail G, Casula R, Zakkar M, Viviano A. Fractional flow reserve and instantaneous wave-free ratio in coronary artery bypass grafting: a meta-analysis and practice review. Front Cardiovasc Med 2024; 11:1348341. [PMID: 38516003 PMCID: PMC10955066 DOI: 10.3389/fcvm.2024.1348341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Accepted: 02/20/2024] [Indexed: 03/23/2024] Open
Abstract
Objective Fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) are invasive methods to assess the functional significance of intermediate severity coronary lesions. Both indexes have been extensively validated in clinical trials in guiding revascularisation in patients with stable ischaemic heart disease undergoing percutaneous coronary intervention (PCI) with improved clinical outcomes. However, the role of these tools in coronary artery bypass grafting (CABG) is less clear. Methods A meta-analysis of randomised trials and observational studies was carried out to help in determining the optimal strategy for assessing lesion severity and selecting graft targets in patients undergoing CABG. Electronic searches were carried out on Embase, MEDLINE, and Web of Science. A group of four authors independently screened and then assessed the retrieved records. Cochrane's Risk of Bias and Robins-I tools were used for bias assessment. A survey was conducted among surgeons and cardiologists to describe current attitudes towards the preoperative use of functional coronary investigations in practice. Results Clinical outcomes including mortality at 30 days, perioperative myocardial infarction, number of grafts, incidence of stroke, rate of further need for revascularisation, and patient-reported quality of life did not differ in CABG guided by functional testing from those guided by traditional angiography.The survey revealed that in half of the surgical and cardiology units functional assessment is performed in CABG patients; there is a general perception that functional testing has improved patient care and its use would clarify the role of moderate coronary lesions that often need multidisciplinary rediscussions; moderate stenosis are felt to be clinically relevant; and anatomical considerations need to be taken into account together with functional assessment. Conclusions At present, the evidence to support the routine use of functional testing in intermediate lesions for planning CABG is currently insufficient. The pooled data currently available do not show an increased risk in mortality, myocardial injury, and stroke in the FFR/iFR-guided group. Further trials with highly selected populations are needed to clarify the best strategy. Systematic Review Registration ClinicalTrials.gov, identifier (CRD42023414604).
Collapse
Affiliation(s)
- R. G. Abbasciano
- Department of Cardiothoracic Surgery, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - G. R. Layton
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
- Department of Cardiac Surgery, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - S. Torre
- Cardiac Surgery Unit, Giaccone Hospital, Palermo, Italy
| | - N. Abbaker
- Department of Cardiothoracic Surgery, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - A. Copperwheat
- Department of Cardiac Surgery, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - C. Lucarelli
- Department of Cardiothoracic Surgery, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - S. Bhandari
- Department of Cardiology, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - S. Nijjer
- Department of Cardiothoracic Surgery, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - G. Mikhail
- Department of Cardiothoracic Surgery, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - R. Casula
- Department of Cardiothoracic Surgery, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - M. Zakkar
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
- Department of Cardiac Surgery, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - A. Viviano
- Department of Cardiothoracic Surgery, Imperial College Healthcare NHS Trust, London, United Kingdom
| |
Collapse
|
15
|
Molossi S, Doan T, Sachdeva S. Anomalous Coronary Arteries: A State-of-the-Art Approach. Card Electrophysiol Clin 2024; 16:51-69. [PMID: 38280814 DOI: 10.1016/j.ccep.2023.09.007] [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] [Indexed: 01/29/2024]
Abstract
Congenital coronary anomalies are not an infrequent occurrence and their clinical presentation typically occurs during early years, though may be manifested only in adulthood. In the setting of anomalous aortic origin of a coronary artery, this is particularly concerning as it inflicts sudden loss of healthy young lives. Risk stratification remains a challenge and so does the best management decision-making in these patients, particularly if asymptomatic. Standardized approach to evaluation and management, with careful data collection and collaboration among centers, will likely impact future outcomes in this patient population, thus allowing for exercise participation and healthier lives.
Collapse
Affiliation(s)
- Silvana Molossi
- Coronary Artery Anomalies Program, Texas Children's Hospital, 6651 Main Street, MC E1920, Houston, TX 77030, USA; The Lillie Frank Abercrombie Section of Cardiology, Texas Children's Hospital, Baylor College of Medicine, 6651 Main Street, MC E1920, Houston, TX 77030, USA.
| | - Tam Doan
- Coronary Artery Anomalies Program, Texas Children's Hospital, 6651 Main Street, MC E1920, Houston, TX 77030, USA; The Lillie Frank Abercrombie Section of Cardiology, Texas Children's Hospital, Baylor College of Medicine, 6651 Main Street, MC E1920, Houston, TX 77030, USA
| | - Shagun Sachdeva
- Coronary Artery Anomalies Program, Texas Children's Hospital, 6651 Main Street, MC E1920, Houston, TX 77030, USA; The Lillie Frank Abercrombie Section of Cardiology, Texas Children's Hospital, Baylor College of Medicine, 6651 Main Street, MC E1920, Houston, TX 77030, USA
| |
Collapse
|
16
|
Chen Z, Zhang J, Cai Y, Zhao H, Wang D, Li C, He Y. Diagnostic performance of angiography-derived fractional flow reserve and CT-derived fractional flow reserve: A systematic review and Bayesian network meta-analysis. J Evid Based Med 2024; 17:119-133. [PMID: 38205918 DOI: 10.1111/jebm.12573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 12/05/2023] [Indexed: 01/12/2024]
Abstract
OBJECTIVE Accumulating evidence has demonstrated that fractional flow reserves (FFRs) derived from invasive coronary angiograms (CA-FFRs) and coronary computed tomography angiography-derived FFRs (CT-FFRs) are promising alternatives to wire-based FFRs. However, it remains unclear which method has better diagnostic performance. This systematic review and meta-analysis aimed to compare the diagnostic performances of the two approaches. METHODS The Cochrane Library, PubMed, Embase, Medline (Ovid), the Chinese China National Knowledge Infrastructure Database (CNKI), VIP, and WanFang Data databases were searched for relevant studies that included comparisons between CA-FFR and CT-FFR, from their respective database inceptions until January 1, 2023. Studies where both noninvasive FFR (including CA-FFR and CT-FFR) and invasive FFR (as a reference standard) were performed for the diagnosis of ischemic coronary artery disease and were designed as prospective, paired diagnostic studies, were pulled. The diagnostic test accuracy method and Bayesian hierarchical summary receiver operating characteristic (ROC) model for network meta-analysis (NMA) of diagnostic tests (HSROC-NMADT) were both used to perform a meta-analysis on the data. RESULTS Twenty-six studies were included in this NMA. The results from both the diagnostic test accuracy and HSROC-NMADT methods revealed that the diagnostic accuracy of CA-FFR was higher than that of CT-FFR, in terms of sensitivity (Se; 0.86 vs. 0.84), specificity (Sp; 0.90 vs. 0.78), positive predictive value (PPV; 0.83 vs. 0.70), and negative predictive value (NPV; 0.91 vs. 0.89) for the detection of myocardial ischemia. A cumulative ranking curve analysis indicated that CA-FFR had a higher diagnostic accuracy than CT-FFR in the context of this study, with a higher area under the ROC curve (AUC; 0.94 vs. 0.87). CONCLUSIONS Although both of these two commonly used virtual FFR methods showed high levels of diagnostic accuracy, we demonstrated that CA-FFR had a better Se, Sp, PPV, NPV, and AUC than CT-FFR. However, this study provided only indirect comparisions; therefore, larger studies are warranted to directly compare the diagnostic performances of these two approaches.
Collapse
Affiliation(s)
- Zhongxiu Chen
- Department of Cardiology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Junyan Zhang
- Department of Cardiology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Yujia Cai
- Chinese Evidence-based Medicine Center and MAGIC-China Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Hongsen Zhao
- Information Center, West China Hospital, Sichuan University, Chengdu, China
| | - Duolao Wang
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, UK
| | - Chen Li
- Department of Cardiology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Yong He
- Department of Cardiology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| |
Collapse
|
17
|
Vira A, Balanescu DV, George JA, Dixon SR, Hanson ID, Safian RD. Diagnostic Performance of Diastolic Hyperemia-Free Ratio Compared With Invasive Fractional Flow Reserve for Evaluation of Coronary Artery Disease. Am J Cardiol 2024; 214:55-58. [PMID: 38199309 DOI: 10.1016/j.amjcard.2023.12.050] [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: 10/09/2023] [Revised: 12/04/2023] [Accepted: 12/24/2023] [Indexed: 01/12/2024]
Abstract
Hyperemic and nonhyperemic pressure ratios are frequently used to assess the hemodynamic significance of coronary artery disease and to guide the need for myocardial revascularization. However, there are limited data on the diagnostic performance of the diastolic hyperemia-free ratio (DFR). We evaluated the diagnostic performance of the DFR compared with invasive fractional flow reserve (FFR). We performed a prospective, single-center study of 308 patients (343 lesions) who underwent DFR and FFR for evaluation of visually estimated 40% to 90% stenoses. Diagnostic performance of the DFR compared with FFR was evaluated using linear regression, Bland-Altman analysis, and receiver operating characteristic curves. The overall diagnostic accuracy of the DFR was 83%; the accuracy rates were 86%, 40%, and 95% when the DFR was <0.86, 0.88 to 0.90, and >0.93, respectively. The sensitivity, specificity, positive predicative value, and negative predictive value were 60%, 91%, 71%, and 87%, respectively. The Pearson correlation coefficient was 0.75 (p <0.05). The Bland-Altman analysis showed a mean difference of 0.09, and the area under the receiver operating characteristic curve was 0.88 (95% confidence interval 0.84 to 0.92, p <0.05). In conclusion, the DFR has a good diagnostic performance compared with FFR but 17% of the measurements were discordant. The diagnostic accuracy of the DFR was only 40% when the DFR was 0.88 to 0.90, suggesting that FFR may be useful in these arteries.
Collapse
Affiliation(s)
- Amit Vira
- Department of Cardiovascular Medicine, William Beaumont University Hospital-Corewell Health East, Royal Oak, Michigan
| | - Dinu-Valentin Balanescu
- Department of Cardiovascular Medicine, William Beaumont University Hospital-Corewell Health East, Royal Oak, Michigan
| | - Julie A George
- Department of Cardiovascular Medicine, William Beaumont University Hospital-Corewell Health East, Royal Oak, Michigan
| | - Simon R Dixon
- Department of Cardiovascular Medicine, William Beaumont University Hospital-Corewell Health East, Royal Oak, Michigan
| | - Ivan D Hanson
- Department of Cardiovascular Medicine, William Beaumont University Hospital-Corewell Health East, Royal Oak, Michigan
| | - Robert D Safian
- Department of Cardiovascular Medicine, William Beaumont University Hospital-Corewell Health East, Royal Oak, Michigan.
| |
Collapse
|
18
|
Li W, Takahashi T, Sehatbakhsh S, Parikh MA, Garcia-Garcia HM, Fearon WF, Kobayashi Y. Diagnostic performances of Nonhyperemic Pressure Ratios and Coronary Angiography-Based Fractional Flow Reserve against conventional Wire-Based Fractional Flow Reserve. Coron Artery Dis 2024; 35:83-91. [PMID: 38088790 DOI: 10.1097/mca.0000000000001309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Abstract
BACKGROUND Nonhyperemic pressure ratios (NHPRs) have been proposed as alternatives to fractional flow reserve (FFR) without induction of hyperemia. More recently, imaging based-FFR estimation, especially coronary angiography-derived FFR (Angio-FFR) measurement, is proposed to estimate wire-based FFR. However, little is known about the diagnostic performance of these indices against conventional FFR. AIMS We aimed to assess and compare the diagnostic performance of both NHPRs and coronary Angio-FFR against wire-based conventional FFR. METHODS PubMed and Embase databases were systematically searched for peer-reviewed original articles up to 08/2022. The primary outcomes were the pooled sensitivity and specificity as well as the area under the curve (AUC) of the summary receiver-operating characteristic curve of those indices. RESULTS A total of 6693 records were identified after a literature search, including 37 reports for NHPRs and 34 for Angio-FFR. Overall, NHPRs have a lower diagnostic performance in estimating wire-based FFR with an AUC of 0.85 (0.81, 0.88) when compared with Angio-FFR of 0.95 (0.93, 0.97). When all four modalities of NHPRs (iFR, Pd/Pa, DPR, RFR) were compared, those had overlapping AUCs without major differences among each other. Similarly, when the two most commonly used Angio-FFR (QFR, FFR angio ) were compared, those had overlapping AUCs without major differences among each other. CONCLUSION Angio-FFR may offer a better estimation of wire-based FFR than NHPRs. Our results support a wider use of Angio-FFR in the cardiac catheterization laboratory to streamline our workflow for coronary physiologic assessment. CLASSIFICATIONS FFR,, stable ischemic disease and non-ST elevation acute coronary syndrome.
