Prospective Assessment of the Diagnostic Accuracy of Instantaneous Wave-Free Ratio to Assess Coronary Stenosis Relevance

Escaned, Javier; Echavarría‐Pinto, Mauro; García‐García, Héctor M.; Hoef, Tim P. van der; Vries, Ton de; Kaul, Prashant; Raveendran, Ganesh; Altman, John D.; Kurz, Howard I.; Brechtken, Johannes; Tulli, Mark A.; Birgelen, Clemens von; Schneider, Joel E.; Khashaba, Ahmed; Jeremias, Allen; Baucum, Jim; Moreno, Raúl; Meuwissen, Martijn; Mishkel, Gregory; Geuns, Robert‐Jan van; Levite, Howard; Palop, Ramón Lopéz; Mayhew, Marc; Serruys, Patrick W.; Samady, Habib; Piek, Jan J.; Lerman, Amir

doi:10.1016/j.jcin.2015.01.029

Cited by 179 publications

(47 citation statements)

References 23 publications

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“…During the assessment of eligibility, further 6 studies were excluded. 8,[30][31][32][33][34] Finally, a total of 23 studies were available for the analysis, 7,[9][10][11][12][13][14][15][16][17][18][19][20][21]28,29,[35][36][37][38][39][40][41] including 6381 stenoses. The study selection procedure is reported in details in Figure 1 while the Table summarizes the most relevant characteristics of the selected studies.…”

Section: Resultsmentioning

confidence: 99%

Diagnostic Performance of the Instantaneous Wave-Free Ratio

Rosa

Polimeni

Petraco

et al. 2018

Circ: Cardiovascular Interventions

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Background— Aim of the present study was to perform a meta-analysis of all available studies comparing the instantaneous wave-free ratio (iFR) with fractional flow reserve (FFR). Methods and Results— Published trials comparing the iFR with FFR were searched for in PubMed, Google Scholar, and Scopus electronic databases. A total of 23 studies were available for the analysis, including 6381 stenoses. First, a meta-analysis of all studies was performed exploring the correlation between FFR and iFR. Interestingly, we found good correlation (0.798 [0.78–0.82]) between the 2 indices ( P <0.001). In addition, to evaluate the diagnostic performance of iFR to identify FFR-positive coronary stenoses, we performed an additional meta-analysis, summarizing the results of receiver operating characteristics analyses from individual studies reporting the area under the curve. Summing the results of these studies, we found that iFR has a good diagnostic performance for the identification of FFR-positive stenoses (area under the curve=0.88 [0.86–0.90]; P <0.001). Furthermore, our search results included 5 studies that compared iFR and FFR to a third independent reference standard. Interestingly, no significant differences between iFR and FFR were reported in those studies. Conclusions— The present meta-analysis shows that iFR significantly correlates with standard FFR and shows a good diagnostic performance in identifying FFR-positive coronary stenoses. Finally, iFR and FFR have similar diagnostic efficiency for detection of ischemia-inducing stenoses when tested against a third comparator.

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Section: Resultsmentioning

confidence: 99%

Diagnostic Performance of the Instantaneous Wave-Free Ratio

Rosa

Polimeni

Petraco

et al. 2018

Circ: Cardiovascular Interventions

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“…Several thresholds for pressure drift are proposed and used in core laboratory analyses. 7,8 Core laboratories apply a threshold of ±2 mm Hg, although the present study shows that it already causes severe reclassification. Unfortunately, data on the influence of pressure drift on physiological indices are lacking, and the present study provides valuable insight into a phenomenon frequently encountered by those performing these physiological measurements in clinical practice.…”

