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Stegehuis V, Boerhout C, Kikuta Y, Cambero-Madera M, van Royen N, Matsuo H, Nakayama M, de Waard G, Knaapen P, Nijjer S, Petraco R, Siebes M, Davies J, Escaned J, van de Hoef T, Piek J. Impact of stenosis resistance and coronary flow capacity on fractional flow reserve and instantaneous wave-free ratio discordance: a combined analysis of DEFINE-FLOW and IDEAL. Neth Heart J 2023; 31:434-443. [PMID: 37594612 PMCID: PMC10602988 DOI: 10.1007/s12471-023-01796-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2023] [Indexed: 08/19/2023] Open
Abstract
BACKGROUND The pressure-derived parameters fractional flow reserve (FFR) and the emerging instantaneous wave-free ratio (iFR) are the most widely applied invasive coronary physiology indices to guide revascularisation. However, approximately 15-20% of intermediate stenoses show discordant FFR and iFR, and therapeutical consensus is lacking. AIMS We sought to associate hyperaemic stenosis resistance index, coronary flow reserve (CFR) and coronary flow capacity (CFC) to FFR/iFR discordance. METHODS We assessed pressure and flow measurements of 647 intermediate lesions (593 patients) of two multi-centre international studies. RESULTS FFR and iFR were discordant in 15% of all lesions (97 out of 647). FFR+/iFR- lesions had similar hyperaemic average peak velocity (hAPV), CFR and CFC as FFR-/iFR- lesions, whereas FFR-/iFR+ lesions had similar hAPV, CFR and CFC as FFR+/iFR+ lesions (p > 0.05 for all). FFR+/iFR- lesions were associated with lower baseline stenosis resistance, but not hyperaemic stenosis resistance, compared with FFR-/iFR+ lesions (p < 0.001). CONCLUSIONS Discordance with FFR+/iFR- is characterised by maximal flow values, CFR, and CFC patterns similar to FFR-/iFR- concordance that justifies conservative therapy. Discordance with FFR-/iFR+ on the other hand, is characterised by low flow values, CFR, and CFC patterns similar to iFR+/FFR+ concordance that may benefit from percutaneous coronary intervention.
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Affiliation(s)
- Valérie Stegehuis
- Heart Centre, Amsterdam Cardiovascular Sciences, Amsterdam UMC-location AMC, Department of Cardiology, University of Amsterdam, Amsterdam, The Netherlands
| | - Coen Boerhout
- Heart Centre, Amsterdam Cardiovascular Sciences, Amsterdam UMC-location AMC, Department of Cardiology, University of Amsterdam, Amsterdam, The Netherlands
| | | | | | - Niels van Royen
- Department of Cardiology, Radboud University Nijmegen, Nijmegen, The Netherlands
| | | | | | - Guus de Waard
- Amsterdam UMC-location VUMC, Department of Cardiology, Heart Centre, Amsterdam Cardiovascular Sciences, VU University, Amsterdam, The Netherlands
| | - Paul Knaapen
- Amsterdam UMC-location VUMC, Department of Cardiology, Heart Centre, Amsterdam Cardiovascular Sciences, VU University, Amsterdam, The Netherlands
| | | | | | - Maria Siebes
- Department of Biomedical Engineering and Physics, Amsterdam UMC-location AMC, Amsterdam, The Netherlands
| | | | - Javier Escaned
- Hospital Clinico San Carlos IDISSC, Complutense University, Madrid, Spain
| | - Tim van de Hoef
- Heart Centre, Amsterdam Cardiovascular Sciences, Amsterdam UMC-location AMC, Department of Cardiology, University of Amsterdam, Amsterdam, The Netherlands
| | - Jan Piek
- Heart Centre, Amsterdam Cardiovascular Sciences, Amsterdam UMC-location AMC, Department of Cardiology, University of Amsterdam, Amsterdam, The Netherlands.
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Van Tosh A, Khalique O, Cooke CD, Palestro CJ, Nichols KJ. Indicators of abnormal PET coronary flow capacity in detecting cardiac ischemia. Int J Cardiovasc Imaging 2023; 39:631-639. [PMID: 36543909 DOI: 10.1007/s10554-022-02755-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 10/30/2022] [Indexed: 12/24/2022]
Abstract
Coronary flow capacity (CFC) categorizes severity of left ventricular (LV) ischemia by PET myocardial blood flow (MBF). Our objective was to correlate abnormal CFC with other indicators of regional ischemia. Data were examined retrospectively for 231 patients evaluated for known/suspected CAD who underwent rest and regadenoson-stress 82Rb PET/CT. MBF and myocardial flow reserve (MFR) were quantified, from which CFC was categorized as Normal CFC (1), Minimally reduced (2), Mildly reduced (3), Moderately reduced (4), and Severely reduced (5) for the three main arterial territories as well as globally. Relative perfusion summed stress score (SSS) and systolic phase contraction bandwidth (BW) were assessed. Accuracy to detect arteries with CFC ≥ 4 was highest for a Regional Index combining SSS and BW (88 ± 3%). A Global Index formed from stress ejection fraction, SSS and BW was the most accurate means of identifying patients with global CFC ≥ 4 (84 ± 3%). Arteries with abnormal CFC derived from absolute myocardial blood flow measurements are accurately identified by composite parameters combining regionally aberrant relative perfusion patterns and asynchrony.