Collapse
Affiliation(s)
- Weijia Li
- Heart, Lung and Vascular Institute, AdventHealth Orlando, Orlando, Florida
| | - Tatsunori Takahashi
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Samineh Sehatbakhsh
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Manish A Parikh
- Division of Cardiology, New York-Presbyterian Brooklyn Methodist Hospital, Weill Cornell Medical College, Brooklyn, New York
| | - Hector M Garcia-Garcia
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, District of Columbia
- MedStar Cardiovascular Research Network, MedStar Washington Hospital Center, Washington, District of Columbia
| | - William F Fearon
- Division of Cardiovascular Medicine, Stanford University Medical Center, Stanford, California, USA
| | - Yuhei Kobayashi
- Division of Cardiology, New York-Presbyterian Brooklyn Methodist Hospital, Weill Cornell Medical College, Brooklyn, New York
| |
Collapse
|
19
|
Kanoun Schnur SS, Pranevičius R, Stark C, Prunea D, Andreka J, Schmidt A, Harb S, Ruzsa Z, Zweiker R, Kane J, Toth GG. Operator decision-making in angiography-only guided revascularization for lesions not indicated for FFR: a QFR-based functional assessment in chronic coronary syndrome. Front Cardiovasc Med 2024; 11:1336341. [PMID: 38468724 PMCID: PMC10925875 DOI: 10.3389/fcvm.2024.1336341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 02/13/2024] [Indexed: 03/13/2024] Open
Abstract
Background Discordance between coronary angiographic findings and invasive functional significance is well-established. Yet, the prevalence of this mismatch in an era increasingly utilizing invasive functional assessments, such as fractional flow reserve (FFR), remains unclear. This study examines the extent of such discrepancies in current clinical practice. Methods This single-center prospective registry included consecutive patients with chronic coronary syndrome (CCS) who underwent elective coronary angiography, with or without revascularization. Coronary angiograms deemed not requiring FFR due to clear anatomical distinctions, either anatomically severe indicating a need for revascularization or mild suggesting no need for intervention, were selected for evaluation. These were then subjected to post-hoc analysis by three independent operators who were blinded to the definitive treatment strategies. Importantly, the post-hoc analysis was conducted in two distinct phases: firstly, a re-evaluation of coronary stenosis, and secondly, a separate functional assessment, each carried out independently. Coronary stenosis severity was assessed visually, while functional relevance was determined by quantitative flow ratio (QFR), calculated using a computational fluid dynamics algorithm applied to angiographic images. Analysis focused on discrepancies between QFR-based functional indications and revascularization strategies actually performed. Results In 191 patients, 488 vessels were analyzed. Average diameter stenosis (DS) was 37 ± 34%, and QFR was 0.87 ± 0.15, demonstrating a moderate correlation (r = -0.84; 95% CI: -0.86 to -0.81, p < 0.01). Agreement with QFR at conventional anatomical cutoffs was 88% for 50% DS and 91% for 70% DS. Mismatches between revascularization decisions and QFR indications occurred in 10% of cases. Discrepancies were more frequent in the left anterior descending artery (14%) compared to the left circumflex (6%) and the right coronary artery (9%; p = 0.07). Conclusion In a cardiac-center where FFR utilization is high, discordance between coronary angiography and functional significance persists, even when operators are confident in their decisions not to use functional interrogation. This gap, most evident in the left anterior descending artery, highlights the potential need for integrated angiography-based functional assessments to refine revascularization decisions in CCS.
Collapse
Affiliation(s)
- Sadeek S. Kanoun Schnur
- Department of Cardiology, UniversityHeart Center Graz, Medical University Graz, Graz, Austria
- Peninsula Deanery, Royal Devon University Healthcare NHS Foundation Trust, Exeter, United Kingdom
- Doctoral School of Clinical Medicine, Faculty of Medicine, University of Szeged, Szeged, Hungary
| | - Robertas Pranevičius
- Department of Cardiology, UniversityHeart Center Graz, Medical University Graz, Graz, Austria
- Department of Cardiology, Heart and Vascular Center, Republican Siauliai Hospital, Siauliai, Lithuania
| | - Cosima Stark
- Department of Cardiology, UniversityHeart Center Graz, Medical University Graz, Graz, Austria
| | - Dan Prunea
- Department of Cardiology, UniversityHeart Center Graz, Medical University Graz, Graz, Austria
- “Niculae Stancioiu” Heart Institute, University of Medicine “Iuliu Hatieganu”, Cluj-Napoca, Romania
| | - Judit Andreka
- Department of Cardiology, UniversityHeart Center Graz, Medical University Graz, Graz, Austria
- Doctoral School of Clinical Medicine, Faculty of Medicine, University of Szeged, Szeged, Hungary
| | - Albrecht Schmidt
- Department of Cardiology, UniversityHeart Center Graz, Medical University Graz, Graz, Austria
| | - Stefan Harb
- Department of Cardiology, UniversityHeart Center Graz, Medical University Graz, Graz, Austria
| | - Zoltan Ruzsa
- Doctoral School of Clinical Medicine, Faculty of Medicine, University of Szeged, Szeged, Hungary
| | - Robert Zweiker
- Department of Cardiology, UniversityHeart Center Graz, Medical University Graz, Graz, Austria
| | - Jesse Kane
- Department of Cardiology, University of Vermont Larner College of Medicine, Burlington, VT, United States
| | - Gabor G. Toth
- Department of Cardiology, UniversityHeart Center Graz, Medical University Graz, Graz, Austria
| |
Collapse
|
20
|
Campo Dall'Orto C, Eurípedes Vilela L, Vilella Pinto Filho G, Raphael da Silva M. Impact of Sex Differences on the Outcomes of Coronary Invasive Physiological Assessment: Long-Term Follow-Up in a Brazilian Population. WOMEN'S HEALTH REPORTS (NEW ROCHELLE, N.Y.) 2024; 5:93-103. [PMID: 38404671 PMCID: PMC10890956 DOI: 10.1089/whr.2023.0087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 01/10/2023] [Indexed: 02/27/2024]
Abstract
Objective This study aimed to evaluate the rate of major adverse cardiac events (MACEs; the sum of death, myocardial infarction, and revascularization rates) according to interventional strategies guided by invasive physiological methods in both sexes in a Brazilian population during long-term follow-up for an average of 2 years. Methods This retrospective single-center study included 151 consecutive patients (232 lesions) between January 2018 and January 2022. The participants were divided into two groups: the female group (FG), comprising 59 patients with 88 lesions, and the male group (MG), comprising 92 patients with 144 lesions. Results The FG had a greater mean age (FG: 67.96 ± 13.12 vs. MG: 62.36 ± 12.01 years, p = 0.009) and lower mean creatinine clearance (FG: 79.35 ± 38.63 vs. MG: 92.02 ± 38.62 mL/min, p = 0.02) than did the MG. The percentage of lesions in the left main coronary artery was higher in the FG than in the MG (12.5% vs. 2.78%, p = 0.006). The mean follow-up time was longer in the MG than in the FG (795.61 ± 350 vs. 619.19 ± 318 days, respectively; p = 0.001). MACE occurred in 11.86% and 13.04% of patients in the FG and MG, respectively (p = 0.850). Secondary outcomes, such as death, reinfarction, and the need for new revascularization, showed no significant between-sex differences. Conclusions Our study demonstrated the safety of invasive physiological methods to determine coronary revascularization in both male and female patients in a Brazilian population, as evidenced by the low rates of adverse cardiac events and death after a long-term follow-up.
Collapse
Affiliation(s)
- Clarissa Campo Dall'Orto
- Department of Hemodynamic and Interventional Cardiology, Advanced Hemodynamic Therapy Center, Brazilian Society of Health Support Hospital, Teixeira de Freitas, Bahia, Brazil
| | - Lara Eurípedes Vilela
- Department of Hemodynamic and Interventional Cardiology, Advanced Hemodynamic Therapy Center, Brazilian Society of Health Support Hospital, Teixeira de Freitas, Bahia, Brazil
| | - Gilvan Vilella Pinto Filho
- Department of Hemodynamic and Interventional Cardiology, Advanced Hemodynamic Therapy Center, Brazilian Society of Health Support Hospital, Teixeira de Freitas, Bahia, Brazil
| | - Marcos Raphael da Silva
- Department of Hemodynamic and Interventional Cardiology, Advanced Hemodynamic Therapy Center, Brazilian Society of Health Support Hospital, Teixeira de Freitas, Bahia, Brazil
| |
Collapse
|
21
|
Sehatbakhsh S, Li W, Takahashi T, Takahashi K, Parikh MA, Kobayashi Y. Nonhyperemic Pressure Ratios-All the Same or Nuanced Differences? Cardiol Clin 2024; 42:13-19. [PMID: 37949534 DOI: 10.1016/j.ccl.2023.07.011] [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] [Indexed: 11/12/2023]
Abstract
Fractional flow reserve (FFR) has become the gold standard for invasively assessing the functional significance of coronary artery disease (CAD) to guide revascularization. The amount of evidence supporting the role of FFR in the cardiac catheterization laboratory is large and still growing. However, FFR uptake in the daily practice is limited by a variety of factors such as invasive instrumentation of the coronary artery that requires extra time and need for vasodilator medications for hyperemia. In this review, we describe the details of wire-based alternatives to FFR, providing insights as to their development, clinical evidence, and limitations.
Collapse
Affiliation(s)
- Samineh Sehatbakhsh
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, 111 210th Street, Bronx, NY 10467, USA
| | - Weijia Li
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, 1400 Pelham Parkway South, The Bronx, NY 10461, USA
| | - Tatsunori Takahashi
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, 1400 Pelham Parkway South, The Bronx, NY 10461, USA
| | - Kayo Takahashi
- Department of Cardiology, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime 791-0295, Japan
| | - Manish A Parikh
- Division of Cardiology, New York-Presbyterian Brooklyn Methodist Hospital, Weill Cornell Medical College, 506 6th Street, Brooklyn, NY 11215, USA
| | - Yuhei Kobayashi
- Division of Cardiology, New York-Presbyterian Brooklyn Methodist Hospital, Weill Cornell Medical College, 506 6th Street, Brooklyn, NY 11215, USA.
| |
Collapse
|
22
|
Tehrani DM, Seto AH. Is Coronary Physiology Assessment Valid in Special Circumstances?: Aortic Stenosis, Atrial Fibrillation, Left Ventricular Hypertrophy, and Other. Cardiol Clin 2024; 42:21-29. [PMID: 37949537 DOI: 10.1016/j.ccl.2023.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
Fractional flow reserve (FFR) and nonhyperemic pressure ratios (NHPRs) provide an important clinical tool to evaluate the hemodynamic significance of coronary lesions. However, these indices have major limitations. As these indices are meant to be surrogates of coronary flow, clinical scenarios such as aortic stenosis (with increased end-systolic and end-diastolic pressures) or atrial fibrillation (with significant beat-to-beat cardiac output variability) can have significant effect on the accuracy and reliability of these hemodynamic indices. Here, we provide a comprehensive evaluation of the pitfalls, limitations, and strengths of FFR and NHPRs in common clinical scenarios paired with coronary artery disease.
