Application of the DILEMMA score to improve lesion selection for invasive physiological assessment

Abstract

Objectives We sought to assess the validity of the DILEMMA score against instantaneous wave‐free ratio (iFR) and evaluate its utility in rationalizing the number of patients referred for invasive physiological assessment. Background The DILEMMA score is a validated angiographic scoring tool incorporating minimal lumen diameter, lesion length and subtended myocardial area that has been shown to predict the functional significance of lesions as assessed by fractional flow reserve (FFR). Methods Patients in the DEFINE‐FLAIR study who had coronary stenosis of intermediate severity were randomized to either FFR or iFR. DILEMMA score was calculated retrospectively on a subset of this cohort by operators blinded to FFR or iFR values. Results Three hundred and forty‐six lesions (181 assessed by FFR; 165 by iFR) from 259 patients (mean age 66.0 years, 79% male) were included. A DILEMMA score ≤ 2 had a negative predictive value of 96.3% and 95.7% for identifying lesions with FFR >0.80 and iFR >0.89, respectively. A DILEMMA score ≥ 9 had a positive predictive value of 88.9% and 100% for identifying lesions with FFR ≤0.80 and iFR ≤0.89, respectively. The receiver operating characteristic area under the curve values for DILEMMA score to predict FFR ≤0.80 and iFR ≤0.89 were 0.83 (95% CI 0.77–0.90) and 0.82 (0.75–0.89) respectively. A DILEMMA score ≤ 2 or ≥9 occurred in 172 of the 346 lesions (49.7%). Conclusions Using DILEMMA score in patients with coronary stenosis of intermediate severity may reduce the need for pressure wire use, offering potential cost‐savings and minimizing the risks associated with invasive physiological lesion assessment.

Beyond patency: Functional assessment of adequacy using internal mammary artery grafting to the left anterior descending artery

“…The length of the stenosis could be an important determinant of the ΔFlow, although not statistically significant in our analysis. In this study we used QCA to quantify the severity of the proximal coronary artery lesion, although the use of an alternative angiographic scoring tool that incorporates the minimal lumen diameter, lesion length, and subtended myocardial area, such as DILEMMA score, may better predict the functional significance of lesions . Moderate proximal native coronary artery stenosis and high fractional flow reserve are known to affect the bypass graft flow due to competitive antegrade flow from the native vessel.…”

Clinical prediction models of fractional flow reserve: an exploration of the current evidence and appraisal of model performance

“…Additionally, CPMs could be used as initial screening tools, which would enable unnecessary FFR measurements to be avoided. Indeed, a recent study showed that nearly half of intermediate lesions with a DILEMMA score of ≤2 or ≥9 could potentially have been deferred for invasive functional assessments (7). Second, CPMs can integrate more ischemia-related information than a three-dimensional vessel reconstruction, i n c l u d i n g d e m o g r a p h i c c h a r a c t e r i s t i c s , p h y s i c a l examinations, laboratory tests, and imaging.…”

“…Compared with other types of models based on geometric reconstruction and computational fluid dynamics, CPMs cannot give a specific value of FFR but can help stratify patients or lesions that are more likely to have an abnormal FFR (see Figure 1). These CPMs may diminish the need for pressure wires and thus reduce both medical expenditure and potential complications (7). Despite an increasing number of published FFR CPMs in recent years, there has been no attempt to evaluate recent advances on this topic comprehensively.…”

Fractional Flow Reserve following Percutaneous Coronary Intervention

“…e mechanical forces contributing to carinal shift typically occur in a single direction, making the stenosis even more eccentric and therefore exaggerating angiographic severity of the jailed SB [37]. Physiologically, the trans-stenotic pressure gradient across a lesion and therefore FFR is highly dependent on the area of myocardium subtended [38,39]. is explains the observation that, for a given stenosis and lesion length, lesions in major epicardial arteries tend to have lower FFR values than side-branch vessels by virtue of the degree of myocardium supplied [38].…”