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Affiliation(s)
| | | | - C David Cooke
- Department of Radiology, Emory University, Atlanta, GA, USA
| | - Christopher J Palestro
- Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Kenneth J Nichols
- Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.
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Miura S, Naya M, Kumamaru H, Ando A, Miyazaki C, Yamashita T. Prognostic value of modified coronary flow capacity by 13N-ammonia myocardial perfusion positron emission tomography in patients without obstructive coronary arteries. J Cardiol 2021; 79:247-256. [PMID: 34538532 DOI: 10.1016/j.jjcc.2021.09.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 08/14/2021] [Accepted: 08/24/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Vasodilator capacity of coronary circulation is an important diagnostic and prognostic tool in patients with coronary artery disease (CAD). We aimed to clarify the incidence of coronary microvascular dysfunction (CMD), defined as impaired modified coronary flow capacity (mCFC) proposed by Johnson and Gould and measured by 13N-ammonia myocardial perfusion positron emission tomography (PET), in patients without obstructive CAD and to evaluate the risk of future cardiovascular events. METHODS This retrospective study recruited 407 consecutive CAD-suspected patients who underwent both pharmacological stress/rest 13N-ammonia PET and coronary angiography. Of the 407 patients, 137 patients (median age, 70 years; 63 women) were eligible and followed up (median, 19.8 months). Endpoints were defined as cardiovascular death or major adverse cardiovascular events (MACEs), such as cardiovascular death, nonfatal myocardial infarction, unplanned hospitalization for any cardiac reasons, and unplanned coronary revascularization. The impaired mCFC group included patients with mildly to severely reduced regional CFC in, at least, one vascular territory (n=34), while the remaining patients (n=103) were categorized as having preserved mCFC. RESULTS Overall, cardiovascular death and MACEs occurred in five (4%) patients. The Kaplan-Meier curve showed a significant reduction in event-free survival for cardiovascular death (p=0.004) and MACEs (p<0.0001) in the impaired mCFC group, compared to the preserved mCFC group. Impaired mCFC was independently associated with the incidence of both cardiovascular death and MACEs after propensity-score adjustments [hazard ratio (HR), 10.7; 95% confidence interval (CI), 1.0-106.0; p=0.04 and HR, 9.5; 95% CI, 2.5-36.2; p<0.001, respectively]. CONCLUSIONS In CAD-suspected patients without obstructive coronary arteries, impaired mCFC was observed in approximately 25% and was associated with a higher risk of cardiovascular death and MACEs. The mCFC concept can help identify patients who would benefit from specific therapies or lifestyle modifications to prevent future MACEs and can clarify potential mechanisms of CMD.
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Affiliation(s)
- Shiro Miura
- Department of Cardiology, Hokkaido Ohno Memorial Hospital, Sapporo, Japan.
| | - Masanao Naya
- Department of Cardiovascular Medicine, Hokkaido University, Graduate School of Medicine, Sapporo, Japan
| | - Hiraku Kumamaru
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Akira Ando
- Division of Diagnostic Radiology Imaging, Hokkaido Ohno Memorial Hospital, Sapporo, Japan
| | - Chihoko Miyazaki
- Department of Radiology, Hokkaido Ohno Memorial Hospital, Sapporo, Japan
| | - Takehiro Yamashita
- Department of Cardiology, Hokkaido Ohno Memorial Hospital, Sapporo, Japan
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Bober RM, Milani RV, Krim SR, Morin DP. PET Stress Testing with Coronary Flow Capacity in the Evaluation of Patients with Coronary Artery Disease and Left Ventricular Dysfunction: Rethinking the Current Paradigm. Curr Cardiol Rep 2021; 23:50. [PMID: 33761005 PMCID: PMC7990801 DOI: 10.1007/s11886-021-01478-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/17/2021] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW Cardiomyopathy with underlying left ventricular (LV) dysfunction is a heterogenous group of disorders that may be present with, and/or secondary to, coronary artery disease (CAD). The purpose of this review is to demonstrate, via case illustrations, the benefits offered by cardiac positron-emission tomography (PET) stress testing with coronary flow capacity (CFC) in the evaluation and treatment of patients with left ventricular (LV) dysfunction and CAD. RECENT FINDINGS CFC, a metric that is increasing in prominence, represents the integration of several absolute perfusion metrics into clinical strata of CAD severity. Our prior work has demonstrated improvement in regional perfusion metrics as a result of revascularization to territories with severe reduction in CFC. Conversely, when CFC is adequate, there is no change in regional perfusion metrics following revascularization, despite angiographically severe stenosis. Furthermore, Gould et al. demonstrated decreased rates of myocardial infarction and death following revascularization of myocardium with severely reduced CFC, with no clinical benefit observed following revascularization of patients with preserved CFC. In a series of cases, we present pre-revascularization and post-revascularization PET scans with perfusion metrics in patients with LV dysfunction and CAD. In these examples, we demonstrate improvement in LV function and perfusion metrics following revascularization only in cases where baseline CFC is severely reduced. PET with CFC offers unique guidance regarding revascularization in patients with reduced LV function and CAD.