Collapse
Affiliation(s)
- David M Tehrani
- Ronald Reagan UCLA Medical Center, 650 Charles East Young Drive South, CHS A2-237, Los Angeles, CA 90095-1679, USA.
| | - Arnold H Seto
- Long Beach Veterans Administration Medical Center, 5901 East 7th Street, 111C, Long Beach, CA 90822, USA. https://twitter.com/arnoldseto
| |
Collapse
|
23
|
Shin D, Lee SH, Hong D, Choi KH, Lee JM. Physiologic Assessment After Percutaneous Coronary Interventions and Functionally Optimized Revascularization. Cardiol Clin 2024; 42:55-76. [PMID: 37949540 DOI: 10.1016/j.ccl.2023.07.007] [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] [Indexed: 11/12/2023]
Abstract
Coronary physiologic assessment has become a standard of care for patients with coronary atherosclerotic disease. While most attention has focused on pre-interventional physiologic assessment to aid in revascularization decision-making, post-interventional physiologic assessment has not been as widely used, despite evidence supporting its role in assessment and optimization of the revascularization procedure. A thorough understanding of such evidence and ongoing studies would be crucial to incorporate post-interventional physiologic assessment into daily practice. Thus, this review provides a comprehensive overview of current evidence regarding the evolving role of physiologic assessment as a functional optimization tool for the entire revascularization process.
Collapse
Affiliation(s)
- Doosup Shin
- Division of Cardiology, Duke University Medical Center, 2301 Erwin Rd, Durham, NC 27710, USA
| | - Seung Hun Lee
- Department of Internal Medicine and Cardiovascular Center, Chonnam National University Hospital, 42, Jebong-ro, Dong-gu, Gwangju 61469, Republic of Korea
| | - David Hong
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Republic of Korea
| | - Ki Hong Choi
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Republic of Korea
| | - Joo Myung Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Republic of Korea.
| |
Collapse
|
24
|
Nijjer SS. Using Physiology Pullback for Percutaneous Coronary Intervention Guidance: Is this the Future? Cardiol Clin 2024; 42:41-53. [PMID: 37949539 DOI: 10.1016/j.ccl.2023.07.008] [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] [Indexed: 11/12/2023]
Abstract
Modern coronary intervention requires integration of angiographic, physiologic, and intravascular imaging. This article describes the use and techniques needed to understand coronary physiology pullback data and how use it to make revascularization decisions. The article describes instantaneous wave-free ratio, fractional flow reserve, and the data that support their use and how they differ when used in tandem disease. Common practical mistakes and errors are discussed together with a brief review of the limited published research data.
Collapse
Affiliation(s)
- Sukhjinder Singh Nijjer
- Department of Cardiology, Imperial College London, Hammersmith Hospital, Du Cane Road, London, W12 0HS, United Kingdom. https://twitter.com/SukhNijjer
| |
Collapse
|
25
|
Fawaz S, Cook CM. Understanding the Basis for Hyperemic and Nonhyperemic Coronary Pressure Assessment. Cardiol Clin 2024; 42:1-11. [PMID: 37949531 DOI: 10.1016/j.ccl.2023.07.012] [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] [Indexed: 11/12/2023]
Abstract
Despite the now routine integration of invasive physiologic systems into coronary catheter laboratories worldwide, it remains critical that all operators maintain a sound understanding of the fundamental physiologic basis for coronary pressure assessment. More specifically, performing operators should be well informed regarding the basis for hyperemic (ie, fractional flow reserve) and nonhyperemic (ie, instantaneous wave-free ratio and other nonhyperemic pressure ratio) coronary pressure assessment. In this article, we provide readers a comprehensive history charting the inception, development, and validation of hyperemic and nonhyperemic coronary pressure assessment.
Collapse
Affiliation(s)
- Samer Fawaz
- Essex Cardiothoracic Centre, Mid and South Essex NHS Hospitals Trust, Basildon SS16 5NL, United Kingdom; Anglia Ruskin University, Chelmsford, Essex CM1 1SQ, United Kingdom
| | - Christopher M Cook
- Essex Cardiothoracic Centre, Mid and South Essex NHS Hospitals Trust, Basildon SS16 5NL, United Kingdom; Anglia Ruskin University, Chelmsford, Essex CM1 1SQ, United Kingdom.
| |
Collapse
|
26
|
Shabbir A, Travieso A, Mejía-Rentería H, Espejo-Paeres C, Gonzalo N, Banning AP, Serruys PW, Escaned J. Coronary Physiology as Part of a State-of-the-Art Percutaneous Coronary Intervention Strategy: Lessons from SYNTAX II and Beyond. Cardiol Clin 2024; 42:147-158. [PMID: 37949536 DOI: 10.1016/j.ccl.2023.07.001] [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] [Indexed: 11/12/2023]
Abstract
The use of coronary physiology allows for rational decision making at the time of PCI, contributing to better patient outcomes. Yet, coronary physiology is only one aspect of optimal revascularization. State-of-the-art PCI must also consider other important aspects such as intracoronary imaging guidance and specific procedural expertise, as tested in the SYNTAX II study. In this review, we highlight the technical aspects pertaining to the use of physiology as used in that trial and offer a glimpse into the future with emerging physiologic metrics, including functional coronary angiography, which have already established themselves as useful indices to guide decision making.
Collapse
Affiliation(s)
- Asad Shabbir
- Interventional Cardiology Unit, Hospital Clínico San Carlos IDISCC, Complutense University of Madrid, Calle del Prof Martín Lagos, Madrid 28040, Spain
| | - Alejandro Travieso
- Interventional Cardiology Unit, Hospital Clínico San Carlos IDISCC, Complutense University of Madrid, Calle del Prof Martín Lagos, Madrid 28040, Spain
| | - Hernán Mejía-Rentería
- Interventional Cardiology Unit, Hospital Clínico San Carlos IDISCC, Complutense University of Madrid, Calle del Prof Martín Lagos, Madrid 28040, Spain
| | - Carolina Espejo-Paeres
- Interventional Cardiology Unit, Hospital Clínico San Carlos IDISCC, Complutense University of Madrid, Calle del Prof Martín Lagos, Madrid 28040, Spain
| | - Nieves Gonzalo
- Interventional Cardiology Unit, Hospital Clínico San Carlos IDISCC, Complutense University of Madrid, Calle del Prof Martín Lagos, Madrid 28040, Spain
| | - Adrian P Banning
- Heart Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Patrick W Serruys
- Department of Cardiology, National University of Ireland, Galway, Ireland; National Heart and Lung Institute, Imperial College London, London, UK
| | - Javier Escaned
- Interventional Cardiology Unit, Hospital Clínico San Carlos IDISCC, Complutense University of Madrid, Calle del Prof Martín Lagos, Madrid 28040, Spain.
| |
Collapse
|
27
|
Albayati MA, Patel A, Modi B, Saha P, Karim L, Perera D, Smith A, Modarai B. Intra-arterial Fractional Flow Reserve Measurements Provide an Objective Assessment of the Functional Significance of Peripheral Arterial Stenoses. Eur J Vasc Endovasc Surg 2024; 67:332-340. [PMID: 37500005 PMCID: PMC10917690 DOI: 10.1016/j.ejvs.2023.07.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 07/05/2023] [Accepted: 07/21/2023] [Indexed: 07/29/2023]
Abstract
OBJECTIVE Peripheral arterial stenoses (PAS) are commonly investigated with duplex ultrasound (DUS) and angiography, but these are not functional tests. Fractional flow reserve (FFR), a pressure based index, functionally assesses the ischaemic potential of coronary stenoses, but its utility in PAS is unknown. FFR in the peripheral vasculature in patients with limb ischaemia was investigated. METHODS Patients scheduled for angioplasty and or stenting of isolated iliac and superficial femoral artery stenoses were recruited. Resting trans-lesional pressure gradient (Pd/Pa) and FFR were measured after adenosine provoked hyperaemia using an intra-arterial 0.014 inch flow and pressure sensing wire (ComboWire XT, Philips). Prior to revascularisation, exercise ABPI (eABPI) and DUS derived peak systolic velocity ratio (PSVR) of the index lesion were determined. Calf muscle oxygenation was measured using blood oxygenation level dependent cardiovascular magnetic resonance prior to and after revascularisation. RESULTS Forty-one patients (32, 78%, male, mean age 65 ± 11 years) with 61 stenoses (iliac 32; femoral 29) were studied. For lesions < 80% stenosis, resting Pd/Pa was not influenced by the degree of stenosis (p = .074); however, FFR was discriminatory, decreasing as the severity of stenosis increased (p = .019). An FFR of < 0.60 was associated with critical limb threatening ischaemia (area under the curve [AUC] 0.87; 95% CI 0.75 - 0.95), in this study performing better than angiographic % stenosis (0.79; 0.63 - 0.89), eABPI (0.72; 0.57 - 0.83), and PSVR (0.65; 0.51 - 0.78). FFR correlated strongly with calf oxygenation (rho, 0.76; p < .001). A greater increase in FFR signalled resolution of symptoms and signs (ΔFFR 0.25 ± 0.15 vs. 0.13 ± 0.09; p = .009) and a post-angioplasty and stenting FFR of > 0.74 predicted successful revascularisation (combined sensitivity and specificity of 95%; AUC 0.98; 0.91 - 1.00). CONCLUSION This pilot study demonstrates that FFR can objectively measure the functional significance of PAS that compares favourably with visual and DUS based assessments. Its role as a quality control adjunct that confirms optimal vessel patency after angioplasty and or stenting also merits further investigation.
