An assessment of the safety, hemodynamic response, and diagnostic accuracy of commonly used vasodilator stressors in patients with severe aortic stenosis

Hussain, Nasir; Chaudhry, Waseem; Ahlberg, Alan W.; Amara, Richard; Elfar, Ahmed; Parker, Matthew W.; Savino, John A.; Titano, Ruwanthi; Henzlova, Milena J.; Duvall, W. Lane

doi:10.1007/s12350-016-0427-1

Cited by 17 publications

(12 citation statements)

References 27 publications

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“…Exercise-induced myocardial ischemia may occur in these patients, even in the absence of CAD ( 35 – 41 ). While exercise-stress testing is contraindicated for symptomatic patients with severe AS, it has clinical relevance for identifying those asymptomatic AS-patients who are at high-risk of poor prognosis ( 8 , 9 , 35 – 41 ). Pharmacological stress tests such as single photon emission computed tomography (SPECT), positron emission tomography (PET) or cardiac magnetic resonance (CMR) with different vasodilators (adenosine, dipyridamole or regadenoson) have been shown to be a valuable alternative to exercise-stress testing for the CAD assessment in these patients ( 35 – 41 ).…”

Section: Coronary Artery Disease Assessment In Patients With Aortic S...mentioning

confidence: 99%

Section: Coronary Artery Disease Assessment In Patients With Aortic S...mentioning

confidence: 99%

“…In patients with severe AS, the conventional exercise-stress test and thallium-201 exercise-scintigraphy are generally found to be inaccurate with low specificity for CAD assessment since clinical symptoms and baseline ECG abnormalities are neither specific nor sensitive (35)(36)(37)(38)(39)(40)(41). Exercise-induced myocardial ischemia may occur in these patients, even in the absence of CAD (35)(36)(37)(38)(39)(40)(41). While exercise-stress testing is contraindicated for symptomatic patients with severe AS, it has clinical relevance for identifying those asymptomatic ASpatients who are at high-risk of poor prognosis (8,9,(35)(36)(37)(38)(39)(40)(41).…”

Section: Coronary Artery Disease Assessment In Patients With Aortic S...mentioning

confidence: 99%

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Challenges in Diagnosis and Functional Assessment of Coronary Artery Disease in Patients With Severe Aortic Stenosis

Aleksandric¹,

Banović²,

Beleslin³

2022

Front. Cardiovasc. Med.

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More than half of patients with severe aortic stenosis (AS) over 70 years old have coronary artery disease (CAD). Exertional angina is often present in AS-patients, even in the absence of significant CAD, as a result of oxygen supply/demand mismatch and exercise-induced myocardial ischemia. Moreover, persistent myocardial ischemia leads to extensive myocardial fibrosis and subsequent coronary microvascular dysfunction (CMD) which is defined as reduced coronary vasodilatory capacity below ischemic threshold. Therefore, angina, as well as noninvasive stress tests, have a low specificity and positive predictive value (PPV) for the assessment of epicardial coronary stenosis severity in AS-patients. Moreover, in symptomatic patients with severe AS exercise testing is even contraindicated. Given the limitations of noninvasive stress tests, coronary angiography remains the standard examination for determining the presence and severity of CAD in AS-patients, although angiography alone has poor accuracy in the evaluation of its functional severity. To overcome this limitation, the well-established invasive indices for the assessment of coronary stenosis severity, such as fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR), are now in focus, especially in the contemporary era with the rapid increment of transcatheter aortic valve replacement (TAVR) for the treatment of AS-patients. TAVR induces an immediate decrease in hyperemic microcirculatory resistance and a concomitant increase in hyperemic flow velocity, whereas resting coronary hemodynamics remain unaltered. These findings suggest that FFR may underestimate coronary stenosis severity in AS-patients, whereas iFR as the non-hyperemic index is independent of the AS severity. However, because resting coronary hemodynamics do not improve immediately after TAVR, the coronary vasodilatory capacity in AS-patients treated by TAVR remain impaired, and thus the iFR may overestimate coronary stenosis severity in these patients. The optimal method for evaluating myocardial ischemia in patients with AS and co-existing CAD has not yet been fully established, and this important issue is under further investigation. This review is focused on challenges, limitations, and future perspectives in the functional assessment of coronary stenosis severity in these patients, bearing in mind the complexity of coronary physiology in the presence of this valvular heart disease.

