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Beck S, Pereyra VM, Seitz A, McChord J, Hubert A, Bekeredjian R, Sechtem U, Ong P. Invasive Diagnosis of Coronary Functional Disorders Causing Angina Pectoris. Eur Cardiol 2021; 16:e27. [PMID: 34276812 PMCID: PMC8280748 DOI: 10.15420/ecr.2021.06] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 04/26/2021] [Indexed: 01/16/2023] Open
Abstract
Coronary vasomotion disorders represent a frequent cause of angina and/or dyspnoea in patients with non-obstructed coronary arteries. The highly sophisticated interplay of vasodilatation and vasoconstriction can be assessed in an interventional diagnostic procedure. Established parameters characterising adequate vasodilatation are coronary blood flow at rest, and, after drug-induced vasodilation, coronary flow reserve, and microvascular resistance (hyperaemic microvascular resistance, index of microcirculatory resistance). An increased vasoconstrictive potential is diagnosed by provocation testing with acetylcholine or ergonovine. This enables a diagnosis of coronary epicardial and/or microvascular spasm. Ischaemia associated with microvascular spasm can be confirmed by ischaemic ECG changes and the measurement of lactate concentrations in the coronary sinus. Although interventional diagnostic procedures are helpful for determining the mechanism of the angina, which may be the key to successful medical treatment, they are still neither widely accepted nor applied in many medical centres. This article summarises currently well-established invasive methods for the diagnosis of coronary functional disorders causing angina pectoris.
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Affiliation(s)
- Sascha Beck
- Department of Cardiology and Angiology, Robert-Bosch-Krankenhaus Stuttgart, Germany
| | | | - Andreas Seitz
- Department of Cardiology and Angiology, Robert-Bosch-Krankenhaus Stuttgart, Germany
| | - Johanna McChord
- Department of Cardiology and Angiology, Robert-Bosch-Krankenhaus Stuttgart, Germany
| | - Astrid Hubert
- Department of Cardiology and Angiology, Robert-Bosch-Krankenhaus Stuttgart, Germany
| | - Raffi Bekeredjian
- Department of Cardiology and Angiology, Robert-Bosch-Krankenhaus Stuttgart, Germany
| | - Udo Sechtem
- Department of Cardiology and Angiology, Robert-Bosch-Krankenhaus Stuttgart, Germany
| | - Peter Ong
- Department of Cardiology and Angiology, Robert-Bosch-Krankenhaus Stuttgart, Germany
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Okabe Y, Otowa K, Mitamura Y, Murai H, Usui S, Kaneko S, Takamura M. Evaluation of the risk factors for ventricular arrhythmias secondary to QT prolongation induced by papaverine injection during coronary flow reserve studies using a 4 Fr angio-catheter. Heart Vessels 2018; 33:1358-1364. [PMID: 29713819 DOI: 10.1007/s00380-018-1175-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 04/20/2018] [Indexed: 02/07/2023]
Abstract
Estimation of the fractional flow reserve (FFR) is considered to be an established method by which to assess stable coronary artery stenosis. Induction of maximal coronary hyperemia is important during the FFR procedure. Papaverine has been reported to increase the risk of ventricular arrhythmia (VA). The purpose of the present study was to discover predictors of papaverine-induced VAs developing during FFR measurement. A total of 213 clinically stable patients were included in the study. FFRs were determined after intracoronary papaverine administration (12 mg into the left and 8 mg into the right coronary arteries). We compared patients in whom VA did and did not develop in terms of clinical and electrocardiogram characteristics. FFR measurements were performed on 244 lesions (133 in the left anterior descending arteries, 43 in the left circumflex arteries, and 68 in the right coronary arteries). We found that the QTc interval was prolonged in all patients after papaverine administration (average post-administration QTc interval = 569 ± 89 ms; average ΔQTc interval = 144 ± 80 ms). VA developed in three patients with significantly prolonged QT intervals (average post-administration QTc interval = 639 ± 19 ms, average ΔQTc interval = 220 ± 64 ms, p < 0.02) and transitioned from torsade de pointes to ventricular fibrillation. Bradycardia (< 50 beats/min), hypokalemia (serum K < 3.5 mEp/L), and low left ventricular function (ejection fraction (EF) < 50%) were associated with VA (bradycardia, p < 0.01; hypokalemia, p < 0.01; low left ventricular function, p < 0.01). Three-vessel disease was significantly predictive of VA (p < 0.003). In the three-vessel group, the complications of low left ventricular function, hypokalemia, and bradycardia were significantly associated with VA (p < 0.045). Three-vessel disease is a predictor of the development of VA during FFR measurement performed with the aid of papaverine, especially if accompanied by one or more of the following: low left ventricular function, hypokalemia, or bradycardia.