Collapse
Affiliation(s)
- Mostafa A Albayati
- Academic Department of Vascular Surgery, Guy's & St Thomas' NHS Foundation Trust and King's College London, United Kingdom
| | - Ashish Patel
- Academic Department of Vascular Surgery, Guy's & St Thomas' NHS Foundation Trust and King's College London, United Kingdom
| | - Bhavik Modi
- Department of Cardiology, School of Cardiovascular and Metabolic Medicine and Sciences, King's BHF Centre of Excellence, Guy's & St Thomas' NHS Foundation Trust and King's College London, United Kingdom
| | - Prakash Saha
- Academic Department of Vascular Surgery, Guy's & St Thomas' NHS Foundation Trust and King's College London, United Kingdom
| | - Lawen Karim
- Academic Department of Vascular Surgery, Guy's & St Thomas' NHS Foundation Trust and King's College London, United Kingdom
| | - Divaka Perera
- Department of Cardiology, School of Cardiovascular and Metabolic Medicine and Sciences, King's BHF Centre of Excellence, Guy's & St Thomas' NHS Foundation Trust and King's College London, United Kingdom
| | - Alberto Smith
- Academic Department of Vascular Surgery, Guy's & St Thomas' NHS Foundation Trust and King's College London, United Kingdom
| | - Bijan Modarai
- Academic Department of Vascular Surgery, Guy's & St Thomas' NHS Foundation Trust and King's College London, United Kingdom.
| |
Collapse
|
28
|
Omerovic E, Petrie M, Redfors B, Fremes S, Murphy G, Marquis-Gravel G, Lansky A, Velazquez E, Perera D, Reid C, Smith J, van der Meer P, Lipsic E, Juni P, McMurray J, Bauersachs J, Køber L, Rouleau JL, Doenst T. Pragmatic randomized controlled trials: strengthening the concept through a robust international collaborative network: PRIME-9-Pragmatic Research and Innovation through Multinational Experimentation. Trials 2024; 25:80. [PMID: 38263138 PMCID: PMC10807265 DOI: 10.1186/s13063-024-07935-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 01/15/2024] [Indexed: 01/25/2024] Open
Abstract
In an era focused on value-based healthcare, the quality of healthcare and resource allocation should be underpinned by empirical evidence. Pragmatic clinical trials (pRCTs) are essential in this endeavor, providing randomized controlled trial (RCT) insights that encapsulate real-world effects of interventions. The rising popularity of pRCTs can be attributed to their ability to mirror real-world practices, accommodate larger sample sizes, and provide cost advantages over traditional RCTs. By harmonizing efficacy with effectiveness, pRCTs assist decision-makers in prioritizing interventions that have a substantial public health impact and align with the tenets of value-based health care. An international network for pRCT provides several advantages, including larger and diverse patient populations, access to a broader range of healthcare settings, sharing knowledge and expertise, and overcoming ethical and regulatory barriers. The hypothesis and study design of pRCT answers the decision-maker's questions. pRCT compares clinically relevant alternative interventions, recruits participants from diverse practice settings, and collects data on various health outcomes. They are scarce because the medical products industry typically does not fund pRCT. Prioritizing these studies by expanding the infrastructure to conduct clinical research within the healthcare delivery system and increasing public and private funding for these studies will be necessary to facilitate pRCTs. These changes require more clinical and health policy decision-makers in clinical research priority setting, infrastructure development, and funding. This paper presents a comprehensive overview of pRCTs, emphasizing their importance in evidence-based medicine and the advantages of an international collaborative network for their execution. It details the development of PRIME-9, an international initiative across nine countries to advance pRCTs, and explores various statistical approaches for these trials. The paper underscores the need to overcome current challenges, such as funding limitations and infrastructural constraints, to leverage the full potential of pRCTs in optimizing healthcare quality and resource utilization.
Collapse
Affiliation(s)
- Elmir Omerovic
- Department of Cardiology, Sahlgrenska University Hospital, Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska Academy at University of Gothenburg, Bruna Stråket 16, 41345, Gothenburg, Sweden.
| | - Mark Petrie
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, UK
| | - Björn Redfors
- Department of Cardiology, Sahlgrenska University Hospital, Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska Academy at University of Gothenburg, Bruna Stråket 16, 41345, Gothenburg, Sweden
| | - Stephen Fremes
- Department of Surgery, University of Toronto, Toronto, ON, Canada
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Sunnybrook Research Institute, Toronto, ON, Canada
| | - Gavin Murphy
- Cardiovascular Research Centre, University of Leicester, Glenfield Hospital, Groby Road, Leicester, LE3 9QP, UK
| | | | - Alexandra Lansky
- Division of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Eric Velazquez
- Division of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Divaka Perera
- British Heart Foundation Centre of Research Excellence and National Institute for Health and Care Research Biomedical Research Centre at the School of Cardiovascular and Metabolic Medicine and Sciences, King's College London, London, UK
| | - Christopher Reid
- Curtin School of Population Health, Faculty of Health Sciences, Curtin University, Kent Street, Bentley, WA, 6102, Australia
| | - Julian Smith
- Department of Surgery (School of Clinical Sciences at Monash Health), Monash University, Melbourne, VIC, Australia
- Department of Cardiothoracic Surgery, Monash Health, Melbourne, VIC, Australia
| | - Peter van der Meer
- Department of Cardiology, Center for Blistering Diseases, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Eric Lipsic
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, PO Box 30.001, 9700 RB, Groningen, the Netherlands
| | - Peter Juni
- Oxford Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Oxford, OX3 7LF, UK
| | - John McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, UK
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Lars Køber
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jean L Rouleau
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Canada
| | - Torsten Doenst
- Department of Cardiothoracic Surgery, Friedrich-Schiller-University Jena, University Hospital, Jena, Germany
| |
Collapse
|
29
|
Di Carli MF, Gormsen LC, Chareonthaitawee P, Johnson GB, Beanlands R, DeKemp R, Schindler T, Gropler R, Kulkarni H, McNeely P, Soman P, Oz O, Zaha V, Sorensen J, Harms H, Orlandi C, Vandenbroucke E, Udelson J. Rationale and design of the RAPID-WATER-FLOW trial: Radiolabeled perfusion to identify coronary artery disease using water to evaluate responses of myocardial FLOW. J Nucl Cardiol 2024; 31:101779. [PMID: 38215598 DOI: 10.1016/j.nuclcard.2023.101779] [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] [Indexed: 01/14/2024]
Abstract
OBJECTIVES The objective of this study was to determine the diagnostic performance of 15O-water positron emission tomography (PET) myocardial perfusion imaging to detect coronary artery disease (CAD) using the truth-standard of invasive coronary angiography (ICA) with fractional flow reserve (FFR) or instantaneous wave-Free Ratio (iFR) or coronary computed tomography angiogram (CCTA). BACKGROUND 15O-water has a very high first-pass extraction that allows accurate quantification of myocardial blood flow and detection of flow-limiting CAD. However, the need for an on-site cyclotron and lack of automated production at the point of care and relatively complex image analysis protocol has limited its clinical use to date. METHODS The RAPID WATER FLOW study is an open-label, multicenter, prospective investigation of the accuracy of 15O-water PET to detect obstructive angiographic and physiologically significant stenosis in patients with suspected CAD. The study will include the use of an automated system for producing, dosing, and injecting 15O-water and enrolling approximately 215 individuals with suspected CAD at approximately 10 study sites in North America and Europe. The primary endpoint of the study is the diagnostic sensitivity and specificity of the 15O-water PET study using the truth-standard of ICA with FFR or iFR to determine flow-limiting stenosis, or CCTA to rule out CAD and incorporating a quantitative analytic platform developed for the 15O-water PET acquisitions. Sensitivity and specificity are to be considered positive if the lower bound of the 95% confidence interval is superior to the threshold of 60% for both, consistent with prior registration studies. Subgroup analyses include assessments of diagnostic sensitivity, specificity, and accuracy in female, obese, and diabetic individuals, as well as in those with multivessel disease. All enrolled individuals will be followed for adverse and serious adverse events for up to 32 hours after the index PET scan. The study will have >90% power (one-sided test, α = 0.025) to test the hypothesis that sensitivity and specificity of 15O-water PET are both >60%. CONCLUSIONS The RAPID WATER FLOW study is a prospective, multicenter study to determine the diagnostic sensitivity and specificity of 15O-water PET as compared to ICA with FFR/iFR or CCTA. This study will introduce several novel aspects to imaging registration studies, including a more relevant truth standard incorporating invasive physiologic indexes, coronary CTA to qualify normal individuals for eligibility, and a more quantitative approach to image analysis than has been done in prior pivotal studies. CLINICAL TRIAL REGISTRATION INFORMATION Clinical-Trials.gov (#NCT05134012).
Collapse
Affiliation(s)
- Marcelo F Di Carli
- Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Lars C Gormsen
- Department of Nuclear Medicine & PET Center, Aarhus University Hospital, Denmark
| | | | | | - Rob Beanlands
- National Cardiac PET Centre, Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Canada
| | - Rob DeKemp
- National Cardiac PET Centre, Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Canada
| | - Thomas Schindler
- Department of Radiology, Washington University, St Louis, MO, USA
| | - Robert Gropler
- Department of Radiology, Washington University, St Louis, MO, USA
| | | | - Parren McNeely
- Department of Radiology, University of Iowa, Iowa City, IA, USA
| | - Prem Soman
- Departments of Medicine and Radiology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Orhan Oz
- Department of Radiology, UT Southwestern, Dallas, TX, USA
| | - Vlad Zaha
- Department of Radiology, UT Southwestern, Dallas, TX, USA
| | - Jens Sorensen
- PET Center, Uppsala University Hospital, Uppsala, Sweden
| | | | | | | | - James Udelson
- Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA, USA
| |
Collapse
|
30
|
Nobre Menezes M, Tavares da Silva M, Magalhães A, Melica B, Toste JC, Calé R, Almeida M, Fiuza M, Infante de Oliveira E. Interventional cardiology in cancer patients: A position paper from the Portuguese Cardiovascular Intervention Association and the Portuguese Cardio-Oncology Study Group of the Portuguese Society of Cardiology. Rev Port Cardiol 2024; 43:35-48. [PMID: 37482119 DOI: 10.1016/j.repc.2023.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 04/08/2023] [Indexed: 07/25/2023] Open
Abstract
The field of Cardio-Oncology has grown significantly, especially during the last decade. While awareness of cardiotoxicity due to cancer disease and/or therapies has greatly increased, much of the attention has focused on myocardial systolic disfunction and heart failure. However, coronary and structural heart disease are also a common issue in cancer patients and encompass the full spectrum of cardiotoxicity. While invasive percutaneous or surgical intervention, either is often needed or considered in cancer patients, limited evidence or guidelines are available for dealing with coronary or structural heart disease. The Society for Cardiovascular Angiography and Interventions consensus document published in 2016 is the most comprehensive document regarding this particular issue, but relevant evidence has emerged since, which render some of its considerations outdated. In addition to that, the recent 2022 ESC Guidelines on Cardio-Oncology only briefly discuss this topic. As a result, the Portuguese Association of Cardiovascular Intervention and the Cardio-Oncology Study Group of the Portuguese Society of Cardiology have partnered to produce a position paper to address the issue of cardiac intervention in cancer patients, focusing on percutaneous techniques. A brief review of available evidence is provided, followed by practical considerations. These are based both on the literature as well as accumulated experience with these types of patients, as the authors are either interventional cardiologists, cardiologists with experience in the field of Cardio-Oncology, or both.