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Affiliation(s)
- Robert M. Bober
- Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, 1514 Jefferson Highway, New Orleans, LA 70121-2483 USA
- Ochsner Clinical School, Queensland University School of Medicine, New Orleans, LA USA
| | - Richard V. Milani
- Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, 1514 Jefferson Highway, New Orleans, LA 70121-2483 USA
- Ochsner Clinical School, Queensland University School of Medicine, New Orleans, LA USA
| | - Selim R. Krim
- Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, 1514 Jefferson Highway, New Orleans, LA 70121-2483 USA
- Ochsner Clinical School, Queensland University School of Medicine, New Orleans, LA USA
| | - Daniel P. Morin
- Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, 1514 Jefferson Highway, New Orleans, LA 70121-2483 USA
- Ochsner Clinical School, Queensland University School of Medicine, New Orleans, LA USA
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Gould KL, Bui L, Kitkungvan D, Patel MB. Reliability and Reproducibility of Absolute Myocardial Blood Flow: Does It Depend on the PET/CT Technology, the Vasodilator, and/or the Software? Curr Cardiol Rep 2021; 23:12. [PMID: 33483794 PMCID: PMC7822783 DOI: 10.1007/s11886-021-01449-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/08/2021] [Indexed: 11/01/2022]
Abstract
PURPOSE OF REVIEW The COURAGE and ISCHEMIA trials showed no reduced mortality after revascularization compared to medical treatment. Is this lack of benefit due to revascularization having no benefit regardless of CAD severity or to suboptimal patient selection due to non-quantitative cardiac imaging? RECENT FINDINGS Comprehensive, integrated, myocardial perfusion quantified by regional pixel distribution of coronary flow capacity (CFC) is the final common expression of objective CAD severity for which revascularization reduces mortality. Current lack of revascularization benefit derives from narrow thinking focused on measuring one isolated aspect of coronary characteristics, such as angiogram stenosis, its fractional flow reserve (FFR), anatomic FFR simulations, relative stress imaging, absolute stress ml/min/g or coronary flow reserve (CFR) alone, or even more narrowly on global CFR or fixed regions of interest in assumed coronary artery distributions, or in arbitrary 17 segments on bull's-eye displays, rather than regional pixel distribution of perfusion metrics as they actually are in an individual. Comprehensive integration of all quantitative perfusion metrics per regional pixel into coronary flow capacity guides artery-specific interventions for reduced mortality in non-acute CAD but requires addressing the methodologic questions in the title.
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Affiliation(s)
- K. Lance Gould
- Weatherhead PET Center For Preventing and Reversing Atherosclerosis, Division of Cardiology, Department of Medicine, McGovern Medial Medical School, University of Texas, and Memorial Hermann Hospital, Houston, TX USA
- Weatherhead PET Center For Preventing and Reversing Atherosclerosis, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin St., Room MSB 4.256, Houston, TX 77030 USA
| | - Linh Bui
- Division of Cardiology, McGovern Medical School, Houston, TX USA
| | - Danai Kitkungvan
- Division of Cardiology, McGovern Medical School, Houston, TX USA
| | - Monica B. Patel
- Division of Cardiology, McGovern Medical School, Houston, TX USA
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Abstract
Invasive coronary physiology has been applied since the early days of percutaneous transluminal coronary angioplasty, and has become a rapidly emerging field of research. Many physiology indices have been developed, tested in clinical studies, and are now applied in daily clinical practice. Recent clinical practice guidelines further support the use of advanced invasive physiology methods to optimise the diagnosis and treatment of patients with acute and chronic coronary syndromes. This article provides a succinct review of the history of invasive coronary physiology, the basic concepts of currently available physiological parameters, and will particularly highlight the Dutch contribution to this field of invasive coronary physiology.