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confidence: 53%

Resting Indices of Coronary Lesion Severity

Lavieren

Piek

2016

Circ: Cardiovascular Interventions

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P hysiological guided percutaneous coronary intervention (PCI) has been demonstrated to result in a better clinical outcome compared with angiographic guidance alone. 1Pressure and Doppler-tipped guide wires that can be used for intracoronary physiological assessment were introduced >2 decades ago. Fractional flow reserve (FFR) has emerged as the most widely used physiological index in current clinical practice. This pressure-only index estimates the functional significance of a coronary stenosis by quantifying the transstenotic pressure ratio under hyperemic conditions 2 and has been well validated throughout the years.3 However, the prerequisite of inducing stable hyperemia is considered the main practical limitation of FFR measurements that has hampered its embedment in clinical practice. See Article by Cook et alMore recently, nonhyperemic pressure-derived indices were introduced to accommodate the need to further simplify physiological assessment; instantaneous wave-free ratio (iFR) and whole-cycle distal to proximal pressure ratio (Pd/Pa). Both indices make use of a trans-stenotic pressure gradient across a stenosis during resting conditions, obtained with conventional pressure wires and, in case of iFR, appropriate software. iFR assesses the pressure ratio in a particular part of the diastole, the wave-free period, where microvascular resistance is constant and minimal.4 Thereby, it relies on the same theoretical framework as FFR. Both iFR and whole-cycle Pd/Pa are shown to have equivalent diagnostic accuracy for the detection of ischemia-generating coronary stenoses when compared with FFR. 5These nonhyperemic pressure-derived indices rely on smaller differences in trans-stenotic pressure than FFR and are thereby more vulnerable to technical and procedural errors affecting distal and aortic pressure. These errors result in pressure drift that in general becomes overt at the end of the procedure when equality of signals is verified again with the pressure sensor located just inside the guiding catheter. Drift can be observed as an absolute or relative pressure offset between both signals, which can originate from drift of the pressure wire sensor and changes in aortic pressure. It may cause stenosis misclassification, especially when indices values are close to their cutoff values.In this issue of Circulation: Cardiovascular Interventions, Cook et al 6 report a single-center study in which they quantify the effect of clinically tolerated levels of pressure wire drift on the rates of reclassification with FFR, iFR, and wholecycle Pd/Pa. They enrolled 447 patients (447 stenoses) who underwent physiological stenosis severity assessments and conducted the measurements in a robust and standardized fashion, that is, by fixing the aortic pressure transducer and eliminating coronary artery spasm by the administration of 300 μg nitroglycerine before the procedure. Aortic and distal pressures were recorded during resting condition and stable hyperemia, using intravenous or intracoronary administration routes for ad...

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“…Compared to the FFR reference metric, alternative resting indices achieve a diagnostic accuracy of approximately 80% (80.4 and 82.5% from the RESOLVE and ADVISE-II analyses respectively) when compared to FFR [37, 38]. This interest has been prompted by the desire to avoid adenosine hyperaemia due to short-lived patient side-effects including flushing and dyspnoea, and the cost and limited availability of adenosine in some parts of the world.…”

Section: Resting Pressure Indicesmentioning

confidence: 99%

“…iFR ® was initially proposed by the ADVISE investigators as an adenosine-free test with a threshold of 0.83 being equivalent to the clinical FFR threshold of 0.80 [37, 40], however, research by the VERIFY investigators confirmed that iFR ® is lowered significantly when measured during intravenous adenosine infusion [41]. This threshold has since been revised to 0.89 with a diagnostic accuracy of around 82.5% [38]. Using a hybrid algorithm which incorporates hyperaemic FFR measurements, patients whose iFR ® falls in the 0.86–0.93 range receive adjunctive adenosine and undergo full FFR assessment due to diagnostic uncertainty in the so-called ‘adenosine zone’.…”

Section: Resting Pressure Indicesmentioning

confidence: 99%

Fractional flow reserve: a clinical perspective

Corcoran

Hennigan

Berry

2017

Int J Cardiovasc Imaging

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Fractional flow reserve (FFR) is a reference invasive diagnostic test to assess the physiological significance of an epicardial coronary artery stenosis. FFR-guided percutaneous coronary intervention in stable coronary artery disease has been assessed in three seminal clinical trials and the indications for FFR assessment are expanding into other clinical scenarios. In this article we review the theoretical, experimental and clinical basis for FFR measurement. We place FFR measurement in the context of the comprehensive invasive assessment of coronary physiology in patients presenting with known or suspected angina pectoris in daily clinical practice, and review the recent developments in FFR assessment.

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Prospective Assessment of the Diagnostic Accuracy of Instantaneous Wave-Free Ratio to Assess Coronary Stenosis Relevance

Cited by 179 publications

References 23 publications

Diagnostic Performance of the Instantaneous Wave-Free Ratio

Diagnostic Performance of the Instantaneous Wave-Free Ratio

Resting Indices of Coronary Lesion Severity

Fractional flow reserve: a clinical perspective

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