Collapse
Affiliation(s)
- Miguel Nobre Menezes
- Unidade de Cardiologia de Intervenção Joaquim Oliveira, Serviço de Cardiologia, Departamento de Coração e Vasos, Centro Hospitalar Universitário Lisboa Norte, Hospital de Santa Maria, Portugal; Centro Cardiovascular da Universidade de Lisboa (CCUL@RISE), Centro Académico de Medicina de Lisboa, Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal; Grupo de Estudos de Cardio-Oncologia, Sociedade Portuguesa de Cardiologia, Portugal; Associação Portuguesa de Intervenção Cardiovascular, Sociedade Portuguesa de Cardiologia, Portugal.
| | - Marta Tavares da Silva
- Grupo de Estudos de Cardio-Oncologia, Sociedade Portuguesa de Cardiologia, Portugal; Associação Portuguesa de Intervenção Cardiovascular, Sociedade Portuguesa de Cardiologia, Portugal; Serviço de Cardiologia, Centro Hospitalar e Universitário de São João, Porto, Portugal; UnIC@RISE, Departamento de Cirurgia e Fisiologia, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Andreia Magalhães
- Centro Cardiovascular da Universidade de Lisboa (CCUL@RISE), Centro Académico de Medicina de Lisboa, Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal; Grupo de Estudos de Cardio-Oncologia, Sociedade Portuguesa de Cardiologia, Portugal; Serviço de Cardiologia, Departamento de Coração e Vasos, Centro Hospitalar Universitário Lisboa Norte, Hospital de Santa Maria, Portugal
| | - Bruno Melica
- Associação Portuguesa de Intervenção Cardiovascular, Sociedade Portuguesa de Cardiologia, Portugal; Cardiology Department, Vila Nova de Gaia Hospital, Vila Nova de Gaia, Portugal
| | - Júlia Cristina Toste
- Grupo de Estudos de Cardio-Oncologia, Sociedade Portuguesa de Cardiologia, Portugal; Department of Cardiology, Hospital da Luz, Lisbon, Portugal; NOVA Medical School, Lisbon, Portugal
| | - Rita Calé
- Associação Portuguesa de Intervenção Cardiovascular, Sociedade Portuguesa de Cardiologia, Portugal; Cardiology Department, Hospital Garcia de Orta EPE, Almada, Portugal
| | - Manuel Almeida
- Associação Portuguesa de Intervenção Cardiovascular, Sociedade Portuguesa de Cardiologia, Portugal; Unidade de Intervenção Cardiovascular I Centro Hospitalar de Lisboa Ocidental e CHRC, NOVA Medical School|Faculdade de Ciências Médicas, NMS|FCM, Universidade Nova de Lisboa, Lisboa, Portugal
| | - Manuela Fiuza
- Centro Cardiovascular da Universidade de Lisboa (CCUL@RISE), Centro Académico de Medicina de Lisboa, Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal; Grupo de Estudos de Cardio-Oncologia, Sociedade Portuguesa de Cardiologia, Portugal; Serviço de Cardiologia, Departamento de Coração e Vasos, Centro Hospitalar Universitário Lisboa Norte, Hospital de Santa Maria, Portugal
| | - Eduardo Infante de Oliveira
- Associação Portuguesa de Intervenção Cardiovascular, Sociedade Portuguesa de Cardiologia, Portugal; Hospital Lusíadas Lisboa, Portugal; Hospital Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Carnaxide, Portugal
| |
Collapse
|
31
|
Kesieme EB, Iruolagbe CO, Omoregbee BI, Inuwa IM. Basic Overview of Conventional Coronary Angiography for Planning Cardiac Surgery. Cureus 2024; 16:e52942. [PMID: 38405998 PMCID: PMC10894027 DOI: 10.7759/cureus.52942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2024] [Indexed: 02/27/2024] Open
Abstract
Coronary angiography is a common procedure performed by the cardiologist to evaluate coronary atherosclerotic disease (CAD) and the result is utilized by both cardiologists and cardiac surgeons to perform catheter and surgical interventions on the coronary artery. In addition to evaluating CAD, other useful investigative modalities such as left ventriculography and aortography can be performed at the time of coronary angiography. Despite its limitations and the emergence of newer investigative modalities like coronary computed tomography angiography, intravascular ultrasound scan, and magnetic resonance coronary angiography, conventional coronary angiography has remained the gold standard for the evaluation of coronary artery disease. Hence, it remains an investigative modality that every member of the cardiothoracic team performing coronary artery bypass grafting must learn how to interpret.
Collapse
Affiliation(s)
- Emeka B Kesieme
- Cardiothoracic Surgery, Irrua Specialist Teaching Hospital, Irrua, NGA
- Cardiothoracic Surgery, Castle Hill Hospital, Cottingham, GBR
| | - Christopher O Iruolagbe
- Cardiology, Rosalind Franklin University of Medicine and Science/Chicago Medical School, Chicago, USA
| | | | - Ismail M Inuwa
- Cardiothoracic Surgery, Aminu Kano Teaching Hospital, Kano, NGA
| |
Collapse
|
32
|
Molossi S, Doan T, Sachdeva S. Anomalous Coronary Arteries: A State-of-the-Art Approach. Interv Cardiol Clin 2024; 13:51-70. [PMID: 37980067 DOI: 10.1016/j.iccl.2023.09.001] [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] [Indexed: 11/20/2023]
Abstract
Congenital coronary anomalies are not an infrequent occurrence and their clinical presentation typically occurs during early years, though may be manifested only in adulthood. In the setting of anomalous aortic origin of a coronary artery, this is particularly concerning as it inflicts sudden loss of healthy young lives. Risk stratification remains a challenge and so does the best management decision-making in these patients, particularly if asymptomatic. Standardized approach to evaluation and management, with careful data collection and collaboration among centers, will likely impact future outcomes in this patient population, thus allowing for exercise participation and healthier lives.
Collapse
Affiliation(s)
- Silvana Molossi
- Coronary Artery Anomalies Program, Texas Children's Hospital, 6651 Main Street, MC E1920, Houston, TX 77030, USA; The Lillie Frank Abercrombie Section of Cardiology, Texas Children's Hospital, Baylor College of Medicine, 6651 Main Street, MC E1920, Houston, TX 77030, USA.
| | - Tam Doan
- Coronary Artery Anomalies Program, Texas Children's Hospital, 6651 Main Street, MC E1920, Houston, TX 77030, USA; The Lillie Frank Abercrombie Section of Cardiology, Texas Children's Hospital, Baylor College of Medicine, 6651 Main Street, MC E1920, Houston, TX 77030, USA
| | - Shagun Sachdeva
- Coronary Artery Anomalies Program, Texas Children's Hospital, 6651 Main Street, MC E1920, Houston, TX 77030, USA; The Lillie Frank Abercrombie Section of Cardiology, Texas Children's Hospital, Baylor College of Medicine, 6651 Main Street, MC E1920, Houston, TX 77030, USA
| |
Collapse
|
33
|
Tamaki N, Manabe O. Current status and perspectives of nuclear cardiology. Ann Nucl Med 2024; 38:20-30. [PMID: 37891375 DOI: 10.1007/s12149-023-01878-1] [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: 08/02/2023] [Accepted: 09/29/2023] [Indexed: 10/29/2023]
Abstract
Nuclear cardiology has long been used to identify myocardial ischemia for appropriate treatment strategies for stable coronary artery disease (CAD). After the Ischemia Trial, it is time to reevaluate the significance of ischemia assessment. Functional imaging continues to play pivotal role in detecting microcirculatory disturbances. PET provides a clear image of blood flow distribution and is useful for the quantitative evaluation of myocardial flow reserve (MFR), which plays an important role in predicting treatment strategies and improving prognosis in CAD. Heart failure has become a major area of focus in cardiovascular medicine. Radionuclide imaging has been widely applied in this field. FDG PET is useful in identifying cardiac sarcoidosis and active inflammation. Clinical values of I-123 MIBG and BMIPP SPECT have been reported worldwide from Japan. Additionally, clinical experiences of Tc-99m pyrophosphate imaging have recently gained attention for assessing cardiac amyloidosis. Cardiac PET/CT and PET/MR imaging permit combined assessment of metabolic/functional/structural analyses of various cardiac diseases. While other non-invasive imaging modalities have rapidly been developed, the roles of radionuclide imaging remain to be valuable for early and accurate diagnosis and patient management in most cases of chronic CAD and various cardiovascular diseases.
Collapse
Affiliation(s)
- Nagara Tamaki
- Kyoto College of Medical Science, Kyoto, Japan.
- Department of Radiology, Kyoto Prefectural University of Medicine, Kyoto, Japan.
| | - Osamu Manabe
- Department of Radiology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| |
Collapse
|
34
|
Pierce JB, Applefeld WN, Senman B, Loriaux DB, Lawler PR, Katz JN. Design and Execution of Clinical Trials in the Cardiac Intensive Care Unit. Crit Care Clin 2024; 40:193-209. [PMID: 37973354 DOI: 10.1016/j.ccc.2023.09.003] [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] [Indexed: 11/19/2023]
Abstract
Clinical practice in the contemporary cardiac intensive care unit (CICU) has evolved significantly over the last several decades. With more frequent multisystem organ failure, increasing use of advanced respiratory support, and the advent of new mechanical circulatory support platforms, clinicians in the CICU are increasingly managing patients with complex comorbid disease in addition to their high-acuity cardiovascular illnesses. Here, the authors discuss challenges associated with traditional trial design in the CICU setting and review novel clinical trial designs that may facilitate better evidence generation in the CICU.
Collapse
Affiliation(s)
- Jacob B Pierce
- Department of Internal Medicine, Duke University School of Medicine, Durham, NC, USA.
| | - Willard N Applefeld
- Division of Cardiology, Department of Internal Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Balimkiz Senman
- Division of Cardiology, Department of Internal Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Daniel B Loriaux
- Division of Cardiology, Department of Internal Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Patrick R Lawler
- McGill University Health Centre, Montreal, Quebec, Canada; Peter Munk Cardiac Centre at University Health Network, Toronto, Canada
| | - Jason N Katz
- Division of Cardiology, Department of Internal Medicine, Duke University School of Medicine, Durham, NC, USA
| |
Collapse
|
35
|
Amat-Santos IJ, Marengo G, Sánchez-Luna JP, Cortés Villar C, Rivero Crespo F, Jiménez Díaz VA, de la Torre Hernández JM, Pérez de Prado A, Sabaté M, López-Palop R, Vegas Valle JM, Suárez de Lezo J, Fernandez Cordon C, Gonzalez JC, García-Gómez M, Redondo A, Carrasco Moraleja M, San Román JA. Validation of Quantitative Flow Ratio-Derived Virtual Angioplasty with Post-Angioplasty Fractional Flow Reserve-The QIMERA-I Study. J Cardiovasc Dev Dis 2023; 11:14. [PMID: 38248884 PMCID: PMC10816683 DOI: 10.3390/jcdd11010014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 12/25/2023] [Accepted: 12/29/2023] [Indexed: 01/23/2024] Open
Abstract
Background: Quantitative flow ratio (QFR) virtual angioplasty with pre-PCI residual QFR showed better results compared with an angiographic approach to assess post-PCI functional results. However, correlation with pre-PCI residual QFR and post-PCI fractional flow reserve (FFR) is lacking. Methods: A multicenter prospective study including consecutive patients with angiographically 50-90% coronary lesions and positive QFR results. All patients were evaluated with QFR, hyperemic and non-hyperemic pressure ratios (NHPR) before and after the index PCI. Pre-PCI residual QFR (virtual angioplasty) was calculated and compared with post-PCI fractional flow reserve (FFR), QFR and NHPR. Results: A total of 84 patients with 92 treated coronary lesions were included, with a mean age of 65.5 ± 10.9 years and 59% of single vessel lesions being the left anterior descending artery in 69%. The mean vessel diameter was 2.82 ± 0.41 mm. Procedural success was achieved in all cases, with a mean number of implanted stents of 1.17 ± 0.46. The baseline QFR value was 0.69 ± 0.12 and baseline FFR and NHPR were 0.73 ± 0.08 and 0.82 ± 0.11, respectively. Mean post-PCI FFR increased to 0.87 ± 0.05 whereas residual QFR had been estimated as 0.95 ± 0.05, showing poor correlation with post-PCI FFR (0.163; 95% CI:0.078-0.386) and low diagnostic accuracy (30.9%, 95% CI:20-43%). Conclusions: In this analysis, the results of QFR-based virtual angioplasty did not seem to accurately correlate with post-PCI FFR.
