Correlations between fractional flow reserve and a novel non-hyperemic index: resting full-cycle ratio in patients with an ambiguous coronary artery stenosis

Background

Fractional flow reserve (FFR) measurement has been the gold standard for invasive assessment of coronary ischemia. Resting full cycle ratio (RFR) is a new non-hyperemic index used to define physiologic significance of coronary artery stenosis. However, there are limited data available to establish optimal cut-off value of RFR for decision making on revascularization.

Aim

The aim of our study was to assess optimal cut-off value of RFR at which to predict FFR of 0.8.

Methods

The RFR and FFR values were recorded during invasive coronary angiography in vessels with angiographic stenosis 40–70% according to visual assessment. Maximum hyperemia for FFR measurement was achieved with adenosine iv. infusion at 140 μg/kg/min. Left main disease, acute myocardial infarction and systolic left ventricular dysfunction (EF <40%) were the main exclusion criteria.

Results

We evaluated 332 vessels, including 189 (56.9%) left anterior descending arteries, 77 (23.2%) left circumflex arteries and 66 (19.9%) right coronary arteries. Median diameter stenosis as assed by QCA was 45% (IQR 40; 50). Median RFR and FFR values were 0.90 [IQR 0.85; 0.94] and 0.86 [IQR 0.81; 0.92] respectively, with significant correlation (p<0.001, Figure 1, panel A). Optimal cut-off value for RFR to detect FFR 0.80 was 0.90 with area under the curve of 90.3%, sensitivity of 81.4% and specificity 88.0% (Figure 1, panel B).

Conclusions

Our data confirm RFR cut-off value ≤0.90 as an optimal threshold to detect ischemic lesions with good sensitivity and specificity in comparison to FFR assessment. Further research is necessary to assess outcomes of RFR-guided revascularization strategy.

Figure 1. RFR–FFR correlation and ROC analysis

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): Jagiellonian University statutory grant

Combination treatment in stable effort angina using trimetazidine and metoprolol: results of a randomized, double-blind, multicentre study (TRIMPOL II). TRIMetazidine in POLand

AIMS

To assess the antiischaemic efficacy and tolerability of the metabolic agent trimetazidine in combination with metoprolol in patients with stable effort angina.

METHODS

This was a randomized, multicentre, double-blind, placebo-controlled parallel group study. A total of 426 male and female patients with stable, effort-induced angina and documented coronary artery disease received either placebo or trimetazidine 20 mg three times daily in addition to metoprolol 50 mg twice daily. Treadmill exercise tests were performed at weeks (-1), 0, 4 and 12.

RESULTS

After 12 weeks, there were significantly greater improvements in the metoprolol + trimetazidine group than in the metoprolol + placebo group in: time to 1 mm ST segment depression, total workload, time to onset of angina, maximum ST segment depression, mean weekly number of angina attacks, mean weekly nitrate consumption, and grade of anginal pain. There was no evidence of any development of tolerance to trimetazidine. The tolerability of trimetazidine was excellent.

CONCLUSIONS

Therapy with trimetazidine plus metoprolol produced significant improvements in exercise stress tests and the symptoms of angina relative to metoprolol alone. With its metabolic effect, devoid of any haemodynamic action, trimetazidine is useful for combination therapy in patients with stable angina insufficiently controlled by monotherapy with a beta-blocker.

[Efficacy of mononitrate retard therapy in patients with advanced congestive heart failure]

To determine the efficacy of mononitrate retard therapy in congestive heart failure 54 pts (42 males and 12 females, aged 67.2 +/- 8.7 yrs.) with NYHA functional class 1-3 and left ventricular ejection fraction less than 40% were investigated. Clinical examination, exercise treadmill test (ETT), ecg holter monitoring and echocardiography (echo-2D) were performed before and after 4 weeks of therapy with Olicard 40 mg Retard. 4 weeks treatment with mononitrate improved clinical parameters. The shift to lower functional NYHA class was observed in 12 cases (p < 0.01). Number of anginal pains per week was reduced from average 3.15 to 1.55 (p < 0.01). Mononitrate therapy improved exercise tolerance during ETT. Exercise time increased from 424 +/- 168 to 568 +/- 143 sec. (p < 0.001) as well as total workload in METS (3.6 +/- 1.4 vs. 4.9 +/- 1.9, p < 0.001). The time to 0.1 mV ischemic ST segment depression was extended from 215 +/- 149 to 357 +/- 173 sec. (p < 0.01). Holter monitoring revealed moderate increase in heart rate and significant reduction of ventricular arrhythmia (p < 0.05). No changes in systolic and diastolic echo-2D parameters were observed.

[Influence of nitrates on red blood cell deformability and clinical parameters in patients with silent ischemia]

In 30 patients after myocardial infarctum with actual silent ischemia (no pain during last 12 months) mononitrate (Olicard 40) was administered and red blood cell deformability was determined. Clinical improvement and decrease of aforementioned deformability were observed after mononitrate therapy.

