Nonculprit Stenosis Evaluation Using Instantaneous Wave-Free Ratio in Patients With ST-Segment Elevation Myocardial Infarction

Thim, Troels; Götberg, Matthias; Fröbert, Ole; Nijveldt, Robin; Royen, Niels van; Baptista, Sérgio Bravo; Koul, Sasha; Kellerth, Thomas; Bøtker, Hans Erik; Terkelsen, Christian Juhl; Christiansen, Evald Høj; Jakobsen, Lars; Kristensen, Steen Dalby; Mæng, Michael

doi:10.1016/j.jcin.2017.07.021

Cited by 58 publications

(45 citation statements)

References 25 publications

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“…The iSTEMI results and clinical characteristics of the participants have been presented previously . The iSTEMI trial included 120 patients with staged iFR and FFR data available for 146 lesions in 112 patients.…”

Section: Resultsmentioning

confidence: 99%

“…The iSTEMI study was a prospective international multicenter study including STEMI patients with NCLs. Inclusion and exclusion criteria have been described previously . NCLs were evaluated with iFR in the acute setting and with iFR and FFR at a staged procedure.…”

Section: Methodsmentioning

confidence: 99%

“…Drift of ≤0.02 was considered acceptable for FFR and iFR measurements. No correction for drift was applied …”

Section: Methodsmentioning

confidence: 99%

“…NCLs are therefore mainly evaluated by angiography at the index procedure . However, acute phase FFR and iFR might be useful in the evaluation of NCLs in patients with STEMI …”

Section: Introductionmentioning

confidence: 99%

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Quantitative flow ratio for immediate assessment of nonculprit lesions in patients with ST‐segment elevation myocardial infarction—An iSTEMI substudy

Sejr-Hansen

Thim

Christiansen

et al. 2019

Cathet Cardio Intervent

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Objectives We evaluated the diagnostic performance of quantitative flow ratio (QFR) assessment of nonculprit lesions (NCLs) based on acute setting angiograms obtained in patients with ST‐segment elevation myocardial infarction (STEMI) with QFR, fractional flow reserve (FFR), and instantaneous wave‐free ratio (iFR) in the staged setting as reference. Background QFR is an angiography‐based approach for the functional evaluation of coronary artery lesions. Methods This was a post‐hoc analysis of the iSTEMI study. NCLs were assessed with iFR in the acute setting and with iFR and FFR at staged (median 13 days) follow‐up. Acute and staged QFR values were computed in a core laboratory based on the coronary angiography recordings. Diagnostic cut‐off values were ≤0.80 for QFR and FFR, and ≤0.89 for iFR. Results Staged iFR and FFR data were available for 146 NCLs in 112 patients in the iSTEMI study. Among these, QFR analysis was feasible in 103 (71%) lesions assessed in the acute setting with a mean QFR value of 0.82 (IQR: 0.73–0.91). Staged QFR, FFR, and iFR were 0.80 (IQR: 0.70–0.90), 0.81 (IQR: 0.71–0.88), and 0.91 (IQR: 0.87–0.96), respectively. Classification agreement of acute and staged QFR was 93% (95%Cl: 87–99). The classification agreement of acute QFR was 84% (95%CI: 76–90) using staged FFR as reference and 74% (95%CI: 65–83) using staged iFR as reference. Conclusions Acute QFR showed a very good diagnostic performance with staged QFR as reference, a good diagnostic performance with staged FFR as reference, and a moderate diagnostic performance with staged iFR as reference.

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Section: Resultsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

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Quantitative flow ratio for immediate assessment of nonculprit lesions in patients with ST‐segment elevation myocardial infarction—An iSTEMI substudy

Sejr-Hansen

Thim

Christiansen

et al. 2019

Cathet Cardio Intervent

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“…artery lesions, which encompassed a total of 10 trials with 2285 patients, the reduction in the risk of cardiovascular events was observed irrespective of the timing of non-infarct-related coronary artery revascularization. 13 Moreover, the iFR in ST-segment Elevation Myocardial Infarction (iSTEMI) trial suggested that physiological disarrangements in STEMI patients affect functional assessment of non-culprit lesions for at least 5 days while reevaluation more than 2 weeks after STEMI may yield a physiological assessment comparable to stable conditions (Thim et al 14 …”