Collapse
Affiliation(s)
- Ignacio J. Amat-Santos
- Cardiology Department, Hospital Clínico Universitario de Valladolid, 47003 Valladolid, Spain
| | - Giorgio Marengo
- Cardiology Department, Hospital Clínico Universitario de Valladolid, 47003 Valladolid, Spain
| | - Juan Pablo Sánchez-Luna
- Cardiology Department, Hospital Clínico Universitario de Valladolid, 47003 Valladolid, Spain
| | - Carlos Cortés Villar
- Cardiology Department, Hospital Clínico Universitario de Valladolid, 47003 Valladolid, Spain
- Cardiology Department, Hospital Miguel Servet, 50009 Zaragoza, Spain
| | | | | | | | | | - Manel Sabaté
- Cardiology Department, Hospital Clinic Universitari, 08001 Barcelona, Spain
| | - Ramón López-Palop
- Cardiology Department, Hospital Virgen de la Arrixaca, 30120 Murcia, Spain
| | | | | | - Clara Fernandez Cordon
- Cardiology Department, Hospital Clínico Universitario de Valladolid, 47003 Valladolid, Spain
| | - Jose Carlos Gonzalez
- Cardiology Department, Hospital Clínico Universitario de Valladolid, 47003 Valladolid, Spain
| | - Mario García-Gómez
- Cardiology Department, Hospital Clínico Universitario de Valladolid, 47003 Valladolid, Spain
| | - Alfredo Redondo
- Cardiology Department, Hospital Clínico Universitario de Valladolid, 47003 Valladolid, Spain
- Cardiology Department, Hospital Universitario de Santiago, 15706 Santiago de Compostela, Spain
| | | | - J. Alberto San Román
- Cardiology Department, Hospital Clínico Universitario de Valladolid, 47003 Valladolid, Spain
| |
Collapse
|
36
|
Ciaramella L, Di Serafino L, Mitrano L, De Rosa ML, Carbone C, Rea FS, Monaco S, Scalamogna M, Cirillo P, Esposito G. Invasive Assessment of Coronary Microcirculation: A State-of-the-Art Review. Diagnostics (Basel) 2023; 14:86. [PMID: 38201395 PMCID: PMC10795746 DOI: 10.3390/diagnostics14010086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 12/28/2023] [Accepted: 12/28/2023] [Indexed: 01/12/2024] Open
Abstract
A significant proportion of patients presenting with signs and symptoms of myocardial ischemia have no "significant" epicardial disease; thereby, the assessment of coronary microcirculation gained an important role in improving diagnosis and guiding therapy. In fact, coronary microvascular dysfunction (CMD) could be found in a large proportion of these patients, supporting both symptoms and signs of myocardial ischemia. However, CMD represents a diagnostic challenge for two main reasons: (1) the small dimension of the coronary microvasculature prevents direct angiographic visualization, and (2) despite the availability of specific diagnostic tools, they remain invasive and underused in the current clinical practice. For these reasons, CMD remains underdiagnosed, and most of the patients remain with no specific treatment and quality-of-life-limiting symptoms. Of note, recent evidence suggests that a "full physiology" approach for the assessment of the whole coronary vasculature may offer a significant benefit in terms of symptom improvement among patients presenting with ischemia and non-obstructive coronary artery disease. We analyze the pathophysiology of coronary microvascular dysfunction, providing the readers with a guide for the invasive assessment of coronary microcirculation, together with the available evidence supporting its use in clinical practice.
Collapse
Affiliation(s)
| | - Luigi Di Serafino
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Via Pansini 5, 80131 Naples, Italy; (L.C.); (L.M.); (M.L.D.R.); (C.C.); (F.S.R.); (S.M.); (M.S.); (P.C.); (G.E.)
| | | | | | | | | | | | | | | | | |
Collapse
|
37
|
Matsumura M, Maehara A, Davis JE, Kumar G, Sharp A, Samady H, Seto AH, Cohen D, Patel MR, Ali ZA, Stone GW, Jeremias A. Changes in post-PCI physiology based on anatomical vessel location: a DEFINE PCI substudy. EUROINTERVENTION 2023; 19:e903-e912. [PMID: 38031488 PMCID: PMC10719742 DOI: 10.4244/eij-d-23-00517] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 09/24/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND Anatomical vessel location affects post-percutaneous coronary intervention (PCI) physiology. AIMS We aimed to compare the post-PCI instantaneous wave-free ratio (iFR) in left anterior descending (LAD) versus non-LAD vessels and to identify the factors associated with a suboptimal post-PCI iFR. METHODS DEFINE PCI was a multicentre, prospective, observational study in which a blinded post-PCI iFR pullback was used to assess residual ischaemia following angiographically successful PCI. RESULTS Pre- and post-PCI iFR recordings of 311 LAD and 195 non-LAD vessels were compared. Though pre-PCI iFR in the LAD vessels (median 0.82 [0.63, 0.86]) were higher compared with those in non-LAD vessels (median 0.72 [0.49, 0.84]; p<0.0001), post-PCI iFR were lower in the LAD vessels (median 0.92 [0.88, 0.94] vs 0.98 [0.95, 1.00]; p<0.0001). The prevalence of a suboptimal post-PCI iFR of <0.95 was higher in the LAD vessels (77.8% vs 22.6%; p<0.0001). While the overall frequency of residual physiological diffuse disease (31.4% vs 38.6%; p=0.26) and residual focal disease in the non-stented segment (49.6% vs 50.0%; p=0.99) were similar in both groups, residual focal disease within the stented segment was more common in LAD versus non-LAD vessels (53.7% vs 27.3%; p=0.0009). Improvement in iFR from pre- to post-PCI was associated with angina relief regardless of vessel location. CONCLUSIONS After angiographically successful PCI, post-PCI iFR is lower in the LAD compared with non-LAD vessels, resulting in a higher prevalence of suboptimal post-PCI iFR in LAD vessels. This difference is, in part, due to a greater frequency of a residual focal pressure gradient within the stented segment which may be amenable to more aggressive PCI.
Collapse
Affiliation(s)
| | - Akiko Maehara
- Cardiovascular Research Foundation, New York, NY, USA
- Columbia University Irving Medical Center, New York, NY, USA
| | - Justin E Davis
- Hammersmith Hospital, Imperial College NHS Trust, London, United Kingdom
| | | | - Andrew Sharp
- Royal Devon & Exeter NHS Foundation Trust, Exeter, United Kingdom
| | | | | | - David Cohen
- Cardiovascular Research Foundation, New York, NY, USA
- St. Francis Hospital, Roslyn, NY, USA
| | | | - Ziad A Ali
- Cardiovascular Research Foundation, New York, NY, USA
- St. Francis Hospital, Roslyn, NY, USA
| | - Gregg W Stone
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Allen Jeremias
- Cardiovascular Research Foundation, New York, NY, USA
- St. Francis Hospital, Roslyn, NY, USA
| |
Collapse
|
38
|
Serrao G, Vinayak M, Nicolas J, Subramaniam V, Lai AC, Laskey D, Kini A, Seethamraju H, Scheinin S. The Evaluation and Management of Coronary Artery Disease in the Lung Transplant Patient. J Clin Med 2023; 12:7644. [PMID: 38137713 PMCID: PMC10743826 DOI: 10.3390/jcm12247644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 11/13/2023] [Accepted: 11/22/2023] [Indexed: 12/24/2023] Open
Abstract
Lung transplantation can greatly improve quality of life and extend survival in those with end-stage lung disease. In order to derive the maximal benefit from such a procedure, patients must be carefully selected and be otherwise healthy enough to survive a high-risk surgery and sometimes prolonged immunosuppressive therapy following surgery. Patients therefore must be critically assessed prior to being listed for transplantation with close attention paid towards assessment of cardiovascular health and operative risk. One of the biggest dictators of this is coronary artery disease. In this review article, we discuss the assessment and management of coronary artery disease in the potential lung transplant candidate.
Collapse
Affiliation(s)
- Gregory Serrao
- Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (M.V.); (J.N.); (V.S.); (A.C.L.); (D.L.); (A.K.); (H.S.); (S.S.)
| | | | | | | | | | | | | | | | | |
Collapse
|
39
|
Wong CC, Fearon WF. Where Do We Go With Abnormal Flow? JACC. ASIA 2023; 3:878-880. [PMID: 38155800 PMCID: PMC10751635 DOI: 10.1016/j.jacasi.2023.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/30/2023]
Affiliation(s)
- Christopher C.Y. Wong
- Division of Cardiovascular Medicine and Cardiovascular Institute, Stanford University School of Medicine, Stanford, California, USA
- VA Palo Alto Health Care System, Palo Alto, California, USA
| | - William F. Fearon
- Division of Cardiovascular Medicine and Cardiovascular Institute, Stanford University School of Medicine, Stanford, California, USA
- VA Palo Alto Health Care System, Palo Alto, California, USA
| |
Collapse
|
40
|
Johnsrud DO, Port SC. In 2023 invasive coronary angiography is preferred to PET myocardial perfusion imaging for the initial work-up of a symptomatic patient with a high coronary artery calcium score. J Nucl Cardiol 2023; 30:2269-2272. [PMID: 37845556 DOI: 10.1007/s12350-023-03385-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 09/06/2023] [Indexed: 10/18/2023]
|
41
|
Misumida N, Moliterno DJ. Coronary Physiology Assessment: On Becoming Faster, Friendlier, and a Better Guiding Companion. JACC. ASIA 2023; 3:843-845. [PMID: 38155787 PMCID: PMC10751643 DOI: 10.1016/j.jacasi.2023.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/30/2023]
Affiliation(s)
- Naoki Misumida
- Division of Cardiovascular Medicine, Gill Heart and Vascular Institute, University of Kentucky, Lexington, Kentucky, USA
| | - David J. Moliterno
- Division of Cardiovascular Medicine, Gill Heart and Vascular Institute, University of Kentucky, Lexington, Kentucky, USA
| |
Collapse
|
42
|
Luo Y, Mao M, Wu F, Ma K, Chang J, Xiang R. Diagnostic performance of resting full-cycle ratio in identifying coronary lesions causing myocardial ischaemia: a meta-analysis. Acta Cardiol 2023; 78:1103-1109. [PMID: 37811658 DOI: 10.1080/00015385.2023.2250944] [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: 07/17/2022] [Accepted: 08/17/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND The resting full-cycle ratio (RFR), a new non-congestive resting index, is commonly used for physiological evaluations of coronary arteries. AIMS This study aims to evaluate the accuracy of RFR in detecting coronary artery stenosis with hemodynamic significance using fractional flow reserve (FFR) as the reference standard. METHODS Using 'RFR, resting full-cycle ratio' as the search term, we searched PubMed, Embase, Cochrane Library, and Web of Science databases, screening the literature according to the inclusion and exclusion criteria. By applying FFR ≤ 0.80 and RFR ≤ 0.89 as the diagnostic criteria for ischaemia, we analysed the synthetic sensitivity, specificity, and corresponding 95% confidence intervals, then synthesised the summary receiver operating characteristic curve (SROC). RESULTS Three studies were included in this meta-analysis, comprising 1,084 patients with 1,312 lesions. When we used FFR ≤ 0.80 as the reference standard, the synthesised sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LR+), and negative likelihood ratio (LR-) of RFR in the diagnosis of coronary ischaemia were 73%, 81%, 67%, 85%, 3.95, and 0.33, respectively. Besides, the area under the curve (AUC) was 0.8276. CONCLUSION Using FFR as the reference standard, RFR has good diagnostic accuracy in detecting coronary ischaemic lesions and may be an effective alternative to FFR in the future, to some extent.