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Affiliation(s)
- Yoshitaka Okabe
- Department of Disease Control and Homeostasis, Graduate School of Medical Science, Kanazawa University, 13-1 Takara-machi, Kanazawa, 920-8641, Japan.
| | - Kanichi Otowa
- Municipal Tsuruga Hospital, 6-60, 1-chome Mishima cho, Tsuruga, Fukui, Japan
| | - Yasuhito Mitamura
- Municipal Tsuruga Hospital, 6-60, 1-chome Mishima cho, Tsuruga, Fukui, Japan
| | - Hisayoshi Murai
- Department of Disease Control and Homeostasis, Graduate School of Medical Science, Kanazawa University, 13-1 Takara-machi, Kanazawa, 920-8641, Japan
| | - Soichiro Usui
- Municipal Tsuruga Hospital, 6-60, 1-chome Mishima cho, Tsuruga, Fukui, Japan
| | - Shuichi Kaneko
- Department of Disease Control and Homeostasis, Graduate School of Medical Science, Kanazawa University, 13-1 Takara-machi, Kanazawa, 920-8641, Japan
| | - Masayuki Takamura
- Department of Disease Control and Homeostasis, Graduate School of Medical Science, Kanazawa University, 13-1 Takara-machi, Kanazawa, 920-8641, Japan
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Qureshi AM, Agrawal H. Catheter-based anatomic and functional assessment of coronary arteries in anomalous aortic origin of a coronary artery, myocardial bridges and Kawasaki disease. CONGENIT HEART DIS 2017; 12:615-618. [PMID: 28608519 DOI: 10.1111/chd.12500] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 05/20/2017] [Indexed: 11/28/2022]
Abstract
Most diagnostic testing in patients with anomalous aortic origins of coronary arteries, myocardial bridges, and coronary artery changes after Kawasaki disease are performed with the use of noninvasive techniques. In some cases, however, further diagnostic information is needed to guide the clinician in treating these patients. In such instances, cardiac catheterization with invasive anatomic and functional testing is an invaluable tool. Moreover, interventional treatment in the cardiac catheterization laboratory may be performed in a small subset of these patients. As the diagnosis of these conditions is now becoming more common, it is important for pediatric interventional cardiologists to be familiar with these techniques. In this article, the role of angiography, intravascular ultrasound, fractional flow reserve, and optical coherence tomography in these patients is reviewed.
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Affiliation(s)
- Athar M Qureshi
- CE Mullins Cardiac Catheterization Laboratories, Houston, Texas, USA.,Coronary Anomalies Program and Division of Pediatric Cardiology, Texas Children's Hospital, Houston, Texas, USA.,Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Hitesh Agrawal
- Coronary Anomalies Program and Division of Pediatric Cardiology, Texas Children's Hospital, Houston, Texas, USA.,Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
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Coronary endothelial function testing provides superior discrimination compared with standard clinical risk scoring in prediction of cardiovascular events. Coron Artery Dis 2017; 27:213-20. [PMID: 26882018 DOI: 10.1097/mca.0000000000000347] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Endothelial dysfunction is regarded as the early stage of atherosclerosis and is associated with cardiovascular (CV) events. This study was designed to determine whether assessment of coronary endothelial function (CEF) is safe and can reclassify risk in patients with early coronary artery disease beyond the Framingham risk score (FRS). METHODS AND RESULTS CEF was evaluated using intracoronary acetylcholine in 470 patients who presented with chest pain and nonobstructive coronary artery disease. CV events were assessed after a median follow-up of 9.7 years. The association between CEF and CV events was examined, and the net reclassification improvement index (NRI) was used to compare the incremental contribution of CEF when added to FRS.The mean age was 53 years, and 68% of the patients were women with a median FRS of 8. Complications (coronary dissection) occurred in three (0.6%) and CV events in 61 (13%) patients. In univariate analysis, microvascular CEF [hazard ratio (HR) 0.85, 95% confidence interval (CI) 0.72-0.97, P=0.032] and epicardial CEF (HR 0.73, 95% CI 0.59-0.90, P=0.01) were found to be significant predictors of CV events, whereas FRS was not (HR 1.05, 95% CI 0.85-1.26, P=0.61). When added to FRS, microvascular CEF correctly reclassified 11.3% of patients [NRI 0.11 (95% CI 0.019-0.21)], epicardial CEF correctly reclassified 12.1% of patients [NRI 0.12 (95% CI -0.02 to 0.26)], and the combined microvascular and epicardial CEF correctly reclassified 22.8% of patients [NRI 0.23 (95% CI 0.08-0.37)]. CONCLUSION CEF testing is safe and adds value to the FRS, with superior discrimination and risk stratification compared with FRS alone in patients presenting with chest pain or suspected ischemia.