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Affiliation(s)
- T P van de Hoef
- Department of Clinical and Experimental Cardiology, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam, The Netherlands.
| | - G A de Waard
- Department of Clinical and Experimental Cardiology, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - M Meuwissen
- Department of Cardiology, Amphia Hospital, Breda, The Netherlands
| | - M Voskuil
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - S A J Chamuleau
- Department of Clinical and Experimental Cardiology, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - N van Royen
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - J J Piek
- Department of Clinical and Experimental Cardiology, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam, The Netherlands
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Bober RM, Milani RV, Oktay AA, Javed F, Polin NM, Morin DP. The impact of revascularization on myocardial blood flow as assessed by positron emission tomography. Eur J Nucl Med Mol Imaging 2019; 46:1226-39. [PMID: 30806750 DOI: 10.1007/s00259-019-04278-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 01/23/2019] [Indexed: 11/30/2022]
Abstract
Purpose Revascularization aims to improve myocardial perfusion. However, changes in regional artery-specific quantitative perfusion after revascularization have not been systematically investigated. It is unclear whether artery-specific thresholds for coronary flow capacity (CFC) and/or relative perfusion predict improved stress perfusion after revascularization. We sought to determine the impact of revascularization based on predefined, artery-specific, severity size thresholds for CFC and/or relative perfusion defects. Methods Fifty patients underwent PET imaging before revascularization and then prospectively within 90 days after revascularization. Changes in regional myocardial blood flow (MBF) were stratified based on baseline perfusion abnormalities, baseline reduced CFC, and whether revascularization was performed in that region. Results Following angiographic stenosis-directed revascularization, in regions with relative perfusion abnormalities and decreased CFC, stress MBF (sMBF) increased by 0.51 cm3/min/g (59%) from baseline (p < 0.001). In regions without baseline perfusion abnormalities and yet decreased CFC, sMBF increased by 0.35 cm3/min/g (40%) from baseline (p < 0.001). In regions without perfusion abnormalities and normal CFC, sMBF did not increase significantly (+0.07 cm3/min/g, p = 0.56). Patients in whom revascularization was concordant with abnormal PET findings showed increased whole-heart sMBF (+0.22 cm3/min/g, p < 0.001), but in patients in whom revascularization was targeted only to regions without perfusion abnormalities or low CFC, sMBF did not change significantly (−0.06 cm3/min/g, p = 0.38). Conclusion Revascularization targeted to regions with reduced CFC and relative perfusion abnormalities on baseline PET yielded significant improvements in sMBF. When revascularization was performed in regions without reduced CFC, sMBF did not improve. Electronic supplementary material The online version of this article (10.1007/s00259-019-04278-8) contains supplementary material, which is available to authorized users.
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van de Hoef TP, Echavarría-Pinto M, Escaned J, Piek JJ. Coronary flow capacity: concept, promises, and challenges. Int J Cardiovasc Imaging 2017; 33:1033-1039. [PMID: 28353034 PMCID: PMC5489577 DOI: 10.1007/s10554-017-1125-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 03/21/2017] [Indexed: 10/30/2022]
Abstract
The vasodilator capacity of the coronary circulation is an important diagnostic and prognostic characteristic, and its accurate assessment is therefore an important frontier. The coronary flow capacity (CFC) concept was introduced to overcome the limitations associated with the use of coronary flow reserve (CFR) for this purpose, which are related to the sensitivity of CFR to physiological alterations in systemic and coronary hemodynamics. CFC was developed from positron emission tomography, and was subsequently extrapolated to invasive coronary physiology. These studies suggest that CFC is a robust framework for the identification of clinically relevant coronary flow abnormalities, and improves identification of patients at risk for adverse events over the use of CFR alone. This Review will discuss the concept of CFC, its promises in the setting of ischaemic heart disease, and its challenges both in theoretical and practical terms.
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Affiliation(s)
- Tim P van de Hoef
- AMC Heart Center, Academic Medical Center - University of Amsterdam, Room B2-250, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Mauro Echavarría-Pinto
- AMC Heart Center, Academic Medical Center - University of Amsterdam, Room B2-250, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.,Department of Cardiology, ISSSTE General Hospital, Querétaro, Mexico.,Faculty of Medicine, Autonomous University of Querétaro, Querétaro, Mexico
| | - Javier Escaned
- Cardiovascular Institute, Hospital Universitario Clinico San Carlos, Madrid, Spain
| | - Jan J Piek
- AMC Heart Center, Academic Medical Center - University of Amsterdam, Room B2-250, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
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