Collapse
Affiliation(s)
- Yue Luo
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Min Mao
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Fan Wu
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Kanghua Ma
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jing Chang
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Rui Xiang
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| |
Collapse
|
43
|
Elbadawi A, Sedhom R, Ghoweba M, Etewa AM, Kayani W, Rahman F. Contemporary Use of Coronary Physiology in Cardiology. Cardiol Ther 2023; 12:589-614. [PMID: 37668939 DOI: 10.1007/s40119-023-00329-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 08/11/2023] [Indexed: 09/06/2023] Open
Abstract
Coronary angiography has a limited ability to predict the functional significance of intermediate coronary lesions. Hence, physiological assessment of coronary lesions, via fractional flow reserve (FFR) or instantaneous wave-free ratio (iFR), has been introduced to determine their functional significance. An accumulating body of evidence has consolidated the role of physiology-guided revascularization, particularly among patients with stable ischemic heart disease. The use of FFR or iFR to guide decision-making in patients with stable ischemic heart disease and intermediate coronary lesions received a class I recommendation from major societal guidelines. Nevertheless, the role of coronary physiology testing is less clear among certain patients' groups, including patients with serial coronary lesions, acute coronary syndromes, aortic stenosis, heart failure, as well as post-percutaneous coronary interventions. In this review, we aimed to discuss the utility and clinical evidence of coronary physiology (mainly FFR and iFR), with emphasis on those specific patient groups.
Collapse
Affiliation(s)
- Ayman Elbadawi
- Division of Cardiology, Christus Good Shepherd, 707 East Marshall Avenue, Longview, TX, 75604, USA.
| | - Ramy Sedhom
- Department of Internal Medicine, Einstein Medical Centre, Philadelphia, PA, USA
| | - Mohamed Ghoweba
- Department of Internal Medicine, Christus Good Shepherd, Longview, TX, 75601, USA
| | | | - Waleed Kayani
- Section of Cardiology, Baylor College of Medicine, Houston, TX, USA
| | - Faisal Rahman
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| |
Collapse
|
44
|
Eftekhari A, van de Hoef TP, Hoshino M, Lee JM, Boerhout CKM, de Waard GA, Jung JH, Lee SH, Mejia-Renteria H, Echavarria-Pinto M, Meuwissen M, Matsuo H, Madera-Cambero M, Effat MA, Marques K, Doh JH, Banerjee R, Nam CW, Niccoli G, Murai T, Nakayama M, Tanaka N, Shin ES, Knaapen P, van Royen N, Escaned J, Koo BK, Chamuleau SAJ, Kakuta T, Piek JJ, Christiansen EH. Changes in microvascular resistance following percutaneous coronary intervention - From the ILIAS global registry. Int J Cardiol 2023; 392:131296. [PMID: 37633364 DOI: 10.1016/j.ijcard.2023.131296] [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: 02/17/2023] [Revised: 07/08/2023] [Accepted: 08/23/2023] [Indexed: 08/28/2023]
Abstract
BACKGROUND Microvascular resistance (MR) has prognostic value in acute and chronic coronary syndromes following percutaneous coronary intervention (PCI), however anatomic and physiologic determinants of the relative changes of MR and its association to target vessel failure (TVF) has not been investigated previously. This study aims to evaluate the association between changes in MR and TVF. METHODS This is a sub-study of the Inclusive Invasive Physiological Assessment in Angina Syndromes (ILIAS) registry which is a global multi-centre initiative pooling lesion-level coronary pressure and flow data. RESULTS Paired pre-post PCI haemodynamic data were available in n = 295 vessels out of n = 828 PCI treated patients and of these paired data on MR was present in n = 155 vessels. Vessels were divided according to increase vs. decrease % in microvascular resistance following PCI (ΔMR % ≤ 0 vs. ΔMR > 0%). Decreased microvascular resistance ΔMR % ≤ 0 occurred in vessels with lower pre-PCI fractional flow reserve (0.67 ± 0.15 vs. 0.72 ± 0.09 p = 0.051), coronary flow reserve (1.9 ± 0.8 vs. 2.6 ± 1.8 p < 0.0001) and higher hyperemic microvascular resistance (2.76 ± 1.3 vs. 1.62 ± 0.74 p = 0.001) and index of microvascular resistance (24.4 IQ (13.8) vs. 15. 8 IQ (13.2) p = 0.004). There was no difference in angiographic parameters between ΔMR % ≤ 0 vs. ΔMR > 0%. In a cox regression model ΔMR % > 0 was associated with increased rate of TVF (hazard ratio 95% CI 3.6 [1.2; 10.3] p = 0.018). CONCLUSION Increased MR post-PCI was associated with lesions of less severe hemodynamic influence at baseline and higher rates of TVF at follow-up.
Collapse
Affiliation(s)
- Ashkan Eftekhari
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark; Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark.
| | - Tim P van de Hoef
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Masahiro Hoshino
- Department of Cardiology, Tsuchiura Kyodo General Hospital, Tsuchiura City, Japan
| | - Joo Myung Lee
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Department of Medicine Hearth Vascular Stroke Institute Seoul, Republic of Korea
| | - Coen K M Boerhout
- Department of Cardiology, Amsterdam UMC - Location AMC, Amsterdam, the Netherlands
| | - Guus A de Waard
- Department of Cardiology, Amsterdam UMC- Location VUmc, Amsterdam, the Netherlands
| | - Ji-Hyun Jung
- Sejong General Hospital, Sejong Heart Institute, Bucheon, Republic of Korea
| | - Seung Hun Lee
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Hernan Mejia-Renteria
- Hospital Clínico San Carlos, Instituto de Investigación Sanitaria Hospital Clínico San Carlos, Universidad Complutense de Madrid, Madrid, Spain
| | - Mauro Echavarria-Pinto
- Hospital General Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estad Querétaro, Facultad de Medicina Universidad Autónoma de Querétaro, Querétaro, Mexico
| | | | - Hitoshi Matsuo
- Department of Cardiovascular Medicine, Gifu Hearth Center, Gifu, Japan
| | | | - Mohamed A Effat
- Division of Cardiovascular Health and Disease, University of Cincinnati, Cincinnati, OH, USA
| | - Koen Marques
- Department of Cardiology, Amsterdam UMC- Location VUmc, Amsterdam, the Netherlands
| | - Joon-Hyung Doh
- Department of Medicine, Keimyung University Dongsan Medical Center, Daegu, Republic of Korea
| | - Rupak Banerjee
- Mechanical and Materials Engineering Department, University of Cincinnati, Veterans Affairs Medical Center, Cincinnati, OH, USA
| | - Chang-Wook Nam
- Department of Medicine, Inje University Ilsan Paik Hospital, Goyang, Republic of Korea
| | | | - Tadashi Murai
- Department of Cardiology, Tsuchiura Kyodo General Hospital, Tsuchiura City, Japan
| | - Masafumi Nakayama
- Department of Cardiovascular Medicine, Gifu Heart Center, Gifu, Japan; Cardiovascular Center, Toda Central General Hospital, Toda, Japan
| | - Nobuhiro Tanaka
- Department of Cardiology, Tokyo Medical University Hachioji Medical Center, Tokyo, Japan
| | - Eun-Seok Shin
- Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Paul Knaapen
- Department of Cardiology, Amsterdam UMC- Location VUmc, Amsterdam, the Netherlands
| | - Niels van Royen
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Javier Escaned
- Hospital Clínico San Carlos, Instituto de Investigación Sanitaria Hospital Clínico San Carlos, Universidad Complutense de Madrid, Madrid, Spain
| | - Bon Kwon Koo
- Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Steven A J Chamuleau
- Department of Cardiology, Amsterdam UMC - Location AMC, Amsterdam, the Netherlands; Department of Cardiology, Amsterdam UMC- Location VUmc, Amsterdam, the Netherlands
| | - Tsunekazu Kakuta
- Department of Cardiology, Tsuchiura Kyodo General Hospital, Tsuchiura City, Japan
| | - Jan J Piek
- Department of Cardiology, Amsterdam UMC - Location AMC, Amsterdam, the Netherlands
| | | |
Collapse
|
45
|
Alfonso F, Rivero F. Artificial intelligence-assisted angiographically-derived fractional flow reserve. Coron Artery Dis 2023; 34:542-544. [PMID: 37865859 DOI: 10.1097/mca.0000000000001299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2023]
Affiliation(s)
- Fernando Alfonso
- Department of Cardiology. Hospital Universitario de La Princesa. Universidad Autónoma de Madrid. IIS-IP, CIBER-CV, Madrid, Spain
| | | |
Collapse
|
46
|
Kubota M, Oguri A. Diagnostic accuracy of diastolic pressure ratio using a pressure microcatheter for intracoronary physiological assessment. Heart Vessels 2023; 38:1395-1403. [PMID: 37626238 DOI: 10.1007/s00380-023-02301-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 08/02/2023] [Indexed: 08/27/2023]
Abstract
Recently, instantaneous wave-free ratio (iFR) has emerged as an alternative to the fractional flow reserve (FFR) for intracoronary physiological assessment. Although all diastolic resting indices are reportedly identical to the iFR, limited data exist on diastolic pressure ratio (dPR) measured using a microcatheter (dPRmicro). This study aimed to evaluate the diagnostic accuracy of dPRmicro compared to FFR measured using a microcatheter (FFRmicro) in real-world practice for intracoronary physiological assessment. This was a single-center, retrospective, observational study. We identified 103 consecutive suspected angina pectoris patients (107 lesions) who underwent dPRmicro and FFRmicro measurement using the Navvus® catheter at Takasaki Heart Hospital from March 2019 to June 2019. A total of 103 lesions in 103 patients were finally included in the study. The mean FFRmicro and dPRmicro values were 0.80 and 0.88, respectively. With an FFRmicro ≤ 0.80, the dPRmicro showed a diagnostic accuracy of 79.6%, sensitivity of 74.6%, specificity of 87.5%, positive predictive value of 90.4%, and negative predictive value of 68.6%. The area under the receiver operating characteristic (ROC) curve was 0.894 (95% confidence interval, 0.833-0.956), and the optimal cut-off value for dPRmicro derived from the ROC analysis was 0.90. dPRmicro and FFRmicro values were discordant in 21/103 cases (20.4%). As a multivariable logistic regression analysis was performed, the male sex (vs. female) had a statistically significant association with a dPRmicro-FFRmicro discordance (OR 4.91; 95% CI, 1.04-23.0; P = 0.044). No other factors were found to be significantly associated with the discordance. In conclusion, dPRmicro measured using a microcatheter had good diagnostic accuracy and correlation with FFRmicro, hence, it can be useful for making revascularization decisions. However, re-studies in larger populations will be needed to better understand the properties of diastolic resting index measured using a microcatheter in clinical settings.
Collapse
Affiliation(s)
- Masayuki Kubota
- Department of Cardiology, Takasaki Heart Hospital, Gumma, Japan
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Atsushi Oguri
- Department of Cardiology, Takasaki Heart Hospital, Gumma, Japan.
