Physiological Pattern of Disease Assessed by Pressure-Wire Pullback Has an Influence on Fractional Flow Reserve/Instantaneous Wave-Free Ratio Discordance

Warisawa, Takayuki; Cook, Christopher; Howard, James P.; Ahmad, Yousif; Doi, Shun’ichi; Nakayama, Masafumi; Goto, Sonoka; Yakuta, Yohei; Karube, Kenichi; Shun-Shin, Matthew; Petraco, Ricardo; Sen, Sayan; Nijjer, Sukhjinder; Lamee, Rasha Al; Ishibashi, Yutaka; Matsuda, Hisao; Escaned, Javier; Mario, Carlo Di; Francis, Dárrel P.; Akashi, Yoshihiro J.; Davies, Justin E.

doi:10.1161/circinterventions.118.007494

Cited by 54 publications

(42 citation statements)

References 21 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…27 37 49 88 Most data on discordance currently exist on the comparison between iFR and FFR, with discordance believed to occur ~15%-20% of lesions, particularly in those subtending large areas of myocardium, that is, LMCA and proximal LAD. 49 89 Other areas where discordance has been identified include the pattern of coronary disease (focal vs diffuse), 90 and patient characteristics such as gender, presence of diabetes mellitus and beta blocker use. [91][92][93][94] A summary of these discordant groups associated with FFR and iFR is presented in table 2.…”

Section: Controversies In the Use Of Nhprmentioning

confidence: 99%

Non-hyperaemic pressure ratios to guide percutaneous coronary intervention

et al. 2020

View full text Add to dashboard Cite

The use of fractional flow reserve (FFR) in guiding revascularisation improves patient outcomes and has been well-established in clinical guidelines. Despite this, the uptake of FFR has been limited, likely attributable to the perceived increase in procedural time and use of hyperaemic agents that can cause patient discomfort. This has led to the development of instantaneous wave-free ratio (iFR), an alternative non-hyperaemic pressure ratio (NHPR). Since its inception, the use of iFR has been supported by an increasing body of evidence and is now guideline recommended. More recently, other commercially available NHPRs including diastolic hyperaemia-free ratio and resting full-cycle ratio have emerged. Studies have demonstrated that these indices, in addition to mean distal coronary artery pressure to mean aortic pressure ratio, are mathematically analogous (with specific nuances) to iFR. Additionally, there is increasing data demonstrating the equivalent diagnostic performance of alternative NHPRs in comparison with iFR and FFR. These NHPRs are now integral within most current pressure wire systems and are commonly available in the catheter laboratory. It is therefore key to understand the fundamental differences and evidence for NHPRs to guide appropriate clinical decision-making.

show abstract

Section: Controversies In the Use Of Nhprmentioning

confidence: 99%

Non-hyperaemic pressure ratios to guide percutaneous coronary intervention

et al. 2020

View full text Add to dashboard Cite

show abstract

“…Because FFR requires the induction of a high flow state (hyperemia), it tends to be more sensitive to separation forces (where flow is squared), found with more focal lesions. This association was recently confirmed in a pressure wire pullback study, where iFR−/FFR+ discordance was more frequently associated with predominantly focal disease (59%, 24/41), while iFR+/FFR− disease was more often diffuse (82%, 31/38; p < .001 for difference). Considering that PCI tends to be more useful for focal disease, such data arguably favors the use of FFR in situations of iFR−/FFR+ discordance.…”

Section: Postulated Mechanisms Of Ifr/ffr Discordancementioning

confidence: 63%

“…Separation and frictional components of pressure loss diagram (from Warisawa et al) [Color figure can be viewed at wileyonlinelibrary.com]…”

Section: Postulated Mechanisms Of Ifr/ffr Discordancementioning

confidence: 99%

Vive la difference: Factors and mechanisms predicting discrepancy between iFR and FFR

Kern

Seto

2019

Cathet Cardio Intervent

View full text Add to dashboard Cite

Key Points FFR/iFR is discordant in 15–20% of cases, at times causing confusion about revascularization decisions. The CONTRAST substudy identifies lesion location, lesion severity, and bradycardia as major predictors for FFR/iFR discordance, with age a minor predictor. Each of these predictors can be explained physiologically through the mechanisms related to resting and hyperemic pressure loss across different patterns of atherosclerotic stenoses. A logical approach to using both resting and hyperemic pressure ratios is proposed.