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Abstract
Objective proof of focal lesions is mandatory, and the best invasive method of physiological testing is fractional flow r eserve (FFR). The increased trans-stenotic gradient is measured via the guiding catheter and pressure transducer on a 0.014" coronary wire at maximal hyperaemia induced by adenosine. Patients with a FFR of less than 0.8 should undergo myocardial revascularisation by percutaneous coronary intervention or coronary artery bypass graft, particularly if the proximal and middle segments of the main coronary arteries and large side-branches are affected; there is no prognostic revascularisation benefit in patients with moderate stenoses and FFR greater than 0.80. FFR assessment of coronary lesions is superior to other invasive morphological studies, such as intracoronary ultrasound or optical coherence tomography. Its use in non-culprit vessels in acute coronary syndromes is currently under scrutiny. Recent advances in computed tomographic technique allow non-invasive assessment of FFR, but clinical validation has yet to be obtained.
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Affiliation(s)
- Serban Balanescu
- Cardiology Department, Elias University Hospital, Bucharest, Romania
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Abstract
Coronary angiography is the gold standard for the diagnosis of coronary artery disease and guides revascularization strategies. The emergence of new diagnostic modalities has provided clinicians with adjunctive physiologic and image-based data to help formulate treatment strategies. Fractional flow reserve can predict whether percutaneous intervention will benefit a patient. Intravascular ultrasonography and optical coherence tomography are intracoronary imaging modalities that facilitate the anatomic visualization of the vessel lumen and characterize plaques. Near-infrared spectroscopy can characterize plaque composition and potentially provide valuable prognostic information. This article reviews the indications, basic technology, and supporting clinical studies for these modalities.
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Affiliation(s)
- Elliott M Groves
- Division of Cardiology, Department of Internal Medicine, University of California, 333 City Blvd West, Suite 400, Orange, CA 92868-3298, USA; Department of Biomedical Engineering, University of California, 3120 Natural Sciences II, Irvine, CA 92697-2715, USA
| | - Arnold H Seto
- Division of Cardiology, Department of Internal Medicine, University of California, 333 City Blvd West, Suite 400, Orange, CA 92868-3298, USA; Division of Cardiology, Department of Internal Medicine, Long Beach Veterans Administration Hospital, 5901 East Seventh Street, Long Beach, CA 90822, USA.
| | - Morton J Kern
- Division of Cardiology, Department of Internal Medicine, University of California, 333 City Blvd West, Suite 400, Orange, CA 92868-3298, USA; Division of Cardiology, Department of Internal Medicine, Long Beach Veterans Administration Hospital, 5901 East Seventh Street, Long Beach, CA 90822, USA
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Nakayama M, Tanaka N, Sakoda K, Hokama Y, Hoshino K, Kimura Y, Ogawa M, Yamashita J, Kobori Y, Uchiyama T, Aizawa Y, Yamashina A. Papaverine-induced polymorphic ventricular tachycardia during coronary flow reserve study of patients with moderate coronary artery disease. Circ J 2015; 79:530-6. [PMID: 25746536 DOI: 10.1253/circj.cj-14-1118] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Papaverine is useful for evaluating the functional status of a coronary artery, but it may provoke malignant ventricular arrhythmia (VA). The aim of this study was to investigate the incidence, and clinical and ECG characteristics of patients with papaverine-induced VAs. METHODS AND RESULTS: The 182 consecutive patients underwent fractional flow reserve (FFR) measurement of 277 lesions. FFR was determined after intracoronary papaverine administration by standard procedures. The clinical and ECG characteristics were compared between patients with and without ventricular tachycardia (VT: ≥3 successive premature ventricular beats (PVBs), or ventricular fibrillation (VF)). After papaverine administration, the QTc interval, QTUc interval, and T-peak to U-end interval were prolonged significantly. Single PVBs on the T-wave or U-wave type developed in 29 patients (15.9%). Polymorphic VT (torsade de pointes) occurred in 5 patients (2.8%), and of those, VF developed in 3 patients (1.7%). No clinical and baseline ECG parameters were predictors for VT or VF except for sex and administration of papaverine into the left coronary artery. Excessive prolongation of QT (or QTU), T-peak to U-end intervals and giant T-U waves were found immediately prior to the ventricular tachyarrhythmias (VTAs), which were unpredictable from the baseline data. CONCLUSIONS Intracoronary administration of papaverine induced fatal VTAs, although the incidence is rare. Excessive prolongation of the QT (and QTU) interval appeared prior to VTAs; however, they were unpredictable.
