Long-term prognostic value of CFVR and FFR versus perfusion scintigraphy in patients with multivessel disease

Chamuleau, Steven A.J.; Eck-Smit, Berthe L. F. van; Meuwissen, Martijn; Koch, Karel T.; Dijkgraaf, Marcel G. W.; Verberne, Hein J.; Tijssen, Jan G.P.; Piek, Jan J.

doi:10.1007/bf03086017

Cited by 22 publications

(9 citation statements)

References 18 publications

(21 reference statements)

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“…These patients were enrolled in a series of study protocols, 6,7,15,16 and patient and procedural characteristics were entered into a dedicated database. The study protocols excluded patients with ostial stenoses, serial stenoses, severe renal function impairment (glomerular filtration rate calculated according to the modification of diet in renal disease formula <30mL/min per 1.73 m 2 ), significant left main coronary artery stenosis, atrial fibrillation, recent myocardial infarction (<6 weeks before screening), prior coronary artery bypass graft surgery, or visible collateral development to the perfusion territory of interest.…”

Section: Data Sourcementioning

confidence: 99%

Physiological Basis and Long-Term Clinical Outcome of Discordance Between Fractional Flow Reserve and Coronary Flow Velocity Reserve in Coronary Stenoses of Intermediate Severity

Hoef

Lavieren

Damman

et al. 2014

Circ: Cardiovascular Interventions

334

202

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Background-Discordance between fractional flow reserve (FFR) and coronary flow velocity reserve (CFVR) may reflect important coronary pathophysiology but usually remains unnoticed in clinical practice. We evaluated the physiological basis and clinical outcome associated with FFR/CFVR discordance. Methods and Results-We studied 157 intermediate coronary stenoses in 157 patients, evaluated by FFR and CFVR between April 1997 and September 2006 in which revascularization was deferred. Long-term follow-up was performed to document the occurrence of major adverse cardiac events: cardiac death, myocardial infarction, or target vessel revascularization. Discordance between FFR and CFVR occurred in 31% and 37% of stenoses at the 0.75, and 0.80 FFR cut-off value, respectively, and was characterized by microvascular resistances during basal and hyperemic conditions. Follow-up duration amounted to 11.7 years (Q1-Q3, 9.9-13.3 years). Compared with concordant normal results of FFR and CFVR, a normal FFR with an abnormal CFVR was associated with significantly increased major adverse cardiac events rate throughout 10 years of follow-up, regardless of the FFR cut-off applied. In contrast, an abnormal FFR with a normal CFVR was associated with equivalent clinical outcome compared with concordant normal results: ≤3 years when FFR <0.75 was depicted abnormal and throughout 10 years of follow-up when FFR ≤0.80 was depicted abnormal. Conclusions-Discordance of CFVR with FFR originates from the involvement of the coronary microvasculature. Importantly, the risk for major adverse cardiac events associated with FFR/CFVR discordance is mainly attributable to stenoses where CFVR is abnormal. This emphasizes the requirement of intracoronary flow assessment in addition to coronary pressure for optimal risk stratification in stable coronary artery disease. (Circ Cardiovasc Interv. 2014;7:301-311.)Key Words: coronary flow velocity reserve ◼ coronary microcirculation ◼ fractional flow reserve ◼ stable coronary artery disease

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Section: Data Sourcementioning

confidence: 99%

Physiological Basis and Long-Term Clinical Outcome of Discordance Between Fractional Flow Reserve and Coronary Flow Velocity Reserve in Coronary Stenoses of Intermediate Severity

Hoef

Lavieren

Damman

et al. 2014

Circ: Cardiovascular Interventions

334

202

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“…These patients were enrolled in a series of study protocols, [6][7][8][9] and patient and procedural characteristics were entered into a dedicated database. We excluded patients with ostial lesions, ≥2 stenoses in the same coronary artery, severe renal function impairment (glomerular filtration rate calculated according to the Modification of Diet in Renal Disease formula <30 mL/min per 1.73 m 2 ), significant left main coronary artery stenosis, atrial fibrillation, recent myocardial infarction (<6 weeks before screening), prior coronary artery bypass graft surgery, or visible collateral development to the perfusion territory of interest.…”

Section: Study Populationmentioning

confidence: 99%

Impaired Coronary Autoregulation Is Associated With Long-term Fatal Events in Patients With Stable Coronary Artery Disease

