Prediction of fractional flow reserve with angiographic DILEMMA score

Abstract

Objective:Angiographic assessment of stenosis has limited predictive value for functionally significant lesions compared with fractional flow reserve (FFR). The recently developed angiographic DILEMMA score, which consists of minimal lumen diameter (MLD), lesion length (LL) and Bypass Angioplasty Revascularization Investigation (BARI) Myocardial Jeopardy Index (MJI) was found to have diagnostic value in predicting FFR ≤0.80. The present study was an investigation of prediction of FFR ≤0.80 using DILEMMA score and its relationship to resting distal coronary artery pressure/aortic pressure (Pd/Pa).Methods:Records of consecutive patients who underwent coronary angiography and FFR were retrospectively analyzed. Assessment of MLD and LL was performed using quantitative coronary angiography. BARI MJI was calculated using angiographic calculation index.Results:A total of 185 pressure wire analysis data sets from 150 patients were analyzed retrospectively. There were 82 lesions in FFR >0.80 group and 103 lesions in FFR ≤0.80 group. Negative correlation was found between FFR and DILEMMA score (r=-0.494; p<0.001), FFR and BARI-MJI (r=-0.378; p<0.001), and between FFR and LL (r=-0.314; p<0.001). Positive correlation was found between FFR and baseline Pd/Pa (r=0.713; p<0.001), and between FFR and MLD (r=0.415; p<0.001). DILEMMA score had negative correlation with resting Pd/Pa (r=-0.389; p<0.001). In receiver operating characteristic analysis for diagnosing FFR≤0.80, area under curve values of resting Pd/Pa, DILEMMA score, MLD, BARI-MJI, and LL were 0.862, 0.793, 0.780, 0.728, and 0.686, respectively.Conclusion:DILEMMA score had moderately strong correlation with FFR and good accuracy in diagnosing significant FFR, but it had weak correlation with resting Pd/Pa. (Anatol J Cardiol 2017; 17: 285-92)

Application of the DILEMMA score to improve lesion selection for invasive physiological assessment

“…This, however, is largely mitigated as each of the constituents of the scoring tool is a whole integer representing a range of measurements. This minimizes interobserver variability, which was notably excellent in this study (ICC of 0.96), consistent with the two previous studies . Of note, one of these studies performed extensive analysis to address interobserver and intraobserver variability using 185 lesions demonstrating ICC of 0.97 and 0.98, respectively.…”

“…The interobserver variability of the DILEMMA score was performed by two study investigators on 30 randomly selected lesions. The intraclass correlation coefficient (ICC) was 0.96 (95% CI 0.84–0.99), which was consistent with previous reports . The mean time for DILEMMA score calculation (performed on 30 lesions) was 5 min and 24 sec per lesion.…”

“…We have previously described the DILEMMA score, a simple angiographic scoring tool that strongly correlates with FFR and incorporates MLD, LL and the Bypass Angioplasty Revascularization Investigation Myocardial Jeopardy Index (BARI MJI) (reflecting the percentage of myocardium potentially compromised by a lesion) to provide its user a score from 0 to 12. Importantly, a DILEMMA score of ≤2 has demonstrated an excellent negative predictive value for identifying lesions with FFR >0.80 and conversely, a score ≥ 9 had an excellent positive predictive value for lesions with FFR ≤0.80 . Lesions with a score of 3–8 are considered “gray‐zone” and warrant further assessment.…”

“…Importantly, a DILEMMA score of ≤2 has demonstrated an excellent negative predictive value for identifying lesions with FFR >0.80 and conversely, a score ≥ 9 had an excellent positive predictive value for lesions with FFR ≤0.80. 10,13 Lesions with a score of 3-8 are considered "gray-zone" and warrant further assessment. The DILEMMA score was derived and validated with a retrospective, single-center cohort and given this, its wider applicability remains uncertain.…”

Pooled diagnostic accuracy of resting distal to aortic coronary pressure referenced to fractional flow reserve: The importance of resting coronary physiology

“…Both markers aim to minimize the pressure effect of the microcirculation by achieving maximal vasodilation in the case of FFR and, in the case of iFR, to isolate the gradient across a coronary lesion during the wave‐free period of diastole when coronary flow is not impacted by compression or decompression of the microcirculation. Pd/Pa has not yet been investigated in randomized outcomes trials, but multiple diagnostic accuracy studies have been performed . Our meta‐analysis examines the overall diagnostic accuracy of Pd/Pa referenced to FFR to determine its suitability for investigation as a physiology measurement to guide coronary revascularization.…”