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Affiliation(s)
- Masafumi Nakayama
- Department of Cardiology, Tokyo Medical University; Cardiovascular Center, Toda Central General Hospital, Saitama, Japan.
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Abstract
Coronary blood flow is tightly autoregulated but is subject to epicardial and microvascular obstruction, primarily owing to coronary atherosclerosis. Because coronary flow limitation underlies ischemic heart disease, an understanding of coronary physiology is paramount. Measurement of coronary blood flow, once relegated to the research laboratory is now easily performed in the cardiac catheterization laboratory. In particular, the measurement of fractional flow reserve has been extensively studied and is an important adjunct to clinical decision making. Measurement of coronary flow informs clinicians of prognosis, guides revascularization therapy, and forms the basis of ongoing research in treatment of complex myocardial disease processes. Newer methods of assessing coronary flow measurements are undergoing validation for clinical use and should further enhance our ability to assess the importance of coronary flow in clinical disease.
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Wei J, Mehta PK, Johnson BD, Samuels B, Kar S, Anderson RD, Azarbal B, Petersen J, Sharaf B, Handberg E, Shufelt C, Kothawade K, Sopko G, Lerman A, Shaw L, Kelsey SF, Pepine CJ, Merz CNB. Safety of coronary reactivity testing in women with no obstructive coronary artery disease: results from the NHLBI-sponsored WISE (Women's Ischemia Syndrome Evaluation) study. JACC Cardiovasc Interv 2012; 5:646-53. [PMID: 22721660 DOI: 10.1016/j.jcin.2012.01.023] [Citation(s) in RCA: 153] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2011] [Revised: 01/13/2012] [Accepted: 01/20/2012] [Indexed: 02/07/2023]
Abstract
OBJECTIVES This study evaluated the safety of coronary reactivity testing (CRT) in symptomatic women with evidence of myocardial ischemia and no obstructive coronary artery disease (CAD). BACKGROUND Microvascular coronary dysfunction (MCD) in women with no obstructive CAD portends an adverse prognosis of a 2.5% annual major adverse cardiovascular event (MACE) rate. The diagnosis of MCD is established by invasive CRT, yet the risk of CRT is unknown. METHODS The authors evaluated 293 symptomatic women with ischemia and no obstructive CAD, who underwent CRT at 3 experienced centers. Microvascular function was assessed using a Doppler wire and injections of adenosine, acetylcholine, and nitroglycerin into the left coronary artery. CRT-related serious adverse events (SAEs), adverse events (AEs), and follow-up MACE (death, nonfatal myocardial infarction [MI], nonfatal stroke, or hospitalization for heart failure) were recorded. RESULTS CRT-SAEs occurred in 2 women (0.7%) during the procedure: 1 had coronary artery dissection, and 1 developed MI associated with coronary spasm. CRT-AEs occurred in 2 women (0.7%) and included 1 transient air microembolism and 1 deep venous thrombosis. There was no CRT-related mortality. In the mean follow-up period of 5.4 years, the MACE rate was 8.2%, including 5 deaths (1.7%), 8 nonfatal MIs (2.7%), 8 nonfatal strokes (2.7%), and 11 hospitalizations for heart failure (3.8%). CONCLUSIONS In women undergoing CRT for suspected MCD, contemporary testing carries a relatively low risk compared with the MACE rate in these women. These results support the use of CRT by experienced operators for establishing definitive diagnosis and assessing prognosis in this at-risk population. (Women's Ischemia Syndrome Evaluation [WISE]; NCT00832702).