show abstract

“…Several studies this year attempted to examine the physiological characteristics of lesions with discordant FFR and iwFR and identify lesion types and subgroup of patients where FFR should be preferred to iwFR and vice versa. (37,38) A recent subanalysis of the Functional Lesion Assessment of Intermediate Stenosis to Guide Revascularisation (DEFINE-FLAIR) study comparing outcomes in patients with a lesion in the left anterior descending coronary artery deferred from revascularisation based on the FFR or iwFR estimations showed a lower event rate in the iwFR group at 1-year follow-up that was attributed to a lower incidence of unplanned revascularisations (2.22% vs. 4.99%, p=0.03). (39) Conversely, a post hoc analysis of the same study in diabetic patients showed no differences in outcomes between the FFR and iwFR groups (7.2% vs. 10.0%; p=0.30); however, the incidence of non-fatal MI was higher in the iwFR group (4.7% vs. 1.9%; p=0.05), with a significant interaction for the presence of diabetes (p=0.04).…”

Section: Coronary Physiologymentioning

confidence: 99%

The year in cardiology: coronary interventions

Baumbach¹,

Bourantas²,

Serruys

et al. 2020

SAHJ

View full text Add to dashboard Cite

The year in cardiology 2019 REVASCULARISATION IN PATIENTS WITH CARDIAC ARREST OR ACUTE CORONARY SYNDROMESCoronary Angiography after Cardiac Arrest (COACT) is a landmark study that changed the management of patients admitted with a cardiac arrest who had successful resuscitation and no ST elevation myocardial infarction (STEMI). (1) In this prospective multicentre trial, 552 patients admitted with an out of hospital cardiac arrest with an initial shockable rhythm who did not have an obvious non-cardiac cause of arrest were randomised to immediate coronary angiography and if needed coronary revascularisation or delayed coronary angiography after neurological recovery. An acute thrombotic occlusion was noted only in 3.4% of patients in the immediate angiography and in 7.6% of patients in the delayed angiography group.Survival rate at discharge (65.2% vs. 68.7%) and at 90-day follow-up (64.5% vs. 67.2%) was not different between randomisation groups. In addition, there was no difference for the incidence of the composite endpoint survival, with good cerebral performance or mild or moderate disability (62.9% vs. 64.4%). These findings contradict previous observational studies that penalised a delayed invasive assessment of the coronary artery anatomy and justify both approaches in this setting. Conversely, the Complete vs. Culprit-Only RevascularisationStrategies to Treat Multivessel Disease after Early PCI for STEMI (COMPLETE) study confirmed the value of an aggressive revascularisation strategy in patients admitted with a STEMI. (2) In this study, 4 041 patients who had multivessel CAD were randomised in a 1:1 ratio to complete revascularisation vs. culprit-lesion-only PCI. At 3-year follow-up, the incidence of the composite endpoint cardiovascular death or myocardial infarction (MI) was lower in patients undergoing complete revascularisation as compared to the patients that had PCI only in the culprit vessel (7.8% vs. 10.5%; p=0.004). Of note, the benefit of complete revascularisation was similar in patients who had an in-hospital second procedure compared to a procedure following readmission within 45 days post-discharge; however, this comparison was not randomised, as the choice for timing of the second procedure was left to operator's discretion. The prognostic value of complete revascularisation in patients with non-STEMI has not been fully investigated yet.

show abstract

Physiological Pattern of Disease Assessed by Pressure-Wire Pullback Has an Influence on Fractional Flow Reserve/Instantaneous Wave-Free Ratio Discordance

Abstract: Supplemental Digital Content is available in the text.

Cited by 54 publications

References 21 publications

Non-hyperaemic pressure ratios to guide percutaneous coronary intervention

Non-hyperaemic pressure ratios to guide percutaneous coronary intervention

Vive la difference: Factors and mechanisms predicting discrepancy between iFR and FFR

The year in cardiology: coronary interventions

Contact Info

Product

Resources

About