Current concepts of coronary flow reserve for clinical decision making during cardiac catheterization

Baumgart, Dietrich; Haude, Michael; Liu, Fengqi; Ge, Junbo; Goerge, Guenter; Erbel, Raimund

doi:10.1016/s0002-8703(98)70194-2

Cited by 103 publications

(75 citation statements)

References 87 publications

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“…[11][12][13][14][15]18 In the present study, the CFVR of all coronary arteries improved during follow-up without a change in hemodynamic conditions such as LV rate -pressure product or LVEDP. Although there was no significant difference in APV at rest between the acute phase and 3 weeks later, increased APV at rest might cause decreased CFVR in the acute phase.…”

Section: Discussionmentioning

confidence: 68%

Assessment of Coronary Microcirculation in Patients With Takotsubo-Like Left Ventricular Dysfunction

Kume

Akasaka

Kawamoto

et al. 2005

Circ J

190

131

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akotsubo-like left ventricular (LV) dysfunction ischaracterized by a unique morphologic feature on left ventriculography (LVG) and some clinical features, including a predominance in elderly women, as well as a favorable prognosis. [1][2][3][4][5][6][7][8][9] The LV wall motion abnormality is quite different from that in myocardial infarction; it occurs in the LV apical region (LV apical ballooning), but improves within several weeks. The precise mechanism remains still unclear. Kurisu et al reported that coronary microcirculation, assessed by thrombolysis in myocardial infarction trial frame count, is impaired in patients with takotsubo-like LV dysfunction. 4 And Nishikawa et al reported that coronary microvascular function assessed by 99m Tc-tetrofosmin myocardial single photon emission computed tomography is impaired in patients with takotsubo-like LV dysfunction. 6 It has been also reported that the coronary flow velocity (CFV) pattern and CFV reserve (CFVR), measured with a Doppler guidewire, reflect the degree of coronary microvascular dysfunction under stable hemodynamic conditions in the absence of epicardial coronary stenosis, 10-14 so the aim of the present study was to evaluate coronary microcirculation in patients with takotsubo-like LV dysfunction by analyzing CFV pattern and CFVR in the acute phase and 3 weeks later. Methods Study PatientsWe studied 8 consecutive patients with takotsubo-like LV dysfunction (7 females, 1 male). All patients were diagnosed with takotsubo-like LV dysfunction according to the following criteria: (1) LV wall motion abnormality mainly at the apex on LVG; (2) ST-segment elevation or T-wave abnormality in at least 2 contiguous electrocardiogram (ECG) leads; (3) no history of prior myocardial infarction; and (4) normal coronary angiography (CAG) (luminal narrowing of <25% in all 3 coronary arteries). We excluded patients with subarachnoid hemorrhage, pheochromocytoma crisis, atrial fibrillation, hypertrophic cardiomyopathy, severe valvular heart disease and post-tachycardia condition. The existence of hypertension, hyperlipidemia, diabetes mellitus, and smoking were determined, using the following criteria: hypertension was defined as blood pressure >140/90 mmHg or current medication; hyperlipidemia was defined as total cholesterol concentration >220 mg/dl, triglyceride concentration >150 mg/dl or current medication; diabetes mellitus was defined as fasting plasma glucose concentration >120 mg/dl, plasma glucose concentration (anytime) >200 mg/dl or current medication. Within 24 h of symptom onset, LVG and CAG were performed by the femoral approach after intravenous infusion of 5,000 U of heparin. LV end-diastolic pressure (LVEDP) was obtained before LVG. After confirming the LV apical wall motion abnormality and normal CAG, the phasic CFV spectrum was recorded at rest and during hyperemia induced by an intravenous injection of 0.15 mg·kg -1 ·min -1 adenosine 5'-triphosphate, in the middle portion of the left anterior descending coronary artery (LAD), the left circumflex ar...

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Section: Discussionmentioning

confidence: 68%

Assessment of Coronary Microcirculation in Patients With Takotsubo-Like Left Ventricular Dysfunction

Kume

Akasaka

Kawamoto

et al. 2005

Circ J

190

131

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“…Neither LVH nor increased wall stresses was evident, although the CFR was significantly decreased. Because CFR is decreased in patients with MVA, [13][14][15][16] as well as in those with AS, 6-9 the cause in the present patient could have been either. Resting coronary flow to the hypertrophied myocardium in patients with AS is already significantly increased and cannot increase during tachycardia.…”

Section: Discussionmentioning

confidence: 81%

“…13 Microvascular dysfunction is characterized by an inadequate vasodilator response, such as impaired CFR [13][14][15][16] or the production of myocardial lactate, 12,13,17 in response to dynamic exercise 18 or metabolic and pharmacological stimuli. 13 We describe a patient with moderate AS associated with AP who showed neither LVH nor high wall stress.…”

mentioning

confidence: 99%

Microvascular Angina in a Patient With Aortic Stenosis.