Section: Non-culprit Lesion Treatment In Stsegment Elevation Myocardimentioning

confidence: 99%

The year in cardiology 2017: coronary interventions

Kristensen

Mæng

Capodanno

et al. 2018

European Heart Journal

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PreambleThe first balloon coronary angioplasty was performed in Zurich by Andreas Grüntzig in 1977. The patient, a 38-year-old man with severe angina and a tight stenosis on the left anterior descending artery, is still alive, is doing well, and he celebrated the 40-year anniversary of his percutaneous coronary interventions (PCI) in 2017 ( Figure 1). During the last decades, PCI techniques have undergone major improvements with the first real game changer being the introduction of bare metal stents, which made PCI safer and improved longer-term outcomes. Later on, drug-eluting stents (DESs) were introduced, which resulted in a major reduction in restenosis and also-with the newer generation DES-a low rate of stent thrombosis. Further, the introduction of intracoronary pressure measurements for assessment of severity of coronary stenoses [fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR)] and intracoronary imaging [intravascular ultrasound (IVUS) and optical coherence tomography (OCT)] for lesion assessment has refined lesion and procedure assessment. Improved outcomes were also fostered by development of better and safer adjunctive antithrombotic drugs and secondary prevention, optimizing drug-device synergy. Still, 40 years later the research in the coronary interventional field is very intense, and we aim here to summarize major developments in PCI published in 2017. Myocardial revascularization Percutaneous coronary intervention techniqueThe SYNTAX (Synergy between PCI with Taxus and Cardiac Surgery) II study investigated the impact of a contemporary PCI strategy on clinical outcomes of 454 patients with three-vessel disease. 1Characteristics of the SYNTAX II strategy that captures all components of today's 'best of PCI practice' are summarized in Figure 2. Following this approach systematically, the authors demonstrated major adverse cardiac and cerebrovascular events (MACCE) at 1 year to be much improved with respect to a matched historical PCI cohort from the SYNTAX I trial (10.6% vs. 17.4%; P = 0.006). The better result of the contemporary PCI strategy compared with the procedural technique followed at the time of the SYNTAX I trial was driven by a lower risk of myocardial infarction (MI) and revascularization, with a parallel reduction in stent thrombosis. Overall, the SYNTAX II study suggests that the combination of best practice components in PCI technique portends improved patient outcomes beyond what can be achieved by introducing one single new element. Because these results outperform PCI results obtained in the earlier SYNTAX I trial, the hypothesis was generated that a new randomized study of modern best PCI practice in patients with three-vessel disease might show non-inferiority vs. coronary artery bypass grafting (CABG). 1Glimpsing to the future, the feasibility and technical success of robotically-assisted PCI for complex coronary lesions were investigated in 334 procedures from 315 patients included in the Complex Robotically Assisted Percutaneous Coronary Intervention (...

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Temporal Changes in Coronary Hyperemic and Resting Hemodynamic Indices in Nonculprit Vessels of Patients With ST-Segment Elevation Myocardial Infarction

et al. 2019

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IMPORTANCE Percutaneous coronary intervention (PCI) of nonculprit vessels among patients with ST-segment elevation myocardial infarction (STEMI) is associated with improved clinical outcome compared with culprit vessel-only PCI. Fractional flow reserve (FFR) and coronary flow reserve are hyperemic indices used to guide revascularization. Recently, instantaneous wave-free ratio was introduced as a nonhyperemic alternative to FFR. Whether these indices can be used in the acute setting of STEMI continues to be investigated. OBJECTIVE To assess the value of hemodynamic indices in nonculprit vessels of patients with STEMI from the index event to 1-month follow-up. DESIGN, SETTING, AND PARTICIPANTS This substudy of the Reducing Micro Vascular Dysfunction in Revascularized STEMI Patients by Off-target Properties of Ticagrelor (REDUCE-MVI) randomized clinical trial enrolled 98 patients with STEMI who had an angiographic intermediate stenosis in at least 1 nonculprit vessel. Patient enrollment was between May 1, 2015, and September 19, 2017.After successful primary PCI, nonculprit intracoronary hemodynamic measurements were performed and repeated at 1-month follow-up. Cardiac magnetic resonance imaging was performed from 2 to 7 days and 1 month after primary PCI. MAIN OUTCOMES AND MEASURESThe value of nonculprit instantaneous wave-free ratio, FFR, coronary flow reserve, hyperemic index of microcirculatory resistance, and resting microcirculatory resistance from the index event to 1-month follow-up. RESULTSOf 73 patients with STEMI included in the final analysis, 59 (80.8%) were male, with a mean (SD) age of 60.8 (9.9) years. Instantaneous wave-free ratio (SD) did not change significantly (0.93 [0.07] vs 0.94 [0.06]; P = .12) and there was no change in resting distal pressure/aortic pressure (mean [SD], 0.94 [0.06] vs 0.95 [0.06]; P = .25) from the acute moment to 1-month follow-up. The FFR decreased (mean [SD], 0.88 [0.07] vs 0.86 [0.09]; P = .001) whereas coronary flow reserve increased (mean [SD], 2.9 [1.4] vs 4.1 [2.2]; P < .001). Hyperemic index of microcirculatory resistance decreased and resting microcirculatory resistance increased from the acute moment to follow-up. The decrease in distal pressure from rest to hyperemia was smaller at the acute moment vs follow-up (mean [SD], 10.6 [11.2] mm Hg vs 14.1 [14.2] mm Hg; P = .05). This blunted acute hyperemic response correlated with final infarct size (ρ, -0.29; P = .02). The resistive reserve ratio was lower at the acute moment vs follow-up (mean [SD], 3.4 [1.7] vs 5.0 [2.7]; P < .001). CONCLUSIONS AND RELEVANCEIn the acute setting of STEMI, nonculprit coronary flow reserve was reduced and FFR was augmented, whereas instantaneous wave-free ratio was not altered. These results may be explained by an increased hyperemic microvascular resistance and a blunted adenosine responsiveness at the acute moment that was associated with infarct size.

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Nonculprit Stenosis Evaluation Using Instantaneous Wave-Free Ratio in Patients With ST-Segment Elevation Myocardial Infarction

Cited by 58 publications

References 25 publications

Quantitative flow ratio for immediate assessment of nonculprit lesions in patients with ST‐segment elevation myocardial infarction—An iSTEMI substudy

Quantitative flow ratio for immediate assessment of nonculprit lesions in patients with ST‐segment elevation myocardial infarction—An iSTEMI substudy

The year in cardiology 2017: coronary interventions

Temporal Changes in Coronary Hyperemic and Resting Hemodynamic Indices in Nonculprit Vessels of Patients With ST-Segment Elevation Myocardial Infarction

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