Hoef

Bax²,

Damman³

et al. 2013

Circ: Cardiovascular Interventions

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Background— Abnormalities in the coronary microcirculation are increasingly recognized as an elementary component of ischemic heart disease, which can be accurately assessed by coronary flow velocity reserve in reference vessels (refCFVR). We studied the prognostic value of refCFVR for long-term mortality in patients with stable coronary artery disease. Methods and Results— We included patients with stable coronary artery disease who underwent intracoronary physiological evaluation of ≥1 coronary lesion of intermediate severity between April 1997 and September 2006. RefCFVR was assessed if a coronary artery with <30% irregularities was present. RefCFVR >2.7 was considered normal. Patients underwent revascularization of all ischemia-causing lesions. Long-term follow-up was performed to document the occurrence of (cardiac) mortality. RefCFVR was determined in 178 patients. Kaplan–Meier estimates of 12-year all-cause mortality were 16.7% when refCFVR >2.7 and 39.6% when refCFVR ≤2.7 ( P <0.001), whereas Kaplan–Meier estimates for cardiac mortality were 7.7% when refCFVR >2.7 and 31.6% when refCFVR ≤2.7 ( P <0.001). After multivariable adjustment, refCFVR ≤2.7 was associated with a 2.24-fold increase in all-cause mortality hazard (hazard ratio, 2.24; 95% confidence interval, 1.13–4.44; P =0.020) and a 3.32-fold increase in cardiac mortality hazard (hazard ratio, 3.32; 95% confidence interval, 1.27–8.67; P =0.014). Impairment of refCFVR originated from significantly higher baseline flow velocity in the presence of significantly lower reference vessel baseline microvascular resistance ( P <0.001), indicating impaired coronary autoregulation as its cause. Conclusions— In patients with stable coronary artery disease, impaired refCFVR, resulting from increased baseline flow velocity indicating impaired coronary autoregulation, is associated with a significant increase in fatal events at long-term follow-up.

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confidence: 84%

“…In the same study two patients had positive exercise tests and one patient a positive Thallium SPECT scan with FFR values significantly above .75. Later studies have confirmed that a FFR results can have a prognostic significance which can be better than SPECT in a selected group of patients with untreated intermediate lesions after PCI of a severe lesion [2].In contrast SPECT itself has a significant prognostic value in patients with low or intermediate risk of coronary disease and has been recommended as a first line diagnostic method in coronary disease by the UK National Institute of Clinical Excellence (http:// www.nice.org.uk/nicemedia/pdf/TA073guidance.pdf). A normal Myocardial SPECT scan has been shown in large studies to have a very good prognostic value with adverse event rates of 0.6%/year quoted in one study of 7,376 consecutive patients [3].…”

mentioning

confidence: 85%

The relationship between Myocardial SPECT and Fractional Flow Reserve: Is it drifting apart?

Rees

2009

Int J Cardiovasc Imaging

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In the paper, Tc-99 m sestamibi single photon emission computed tomography for guiding percutaneous coronary intervention in patients with multivessel disease: a comparison with quantitative coronary angiography and fractional flow reserve by Forster et.al. the authors correctly point out that FFR (Fractional Flow Reserve) was initially validated against non-invasive studies which included Thallium SPECT, Stress Echocardiography and standard exercise testing. In the paper by Pijls et.al.in 1995 which was one of the first validation studies of FFR [1] there were a significant number of negative SPECT and stress echo results at FFR values significantly lower than .75 although in all patients myocardial ischaemia was demonstrated on one of the three tests used. In the same study two patients had positive exercise tests and one patient a positive Thallium SPECT scan with FFR values significantly above .75. Later studies have confirmed that a FFR results can have a prognostic significance which can be better than SPECT in a selected group of patients with untreated intermediate lesions after PCI of a severe lesion [2].In contrast SPECT itself has a significant prognostic value in patients with low or intermediate risk of coronary disease and has been recommended as a first line diagnostic method in coronary disease by the UK National Institute of Clinical Excellence (http:// www.nice.org.uk/nicemedia/pdf/TA073guidance.pdf). A normal Myocardial SPECT scan has been shown in large studies to have a very good prognostic value with adverse event rates of 0.6%/year quoted in one study of 7,376 consecutive patients [3]. The prognostic value of SPECT scanning may be improved by using cardiac gating [4] and when ejection fraction and end-systolic volumes are also considered as additional data the overall prognostic value of SPECT scanning improves further [5].The patient conditions under which FFR is measured also have to be taken into account. In this study the patients had multivessel disease. Although a single stenosis in each vessel would not modify the result multiple stenoses in a vessel require a modified approach to FFR measurement [6] and patients with a prior myocardial infarction resulting in microvascular dysfunction [7] may also have a falsely elevated FFR but usually by 5% however in chronic myocardial infarction FFR may still be accurate [8].So can the relative merits of these two tests be put into perspective? How also should we view the role of QCA (quantitative coronary angiography) in this context? This study concludes that SPECT gives a Editorial comment on the article of Förster et al. (

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Long-term prognostic value of CFVR and FFR versus perfusion scintigraphy in patients with multivessel disease

Cited by 22 publications

References 18 publications

Physiological Basis and Long-Term Clinical Outcome of Discordance Between Fractional Flow Reserve and Coronary Flow Velocity Reserve in Coronary Stenoses of Intermediate Severity

Physiological Basis and Long-Term Clinical Outcome of Discordance Between Fractional Flow Reserve and Coronary Flow Velocity Reserve in Coronary Stenoses of Intermediate Severity

Impaired Coronary Autoregulation Is Associated With Long-term Fatal Events in Patients With Stable Coronary Artery Disease

The relationship between Myocardial SPECT and Fractional Flow Reserve: Is it drifting apart?

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