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Affiliation(s)
- Janet Wei
- Division of Cardiology, Women's Heart Center, Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
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Functional measurement in the catheterization lab-or is coronary angiography always flawless? COR ET VASA 2009. [DOI: 10.33678/cor.2009.218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Lu GM, Zhang LJ, Guo H, Huang W, Merges RD. Comparison of myocardial bridging by dual-source CT with conventional coronary angiography. Circ J 2008; 72:1079-85. [PMID: 18577815 DOI: 10.1253/circj.72.1079] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The diagnosis of myocardial bridging (MB) is of clinical importance because of the association between MB and compromised coronary flow. The aim of this study was to compare the ability of dual-source computed tomography (DSCT) and conventional coronary angiography (CAG) to detect MB. METHODS AND RESULTS DSCT were performed in 53 patients and 4-dimensional (D) reconstruction was subsequently performed in 16 patients with MB for double-blinded comparison with the findings of CAG. The diameters at systole and diastole of the coronary segments proximal and distal to the MB and of the tunneled segment were measured. The relationship between the rate of stenosis of the tunneled artery and the "milking" effect on 4-D reconstruction was analyzed. Of the 53 patients, CAG and DSCT detected 4 MBs in 3 patients and 21 MBs in 16 patients, respectively (p<0.001). On a per-patient and per-MB basis, significant difference was found between both methods (p=0.001, p<0.001). The 4-D reconstruction showed the milking effect and abnormal blood flow, detecting more MBs than did CAG (p<0.001). The rate of stenosis of the tunneled artery was related to the milking effect on the 4-D reconstruction (r=0.640, p=0.006). CONCLUSIONS In the present study, DSCT detected more MBs than CAG, suggesting its clinical application for diagnosis of this condition.
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Affiliation(s)
- Guang-Ming Lu
- Department of Medical Imaging, Jinling Hospital, Clinical School of Medical College, Nanjing University, Nangjing, Jiangsu Province 200012, China.
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Kern MJ, Lerman A, Bech JW, De Bruyne B, Eeckhout E, Fearon WF, Higano ST, Lim MJ, Meuwissen M, Piek JJ, Pijls NHJ, Siebes M, Spaan JAE. Physiological assessment of coronary artery disease in the cardiac catheterization laboratory: a scientific statement from the American Heart Association Committee on Diagnostic and Interventional Cardiac Catheterization, Council on Clinical Cardiology. Circulation 2006; 114:1321-41. [PMID: 16940193 DOI: 10.1161/circulationaha.106.177276] [Citation(s) in RCA: 397] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
With advances in technology, the physiological assessment of coronary artery disease in patients in the catheterization laboratory has become increasingly important in both clinical and research applications, but this assessment has evolved without standard nomenclature or techniques of data acquisition and measurement. Some questions regarding the interpretation, application, and outcome related to the results also remain unanswered. Accordingly, this consensus statement was designed to provide the background and evidence about physiological measurements and to describe standard methods for data acquisition and interpretation. The most common uses and support data from numerous clinical studies for the physiological assessment of coronary artery disease in the cardiac catheterization laboratory are reviewed. The goal of this statement is to provide a logical approach to the use of coronary physiological measurements in the catheterization lab to assist both clinicians and investigators in improving patient care.