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Section: Coronary Artery Disease Assessment In Patients With Aortic S...mentioning

confidence: 99%

Section: Coronary Artery Disease Assessment In Patients With Aortic S...mentioning

confidence: 99%

Section: Coronary Artery Disease Assessment In Patients With Aortic S...mentioning

confidence: 99%

See 1 more Smart Citation

Challenges in Diagnosis and Functional Assessment of Coronary Artery Disease in Patients With Severe Aortic Stenosis

Aleksandric¹,

Banović²,

Beleslin³

2022

Front. Cardiovasc. Med.

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“…First, myocardial perfusion SPECT analysis mainly relies on perfusion, which is also dependent on MVD, hence our additional separate analysis of patients with normal and high IMR. Nevertheless, a recent study showed a good diagnostic performance of SPECT in patients with severe AS (35). Furthermore, SPECT is readily available in our institutions for the quantification of myocardial ischemia, and additional imaging with the use of positron emission-computerized tomography or perfusion cardiac magnetic resonance imaging is not feasible due to availability and practical issues in our elderly study population.…”

Section: Limitationsmentioning

confidence: 94%

The coronary and microcirculatory measurements in patients with aortic valve stenosis study: rationale and design

Minten

McCutcheon

Jentjens

et al. 2021

American Journal of Physiology-Heart and Circulatory Physiology

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Objective: Although coronary artery disease (CAD) is frequent in patients with aortic stenosis (AS), hemodynamic assessment of CAD severity in patients undergoing valve replacement for severe AS is challenging. Myocardial hypertrophic remodelling interferes with coronary blood flow and may influence the values of fractional flow reserve (FFR) and non-hyperemic pressure ratios (NHPRs). The aim is to investigate these effects on current CAD indices by comparing intra-coronary hemodynamics prior to, immediately after and six months after aortic valve replacement (AVR), when it is expected that microvascular function has improved. Furthermore, we will compare FFR and Resting Full Cycle Ratio (RFR) with myocardial perfusion SPECT as indicators of myocardial ischemia in patients with AS and CAD. Study design: One hundred patients with AS and CAD will be prospectively included. Patients will undergo pre-AVR SPECT and intra-coronary hemodynamic assessment at baseline, immediately after and six months after AVR. The primary endpoint is the change in FFR. Secondary endpoints include the acute change of FFR after TAVR, the diagnostic accuracy of FFR versus RFR compared with SPECT for the assessment of ischemia, changes in microvascular function as assessed by the index of microcirculatory resistance (IMR), and the effect of these changes on FFR.Conclusion: The present study will evaluate intra-coronary physiology before, immediately after and six months after AVR in patients with AS and intermediate coronary stenosis. The understanding of the impact of AVR on the assessment of FFR, NHPR and microvascular function may help guide the need for revascularization in these patients.

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“…To fill the gap between evidence and practice, Hussain et al recently investigated the safety of vasodilator MPS in 95 patients (average age, 79 years) with severe aortic stenosis (mean aortic valve area, 0.79 cm 2 ). 8 They showed that dipyridamole, adenosine, and regadenoson had comparable safety profiles with no occurrence of major adverse events or serious complications. Although patients with valve disease were nearly twice as likely to experience a marked reduction ([20 mmHg) in systolic blood pressure as patients without disease, none experienced symptomatic hypotension.…”

mentioning

confidence: 99%

Adenosine MPS in octogenarians: Looking safely into the future

Cliffe

Reyes

2019

Journal of Nuclear Cardiology

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An assessment of the safety, hemodynamic response, and diagnostic accuracy of commonly used vasodilator stressors in patients with severe aortic stenosis

Abstract: Severe AS patients are more likely to have a hemodynamically significant decrease in systolic BP with vasodilator stress. There were no serious adverse events in this severe AS cohort with good diagnostic performance of MPI compared to angiography.

Cited by 17 publications

References 27 publications

Challenges in Diagnosis and Functional Assessment of Coronary Artery Disease in Patients With Severe Aortic Stenosis

Challenges in Diagnosis and Functional Assessment of Coronary Artery Disease in Patients With Severe Aortic Stenosis

The coronary and microcirculatory measurements in patients with aortic valve stenosis study: rationale and design

Adenosine MPS in octogenarians: Looking safely into the future

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