- Department of Cardiovascular Medicine, Don-Don Mamorou Clinic, Tochigi, Japan.
| |
Collapse
|
47
|
Yang S, Hwang D, Lee JM, Lee SH, Boerhout CK, Woudstra J, Vink CE, de Waard GA, Jung JH, Renteria HM, Hoshino M, Pinto ME, Meuwissen M, Matsuo H, Cambero MM, Eftekhari A, Effat MA, Murai T, Marques K, Appelman Y, Doh JH, Christiansen EH, Banerjee R, Kim HK, Nam CW, Niccoli G, Nakayama M, Tanaka N, Shin ES, Beijk MA, Chamuleau SA, van Royen N, Knaapen P, Kakuta T, Escaned J, Piek JJ, van de Hoef TP, Koo BK. Prognostic Implications of Individual and Combinations of Resting and Hyperemic Coronary Pressure and Flow Parameters. JACC. ASIA 2023; 3:865-877. [PMID: 38155797 PMCID: PMC10751649 DOI: 10.1016/j.jacasi.2023.07.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 07/11/2023] [Accepted: 07/15/2023] [Indexed: 12/30/2023]
Abstract
Background Coronary pressure- and flow-derived parameters have prognostic value. Objectives This study aims to investigate the individual and combined prognostic relevance of pressure and flow parameters reflecting resting and hyperemic conditions. Methods A total of 1,971 vessels deferred from revascularization after invasive pressure and flow assessment were included from the international multicenter registry. Abnormal resting pressure and flow were defined as distal coronary pressure/aortic pressure ≤0.92 and high resting flow (1/resting mean transit time >2.4 or resting average peak flow >22.7 cm/s), and abnormal hyperemic pressure and flow as fractional flow reserve ≤0.80 and low hyperemic flow (1/hyperemic mean transit time <2.2 or hyperemic average peak flow <25.0 cm/s), respectively. The clinical endpoint was target vessel failure (TVF), myocardial infarction (MI), or cardiac death at 5 years. Results The mean % diameter stenosis was 46.8% ± 16.5%. Abnormal pressure and flow were independent predictors of TVF and cardiac death/MI (all P < 0.05). The risk of 5-year TVF or MI/cardiac death increased proportionally with neither, either, and both abnormal resting pressure and flow, and abnormal hyperemic pressure and flow (all P for trend < 0.001). Abnormal resting pressure and flow were associated with a higher rate of TVF or MI/cardiac death in vessels with normal fractional flow reserve; this association was similar for abnormal hyperemic pressure and flow in vessels with normal resting distal coronary pressure/aortic pressure (all P < 0.05). Conclusions Abnormal resting and hyperemic pressure and flow were independent prognostic predictors. The abnormal flow had an additive prognostic value for pressure in both resting and hyperemic conditions with complementary prognostic between resting and hyperemic parameters.
Collapse
Affiliation(s)
- Seokhun Yang
- Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Doyeon Hwang
- Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Joo Myung Lee
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung Hun Lee
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Coen K.M. Boerhout
- Department of Cardiology, Amsterdam UMC location AMC, Amsterdam, The Netherlands
| | - Janneke Woudstra
- Department of Cardiology, Amsterdam UMC location AMC, Amsterdam, The Netherlands
| | - Caitlin E.M. Vink
- Department of Cardiology, Amsterdam UMC location AMC, Amsterdam, The Netherlands
| | - Guus A. de Waard
- Department of Cardiology, Amsterdam UMC location VUmc, Amsterdam, The Netherlands
| | - Ji Hyun Jung
- Sejong General Hospital, Sejong Heart Institute, Bucheon, Korea
| | - Hernan Mejia Renteria
- Hospital Clínico San Carlos, IDISSC, and Universidad Complutense de Madrid, Madrid, Spain
| | - Masahiro Hoshino
- Tsuchiura Kyodo General Hospital, Department of Cardiology, Tsuchiura city, Japan
| | - Mauro Echavarria Pinto
- Hospital General ISSSTE Querétaro Facultad de Medicina, Universidad Autónoma de Querétaro, Querétaro, México
| | | | - Hitoshi Matsuo
- Gifu Heart Center, Department of Cardiovascular Medicine, Gifu, Japan
| | | | - Ashkan Eftekhari
- Aarhus University Hospital, Department of Cardiology, Aarhus, Denmark
| | - Mohamed A. Effat
- Division of Cardiovascular Health and Disease, University of Cincinnati, Cincinnati, Ohio, USA
| | - Tadashi Murai
- Tsuchiura Kyodo General Hospital, Department of Cardiology, Tsuchiura city, Japan
| | - Koen Marques
- Department of Cardiology, Amsterdam UMC location VUmc, Amsterdam, The Netherlands
| | - Yolande Appelman
- Department of Cardiology, Amsterdam UMC location VUmc, Amsterdam, The Netherlands
| | - Joon Hyung Doh
- Department of Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | | | - Rupak Banerjee
- Department of Mechanical and Materials Engineering, University of Cincinnati, Veterans Affairs Medical Center, Cincinnati, Ohio, USA
| | - Hyun Kuk Kim
- Department of Internal Medicine and Cardiovascular Center, Chosun University Hospital, University of Chosun College of Medicine, Gwangju, Korea
| | - Chang Wook Nam
- Department of Medicine, Keimyung University Dongsan Medical Center, Daegu, Korea
| | | | - Masafumi Nakayama
- Gifu Heart Center, Department of Cardiovascular Medicine, Gifu, Japan
- Toda Central General Hospital, Cardiovascular Center, Toda, Japan
| | - Nobuhiro Tanaka
- Tokyo Medical University Hachioji Medical Center, Department of Cardiology, Tokyo, Japan
| | - Eun Seok Shin
- Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Marcel A.M. Beijk
- Department of Cardiology, Amsterdam UMC location AMC, Amsterdam, The Netherlands
| | - Steven A.J. Chamuleau
- Department of Cardiology, Amsterdam UMC location AMC, Amsterdam, The Netherlands
- Department of Cardiology, Amsterdam UMC location VUmc, Amsterdam, The Netherlands
| | - Niels van Royen
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Paul Knaapen
- Department of Cardiology, Amsterdam UMC location VUmc, Amsterdam, The Netherlands
| | - Tsunekazu Kakuta
- Tsuchiura Kyodo General Hospital, Department of Cardiology, Tsuchiura city, Japan
| | - Javier Escaned
- Hospital Clínico San Carlos, IDISSC, and Universidad Complutense de Madrid, Madrid, Spain
| | - Jan J. Piek
- Department of Cardiology, Amsterdam UMC location AMC, Amsterdam, The Netherlands
| | - Tim P. van de Hoef
- Department of Cardiology, Amsterdam UMC location AMC, Amsterdam, The Netherlands
- Department of Cardiology, Amsterdam UMC location VUmc, Amsterdam, The Netherlands
- Department of Cardiology, NoordWest Ziekenhuisgroep, the Netherlands
| | - Bon-Kwon Koo
- Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| |
Collapse
|
48
|
Ohtani H, Ueshima D, Kawakami T, Hanyu Y, Yoshioka K, Mizukami A, Matsumura A, Sasano T. A novel coronary angiographic index for predicting correlation between fractional flow reserve and resting full-cycle ratio. Coron Artery Dis 2023; 34:545-554. [PMID: 37865863 DOI: 10.1097/mca.0000000000001301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2023]
Abstract
OBJECTIVES The discordant results between fractional flow reserve (FFR) and resting full-cycle ratio (RFR) and the influence of angiographic characteristics on their correlation have not been sufficiently investigated. We aimed to identify angiographic characteristics that can predict FFR and RFR correlations using a novel angiographic scoring system. METHODS This retrospective analysis included 220 patients with 252 intermediate coronary lesions assessed using FFR and RFR. Each branch distal to the target lesion was scored based on the vessel diameter (0 points: < 1.5 mm, 1 point: 1.5-2.0 mm, and 2 points: > 2.0 mm) measured using quantitative coronary angiography. The angiographic score was calculated by adding these scores. RESULTS In a propensity score-matched cohort including 84 lesions (42 lesions in each low-and high-angiographic score group), the correlation between FFR and RFR in the high-angiographic score group (>4) was weaker than that in the low-score group (≤4) (Spearman's correlation: r = 0.44 vs. r = 0.80, P < 0.01). Considering a threshold of functional myocardial ischemia as FFR ≤ 0.80 and RFR ≤ 0.89, the low-angiographic score group showed a significantly lower discordance rate of abnormal FFR/normal RFR than the high-angiographic score group (7.1% vs. 23.8%, P = 0.03), whereas the discordance rates of normal FFR/abnormal RFR were similar in both groups (7.1% vs. 9.5%, P = 0.69). CONCLUSION This retrospective analysis highlights the influence of angiographic characteristics on the correlation between FFR and RFR. Our simple angiographic assessment method may be useful for interpreting physiological evaluations in daily clinical practice.
Collapse
Affiliation(s)
- Hirofumi Ohtani
- Department of Cardiology, Kameda Medical Center, Chiba
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | | | | | | | | | | | | | - Tetsuo Sasano
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| |
Collapse
|
49
|
Liontou C, Kalogera V, Oikonomou D, Stalikas D, Pappas L, Triantafyllou K. Diagnostic performance of quantitative flow ratio in non-ST elevation acute coronary syndromes in comparison to non-hyperemic pressure ratios: a prospective study. THE INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING 2023; 39:2567-2574. [PMID: 37882959 DOI: 10.1007/s10554-023-02967-y] [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: 04/05/2023] [Accepted: 09/21/2023] [Indexed: 10/27/2023]
Abstract
Quantitative flow ratio (QFR) is a new angiography-based coronary physiology tool aimed to evaluate functional relevance of intermediate coronary lesions. Aim of the study is to assess diagnostic performance of QFR in patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) in comparison to currently used non-hyperaemic pressure ratios (NHPRs). In this prospective, single-centre study, coronary physiology of intermediate coronary stenoses of non-culprit vessels in patients presenting with NSTE-ACS was evaluated using NHPRs (iFR, DFR or RFR). Subsequently, QFR was computed offline by a QFR analyst blinded to the NHPR results. Diagnostic performance of QFR was assessed in comparison to NHPRs as reference standard. A total of 60 vessels with intermediate coronary stenoses was investigated. The NHPRs were used as follows: RFR 38%, DFR 47% and iFR 15% of the cases. The NHPR result was positive, showing significant lesion, in 19 cases. A significant correlation was found between NHPR and QFR (r = 0.84, p < 0.001). Classification agreement of the two methods (95%) and diagnostic performance of QFR in comparison to NHPR (AUC: 0.962 [0.914-1.00]) were both high. Sensitivity, specificity, positive and negative predictive value of QFR in comparison to NHPR were 84.2%, 100%, 100% and 93.2% respectively. QFR has high diagnostic performance in detecting functionally significant lesions of non-culprit arteries in patients with NSTE-ACS and multivessel disease. Due to its high negative predictive value, it can be used to safely avoid unnecessary invasive physiological assessment of these lesions.
Collapse
Affiliation(s)
- Catherine Liontou
- 1st Cardiology Department, Evaggelismos General Hospital, Ipsilantou Str. 45-47, 10676, Athens, Greece.
| | - Vasiliki Kalogera
- 1st Cardiology Department, Evaggelismos General Hospital, Ipsilantou Str. 45-47, 10676, Athens, Greece
| | - Dimitrios Oikonomou
- 1st Cardiology Department, Evaggelismos General Hospital, Ipsilantou Str. 45-47, 10676, Athens, Greece
| | - Dimitrios Stalikas
- 1st Cardiology Department, Evaggelismos General Hospital, Ipsilantou Str. 45-47, 10676, Athens, Greece
| | - Loukas Pappas
- 1st Cardiology Department, Evaggelismos General Hospital, Ipsilantou Str. 45-47, 10676, Athens, Greece
| | | |
Collapse
|
50
|
Sreenivasan J, Jamil Y, Ahmad Y. Revascularization and Mortality at 5 Years After Treatment Guided By Instantaneous Wave-Free Ratio and Fractional Flow Reserve: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Am Heart Assoc 2023; 12:e032015. [PMID: 37982225 PMCID: PMC10727296 DOI: 10.1161/jaha.123.032015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 09/22/2023] [Indexed: 11/21/2023]
Affiliation(s)
| | - Yasser Jamil
- Section of Cardiovascular MedicineYale UniversityNew HavenCTUSA
| | - Yousif Ahmad
- Section of Cardiovascular MedicineYale UniversityNew HavenCTUSA
| |
Collapse
|