et al. 2001

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he reported incidence of angina pectoris (AP) in patients with aortic stenosis (AS) and normal coronary arteries varies from 30% to 40%, 1-3 but the pathogenesis of this association remains unclear. AP may be caused by mismatched demand and supply of myocardial oxygen, particularly in response to stress. 4,5 An increase in left ventricular (LV) peak systolic pressure (LVPSP), LV mass, and LV ejection time (LVET) increases myocardial oxygen demand; decreased diastolic time resulting from the increased LVET and increased LV end-diastolic pressure (LVEDP) decreases myocardial oxygen supply. 5 Coronary flow reserve (CFR) is also impaired in severe AS. 6-9 These mechanisms have been explained by LV hypertrophy (LVH) or an increased LV mass 6,7 and by hemodynamic factors, such as elevated LVPSP and LVEDP, and wall stress. 8,9 Marcus et al speculated that the coronary flow to the hypertrophied myocardium is already significantly increased at rest and cannot further increase in response to coronary vasodilation. 7 On the other hand, Julius et al proposed that myocardial ischemia in patients with severe AS, but not LVH, could occur because of the high LVPSP and LVEDP, resulting in high systolic and diastolic wall stress and a consequent reduction in CFR. 9 These findings imply that the cause of AP in patients with AS who have normal coronary arteries is attributable to LVH and/or high wall stress. 10 The condition that features angina or angina-like chest pain and ischemic ST segment depression on electrocardiography (ECG) during exercise, together with angiographically normal coronary arteries without coronary spasm, is sometimes called syndrome X. 11,12 Cannon et al referred to a clinical entity satisfying the criteria of syndrome X, and Japanese Circulation Journal Vol. 65, September 2001 with myocardial ischemia caused by a disorder of the coronary microvasculature, as microvascular angina (MVA). 13 Microvascular dysfunction is characterized by an inadequate vasodilator response, such as impaired CFR [13][14][15][16] or the production of myocardial lactate, 12,13,17 in response to dynamic exercise 18 or metabolic and pharmacological stimuli. 13 We describe a patient with moderate AS associated with AP who showed neither LVH nor high wall stress. Case ReportSevere AS was suspected in a 39-year-old woman who visited her local clinic with heart murmur, exercise-induced dyspnea and chest pain. She was referred to hospital for

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“…Consequently, the reported "normal" CFR value varied considerably. 20 Therefore, even quantitative CFR significant but modest, and there was no significant correlation between FFR and CFR.…”

Section: Mbf Cfr and Cfr Ratiomentioning

confidence: 93%

Clinical Usefulness of Coronary Flow Reserve Ratio for the Detection of Significant Coronary Artery Disease on <sup>13</sup>N-Ammonia Positron Emission Tomography

Kawaguchi

Okayama

Kito

et al. 2018

Circ J

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Background: This study aimed to evaluate the diagnostic performance of coronary flow reserve (CFR), hyperemic myocardial blood flow (hMBF), and CFR ratio for detecting significant coronary artery disease (CAD) on 13 N-ammonia positron emission tomography (PET). Methods and Results:We analyzed 63 patients (mean age, 71±9 years; 43 males) with suspected CAD who underwent both pharmacological stress/rest 13 N-ammonia PET and coronary angiography. CFR and hMBF for PET were calculated automatically using quantitative PET software, and the CFR ratio was defined as the ratio of per-vessel CFR to maximum CFR in a standard 17-segment model. We compared the diagnostic performance among the 3 quantitative values. In the per-vessel analysis, 55 vessels were diagnosed as significant CAD (≥70% stenosis and/or fraction flow reserve ≤0.8). CFR, hMBF, and CFR ratio of significant CAD were significantly lower than for non-significant CAD (1.85±0.69 vs. 2.38±0.69; P<0.01, 1.67±0.54 vs. 2.19±0.52 mL · min −1 · g −1 ; P<0.01, and 0.66±0.15 vs. 0.82±0.09; P<0.01, respectively). In the receiver-operating characteristic curve analysis, CFR, hMBF, and CFR ratio had areas under the curve of 0.71, 0.75, and 0.85 respectively, and the CFR ratio was significantly higher than CFR and hMBF (P<0.05). The sensitivity, specificity, and accuracy of the CFR ratio with an optimal cutoff value of 0.75 were 75%, 85%, and 82%, respectively. Conclusions:Clinically, the CFR ratio in 13 N-ammonia PET was more effective in detecting significant CAD.

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Current concepts of coronary flow reserve for clinical decision making during cardiac catheterization

Cited by 103 publications

References 87 publications

Assessment of Coronary Microcirculation in Patients With Takotsubo-Like Left Ventricular Dysfunction

Assessment of Coronary Microcirculation in Patients With Takotsubo-Like Left Ventricular Dysfunction

Microvascular Angina in a Patient With Aortic Stenosis.

Clinical Usefulness of Coronary Flow Reserve Ratio for the Detection of Significant Coronary Artery Disease on <sup>13</sup>N-Ammonia Positron Emission Tomography

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