[Clinical effect of nitrates (Olicard 40) and their influence on deforming of erythrocytes against the background of 24-hour catecholaminuria]

Progress in the investigations upon factors influencing the course of the ischemic heart disease focused our attention on the deformability of erythrocytes. That attribute of the red blood cells (RBC) is described by their susceptibility to changes in shape without changing volume. Because of that feature, RBC can reach the smallest capillaries of the circulatory system. The aim of the study was to determine the influence of mononitrates (Olicard Ret.) on the deformability of RBC (EDI) in correlation to the clinical course of the ischemic heart disease and to evaluate the role of catecholamines in the course of the disease and their influence upon EDI. 30 patients (pts) treated with mononitrates for 4 weeks were enrolled into the study. In 27 pts clinical improvement was recorded, as evaluated by the results of repeated exercise tests and changes in the number of anginal attacks. Mean weekly number of anginal attacks decreased from 6.2 to 2.1 (p < 0.05), and parameters of exercise tests improved: DP/Wmac decreased from 0.694 to 0.479 (p < 0.001) and maximal workload attained increased from 6.8 to 9.0 METS (p < 0.001). Correspondingly to the clinical improvement, beneficial changes in RBC deformability were seen: 0.033 vs 0.040 (p < 0.01). Correlation factor for changes in EDI (r = 0.628) was higher than that for the number of anginal attacks (r = 0.589), but lower than the correlation factor for exercise test parameters (r = 0.969 for DP/Wmax and r = 0.858 for METS). There were no significant changes in the urinary output of catecholamines and no correlations were seen between urinary output of adrenaline, noradrenaline and EDI.(ABSTRACT TRUNCATED AT 250 WORDS)

[Complex ventricular arrhythmias in ischemic heart disease]

The purpose of the study was to describe the clinical picture in patients with ischemic heart disease (IHD) and verifying severity of ventricular arrhythmias. The study included 856 patients with IHD aged 23-88 years (mean = 55.3), including 659 men and 197 women. Holter monitoring was performed in all patients. Ventricular arrhythmias were graded according to Lown. The patients were divided into five groups: group 1-349 patients with Lown's grade 1 and 2; group 2-95 patients with grade 3; group 3-152 patients with grade 4a and 4b; group 4-11 patients with grade 5; group 5-507 patients (selected from groups 2, 3 and 4) with Lown's grade 3 and 4 or 5. Arterial hypertension was found in 17.1%, myocardial infraction in 66%, and syncope in 12.3% of the patients. The patients with complex ventricular arrhythmias versus Lown's grade 1 and 2 show significant differences especially in respect to: the frequency of previous anterior myocardial infraction, the incidence of pain at rest, loss consciousness, the frequency of ventricular tachycardia and fibrillation, anginal pain and exercise-related arrhythmias. The patients with Lown's ventricular arrhythmia grade 3-5 do not differ significantly in their clinical manifestations of IHD from the patients with ventricular arrhythmias grade from 3 to 5. The development of silent myocardial ischemia during exercise stress testing is typical also for the patients with complex ventricular arrhythmias. A decreased contractility index, ejection fraction and dyskinesis are significantly more frequent in the patients with complex ventricular arrhythmias.

[Palpitin--an anti-arrhythmic drug in ischemic heart disease]

The effectiveness was assessed of the antiarrhythmic treatment with Palpitin in 30 patients with ischaemic heart disease (IHD). The control group comprised 15 patients with IHD and arrhythmia, treated with propranolol. In all patients ECG recording by Holter's method was done before the treatment and after 14 days of the treatment. The effectiveness of Palpitin was expressed as improvement in 66% of cases (reduction of ectopic beats by 75%), and in 40% of cases complete regression of arrhythmia was achieved. These results were slightly better than in the group treated with propranolol (improvement in 60% of cases). Palpitin during the treatment caused no increase in the manifestations of cardiac failure and produced no disturbances of atrioventricular conduction. Fairly frequently the patients complained about mucosal dryness and sporadically about dyspeptic symptoms, but these symptoms were not disturbing the course of the treatment.

[Relation between ischemic heart disease and tobacco smoking]

The incidence of ischaemic heart disease related to tobacco smoking was studied in a population of males aged 35-64 years in the Bródno District of Warsaw. The population comprised 2123 subjects (attendance rate 62%). A relationship was demonstrated between cigarette smoking in the past and the ischaemic heart disease, its incidence was twice as high in former smokers than in non-smokers. No significant difference was found in this incidence between non-smokers and present smokers. A more deep analysis shows that former smokers who quitted smoking due to intensification of clinical symptoms are frequently included into the group of non-smokers, and they are the group at highest risk for ischaemic heart disease development.