Impact of diabetes mellitus on the diagnostic performance of fractional flow reserve in patients with severe aortic stenosis

Abstract

Background:The validity of functional assessment of coronary artery disease with fractional flow reserve (FFR) and/or instantaneous wave-free ratio (iFR) in patients with severe aortic stenosis (AS) might be affected by AS per se and other factors, including diabetes mellitus. Aims:We aimed to evaluate the impact of diabetic status on FFR performance in severe AS. Methods:The functional significance of 416 stenoses of intermediate angiographic severity in 221 patients with severe AS was assessed with iFR and FFR. Patients treated with insulin or oral hypoglycemic agents were classified as diabetic patients.Results: Of 221 enrolled patients, 68 (32.1%) patients were diabetic. A total of 128 (30.8%) lesions in patients with and 288 in patients without diabetes mellitus were assessed. The mean (SD) FFR was 0.85 (0.07), and iFR was 0.90 (0.04) with no difference between nondiabetic and diabetic patients. Good agreement between iFR and FFR was confirmed for non-diabetic (ICC, 0.83 [95% confidence interval, CI, 0.79-0.86]) and diabetic (ICC, 0.82 [95% CI, 0.76-0.87]) patients. Among patients without diabetes mellitus, the optimal cutoff value for FFR to detect iFR ≤0.89 was 0.81 with sensitivity and specificity of 96.6% and 100.0%. The optimal cutoff value for FFR to detect iFR ≤0.89 for diabetic patients was 0.83 with sensitivity and specificity of 98.0% and 100.0%. Conclusions:In patients with severe AS, FFR correlates well with iFR. However, the optimal threshold for FFR to identify significant ischemia (iFR ≤0.89) in those patients may differ from the standard threshold of FFR ≤0.80 and might be affected by the diabetic status.

Coronary flow reserve in degenerative aortic stenosis and diabetes mellitus: An intriguing question

“…In our opinion, the article by Dziewierz et al [15] provides good data that expands our knowledge of a frequent and complex clinical problem, such as the evaluation of the severity of CAD in patients undergoing TAVI, and that can help to shed light on this relevant clinical conundrum.…”

“…In this issue of Kardiologia Polska (Kardiol Pol, Polish Heart Journal), we can read the article by Dziewierz et al [15] that goes further in evaluating the impact of T2DM on the performance of FFR in patients with severe DAS un-dergoing TAVI. They studied the functional significance of 416 angiographically intermediate coronary lesions using iFR and FFR in 221 patients (32.1% with T2DM) with severe DAS.…”

Influence of sex on the functional assessment of myocardial ischemia

“…For instance, the FREAK study found a higher percentage of negative FFR values in patients with chronic kidney disease, suggesting a link between FFR results and creatinine levels [31]. Similarly, diabetes mellitus is often associated with diffuse vascular dysfunction in both large and micro-vessels [7,18,[32][33][34][35]. Women have a longer life expectancy than men, so they are more likely to experience other age-related diseases, such as severe aortic stenosis [36].…”

“…Women have a longer life expectancy than men, so they are more likely to experience other age-related diseases, such as severe aortic stenosis [36]. Notably, in patients with severe aortic stenosis, FFR and iFR/RFR values may be affected by a falsely low aortic pressure due to the restricted orifice of the aortic valve [7,16]. Furthermore, a reduced vasodilation ability in patients with severe aortic stenosis may result from myocardial hypertrophy, microvascular dysfunction, and elevated left ventricular end-diastolic pressure [16].…”

“…Instantaneous wave-free ratio (iFR) and resting full-cycle ratio (RFR) are alternative invasive measurements for evaluating coronary stenosis significance without vasodilators [3,4]. FFR and non-hyperemic methods (iFR/RFR) results are closely correlated [4][5][6][7][8][9]. However, a notable 20% discordance exists in identifying significant ischemia between FFR and iFR/RFR [4,[10][11][12][13][14][15].…”