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Mates M, Hrabos V, Hajek P, Rataj O, Vojacek J. Long-term follow-up after deferral of coronary intervention based on myocardial fractional flow reserve measurement. Coron Artery Dis 2005; 16:169-74. [PMID: 15818086 DOI: 10.1097/00019501-200505000-00006] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To assess long-term results after deferring coronary intervention (percutaneous coronary intervention (PCI)) of an intermediate lesion with a value of myocardial fractional flow reserve (FFR) > or = 0.75 in a 'real life' patient population with no respect to results of stress tests (if performed) or coronary disease extent. METHODS PCI of an intermediate lesion was deferred in a group of 85 consecutive patients (54 men, 61+/-10 years) on the basis of the result of FFR > or = 0.75 (mean FFR, 0.89+/-0.06%). FFR was measured in 111 stenoses (mean diameter stenosis, 54+/-8%, left anterior descending coronary artery, 65 (58%), left circumflex coronary artery, 24 (22%), right coronary artery, 22 (20%). Multi-vessel disease (defined as visually assessed diameter reduction of more than 50% in at least two arteries of more than 1.5 mm diameter, supplying at least two of the three major coronary artery perfusion territories) was present in 67% of patients (one-vessel disease, 28 patients (33%), two-vessel disease, 39 patients (46%), three-vessel disease, 18 patients (21%). Recorded events during follow-up were as follows: all-cause death, cardiac death, non-fatal myocardial infarction, ischemia-driven target lesion transcatheter revascularization (TLR) and coronary artery bypass graft (CABG). Angina class (Canadian Cardiovascular Society (CCS) classification) and the need for anti-anginal drugs were recorded. RESULTS Follow-up was completed in 85 patients (100%). Mean duration of follow-up was 22.6+/-6.6 months (range 4-33 months). Events occurred in 11 patients (13%). Seven patients died; this included two cardiac deaths. A non-fatal myocardial infarction occurred in one patient, one patient needed TLR and three patients underwent CABG. Estimated 33 month cardiac-event-free survival (Kaplan-Meier) was 91+/-4%. Angina class decreased [1.6+/-1.2 compared with 0.8+/-0.8 (P < 0.0001)] without difference with respect to the use of anti-anginal drugs (1.7+/-0.8 compared with 1.7+/-0.9, P = NS). CONCLUSIONS Deferring coronary interventions of intermediate stenosis based on FFR measurement is safe with respect to long-term follow-up, irrespective of the extent of coronary artery disease.
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Affiliation(s)
- Martin Mates
- Department of Medicine, University Hospital Motol, Prague, Czech Republic.
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Ziaee A, Parham WA, Herrmann SC, Stewart RE, Lim MJ, Kern MJ. Lack of relation between imaging and physiology in ostial coronary artery narrowings. Am J Cardiol 2004; 93:1404-7, A9. [PMID: 15165925 DOI: 10.1016/j.amjcard.2004.02.041] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2003] [Revised: 02/12/2004] [Accepted: 02/12/2004] [Indexed: 10/26/2022]
Abstract
This study compared ostial lesion angiographic severity with physiologic assessment and showed that, for diameter narrowings >70%, fractional flow reserves were >0.75 in 20 of 25 lesions and >0.75 in 30 of 30 lesions with <70% diameter narrowings. Using fractional flow reserve in all ostial narrowings > or =70% may prevent patients from undergoing unnecessary interventions.
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Affiliation(s)
- Ali Ziaee
- J. Gerard Mudd Cardiac Catheterization Laboratory, St. Louis University Health Sciences Center, 3635 Vista Avenue at Grand Boulevard, St. Louis, MO 63110-0250, USA
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Hoffman JIE. Do we have agold standard yet?**Editorials published in the Journal of the American College of Cardiologyreflect the views of the authors and do not necessarily represent the views of JACCor the American College of Cardiology. J Am Coll Cardiol 2004; 43:662-4. [PMID: 14975479 DOI: 10.1016/j.jacc.2003.11.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Okayama H, Sumimoto T, Hiasa G, Nishimura K, Morioka N, Yamamoto K, Kawada H. Assessment of intermediate stenosis in the left anterior descending coronary artery with contrast-enhanced transthoracic Doppler echocardiography. Coron Artery Dis 2003; 14:247-54. [PMID: 12702929 DOI: 10.1097/01.mca.0000065923.30320.de] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Visual or quantitative assessment of coronary angiography may not exactly predict the physiological significance of intermediate (40-70%) coronary stenosis. Coronary flow reserve is a well-established marker of the functional significance of coronary stenosis. OBJECTIVES The aim of this study was to compare the coronary flow velocity reserve (CFVR) using contrast-enhanced transthoracic Doppler echocardiography (CE-TTDE) with thallium-201 imaging in assessment of intermediate lesions in the left anterior descending coronary artery (LAD). METHODS A consecutive series of 50 patients with intermediate stenosis in the LAD underwent pharmacological stress thallium-201 imaging and CFVR measured by CE-TTDE. RESULTS CFVR could be measured in 49 of 50 patients by the present method. A CFVR <2.0 predicted the presence of a stress thallium defect in 12 of 14 patients (agreement=90%, kappa=0.76, P < 0.001). The sensitivity and specificity of CFVR for stress thallium-201 results were 86 and 91%, respectively. In contrast, significant stenosis (>50% by diameter) showed fair agreement for stress thallium defects (agreement=59%, kappa=0.28, P < 0.05). CONCLUSIONS In the evaluation of intermediate lesions in the LAD, CFVR as assessed by CE-TTDE could accurately predict the presence of ischemia on stress thallium imaging, whereas angiographic stenosis did not yield reliable results.
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Affiliation(s)
- Hideki Okayama
- Department of Carediology, Kitaishikai Hospital, 2632-3 Tokunomori, Ozu, Ehime 795-0061, Japan.
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Suzuki S, Ohtsuka S, Ishikawa K, Yamaguchi I. Effects of nicardipine on coronary, vertebral and renal arterial flows in patients with essential hypertension. Hypertens Res 2003; 26:193-9. [PMID: 12675274 DOI: 10.1291/hypres.26.193] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We examined the acute effects of a calcium antagonist, nicardipine, on hemodynamics and blood flow in the left anterior descending coronary (LAD), vertebral and renal arteries of essential hypertensive patients who had complained of chest pain and undergone cardiac catheterization. The blood flow velocities of the LAD, vertebral and renal arteries were measured using a Doppler guidewire and the arterial luminal diameters were measured from the arteriograms. The arterial blood flow was calculated by multiplying the blood flow velocity by the obtained vessel diameter. Coronary flow reserve was evaluated by injecting papaverine into the left coronary artery. After the baseline data had been obtained, intravenous infusion of nicardipine was started and the same hemodynamic, blood flow velocity and arterial diameter measurements were repeated. Blood pressure was decreased and cardiac output was increased by nicardipine infusion. There was a correlation between the decrease in systolic blood pressure and the increase in cardiac output (r = 0.71). The blood flow velocity in the LAD, vertebral and renal arteries tended to increase and there was an increase in the arterial luminal diameter. An increase in blood flow and a lowering of vascular resistance were observed for each artery (p < 0.05). During nicardipine infusion, the diastolic blood flow in the LAD artery was improved (p < 0.05); however, the maximal blood flow in the LAD artery induced by papaverine infusion remained unchanged. Therefore, there is evidence that coronary, vertebral and renal blood flows are improved by nicardipine infusion despite the acute blood pressure reduction.
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Affiliation(s)
- Shoji Suzuki
- Cardiovascular Division, Department of Internal Medicine, Institute of Clinical Medicine, University of Tsukuba, Tsukuba, Japan.
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Schratz LM, Meyer RA, Schwartz DC. Serial intracoronary ultrasound in children: feasibility, reproducibility, limitations, and safety. J Am Soc Echocardiogr 2002; 15:782-90. [PMID: 12174347 DOI: 10.1067/mje.2002.119911] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Pediatric patients with heart transplants and Kawasaki disease are at risk to develop coronary artery disease. Selective coronary angiography underestimates vasculopathy in transplant patients and intimal changes in Kawasaki disease. Routine intracoronary ultrasound imaging in adults accurately identifies histopathologic features not visualized by angiography. Little data are available regarding safety and efficacy in children. This study provides sequential data and experience in children between the ages of 2 1/2 and 22 years. Thirty-two patients underwent 62 intracoronary ultrasound examinations at the time of coronary angiography. Careful correlation of the ultrasound crystal locations with the angiographic images of the vessels was made. Images were analyzed for intimal hyperplasia and luminal diameters. Intracoronary ultrasound was more sensitive than angiography in detecting vessel wall disease. Coronary vasospasm occurred in 11 of 62 studies after the intracoronary ultrasound study. All but 1 episode were asymptomatic and resolved after intracoronary nitroglycerine. When a standard protocol is followed and current technology is used, intracoronary ultrasound is feasible, reproducible, efficacious, and safe in the young patient. It allows earlier detection of vasculopathy and intimal disease at angiographically normal sites. As technology improves and greater experience is gained, the long-term safety and prognostic value of these studies in children should be forthcoming.
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Newby DE, Fox KAA. Invasive assessment of the coronary circulation: intravascular ultrasound and Doppler. Br J Clin Pharmacol 2002; 53:561-75. [PMID: 12047480 PMCID: PMC1874337 DOI: 10.1046/j.1365-2125.2002.01582.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Affiliation(s)
- David E Newby
- Cardiovascular Research, Department of Cardiology, Royal Infirmary, 1 Lauriston Place, Edinburgh EH3 9YW.
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Candell-Riera J, Martín-Comín J, Escaned J, Peteiro J. [Physiologic evaluation of coronary circulation. Role of invasive and non invasive techniques]. Rev Esp Cardiol 2002; 55:271-91. [PMID: 11893319 DOI: 10.1016/s0300-8932(02)76596-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
For many years, the evaluation of the extent and severity of coronary artery disease has been mainly anatomical, carried out by coronary angiography. However, this technique has methodological limitations and interobserver variability is considerable. Quantification of coronary reserve with pressure guidewires and intracoronary Doppler now provides more precise physiologic evaluation of coronary circulation. Myocardial perfusion single proton emission computed tomography and echocardiography, combined with stress and/or pharmacological challenge testing, though they are only semiquantitative techniques, also offer appropriate complements to coronary angiography in the functional evaluation of coronary patients. The aim of this paper is to discuss the clinical value of these techniques.
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Kern MJ. Curriculum in interventional cardiology: coronary pressure and flow measurements in the cardiac catheterization laboratory. Catheter Cardiovasc Interv 2001; 54:378-400. [PMID: 11747168 DOI: 10.1002/ccd.1303] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- M J Kern
- J. Gerard Mudd Cardiac Catheterization Laboratory, St. Louis University Health Sciences Center, St. Louis, Missouri 63110, USA.
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Wieneke H, Schmermund A, Ge J, Altmann C, Haude M, Von Birgelen C, Baumgart D, Dirsch O, Erbel R. Increased heterogeneity of coronary perfusion in patients with early coronary atherosclerosis. Am Heart J 2001; 142:691-7. [PMID: 11579361 DOI: 10.1067/mhj.2001.116764] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND In patients with typical angina but angiographically normal coronary arteries, abnormal vasomotor function is assumed to be a major underlying cause. However, data on this issue are conflicting, and recent studies suggest that fluid dynamic abnormalities exist in these patients. The aim of the study was to evaluate whether early stages of atherosclerosis are characterized by alterations of baseline coronary hemodynamics and endothelium-independent vasomotion. Besides established intracoronary Doppler parameters, heterogeneity of perfusion was assessed and related to early signs of atherosclerosis as determined by electron-beam computed tomography (EBCT). METHODS In 59 patients with typical angina and angiographically normal or near-normal coronary arteries, intracoronary Doppler measurements were performed in all 3 major coronary arteries. Baseline average peak velocity (bAPV) and hyperemic average peak velocity (hAPV) in response to intracoronary injection of adenosine were measured, and coronary flow velocity reserve (CFVR) was calculated. Heterogeneity was assessed as variability of bAPV, hAPV, and CFVR and was calculated as (STD/MEAN). 100. Doppler data were analyzed according to tertiles of the EBCT-derived Agatston calcium score (ie, score 0-1 [lowest tertile], 2-28 [medium tertile], and >28 [highest tertile]). RESULTS The mean EBCT-derived Agatston calcium score was 49 +/- 107. No coronary calcium was observed in 17 (29%) patients. The mean values of bAPV, hAPV, and CFVR were not different between the calcium score tertiles. However, patients in the highest tertile had a significantly increased variability index of bAPV (29.6% +/- 11.6%) compared with patients in the lowest tertile (13.4% +/- 7.3%, P <.0001). Variability of CFVR was also increased in these patients (15.5% +/- 11.7% vs 10.5% +/- 4.0%, P =.03). CONCLUSION These results indicate that early stages of atherosclerosis are characterized by microvascular abnormalities that do not uniformly affect the myocardium but are heterogeneous. The high variability of baseline coronary flow velocity with increasing coronary calcium suggests that in patients with early stages of atherosclerosis fluid dynamic effects may play a crucial role even in the absence of angiographically appreciable epicardial stenoses.
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Affiliation(s)
- H Wieneke
- Department of Cardiology, University Clinic Essen, Germany.
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Affiliation(s)
- H M Farouque
- Centre for Heart and Chest Research, Monash Medical Centre and Monash University, Melbourne, Australia
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Affiliation(s)
- R B Naidu
- Department of Cardiology, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
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