The use of the acute <scp>P</scp>d/<scp>P</scp>a drop after intracoronary nitroglycerin infusion to rule out significant <scp>FFR</scp>: <scp>CANICA</scp> (Can intracoronary nitroglycerin predict fractional flow reserve without adenosine?) multicenter study

Martín-Reyes, Roberto; Peláez, Juan Antonio Franco; Palop, Ramón Lopéz; Arrieta, Miren Telleria; Santos, Ignacio J. Amat; Sáez, Pilar Carrillo; Sánchez‐Recalde, Ángel; Peña, Jamy Chanes; Camarero, Tamara García; Brugaletta, Salvatore; Carlos, Federico Gimeno de; Piñero, Antonio; Sanchez, D.C. Sorto; Frutos, Araceli; Larraya, Garikoitz Lasa; Navarro, Felipe; Farré, Jerónimo

doi:10.1002/ccd.25983

Cited by 12 publications

(11 citation statements)

References 16 publications

(19 reference statements)

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“…regadenoson (agonist of adenosine receptor A2A) [25], i.c. sodium nitroprusside [26], nicorandil [27], nitrates [28] and papaverine [17,29]. It is important to note that these substances are much less frequently used and thus, do not often appear in the protocols for large RCTs.…”

Section: Additional Aspects Of Ffr Measurement In Patients Presentingmentioning

confidence: 99%

Fractional flow reserve (FFR)-based therapy in patients presenting with acute coronary syndrome: Current data and everyday practice

Żuk¹,

Ciećwierz²,

Cwalina³

et al. 2017

Cardiol J

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Section: Additional Aspects Of Ffr Measurement In Patients Presentingmentioning

confidence: 99%

Fractional flow reserve (FFR)-based therapy in patients presenting with acute coronary syndrome: Current data and everyday practice

Żuk¹,

Ciećwierz²,

Cwalina³

et al. 2017

Cardiol J

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“…From these data, it would appear that a Pd/Pa-NTG>0.88 could be used to defer intervention and that an adenosine-FFR could be avoided in almost half of lesions encountered in routine practice. Unfortunately, based on the author's data scatterplot [2], the ability of Pd/Pa-NTG to identify a lesion with an FFR <0.80 appears weaker, with a Pd/Pa-NTG value of <0.83 required to have high specificity, at the cost of 25% false negatives.…”

mentioning

confidence: 92%

“…In this issue of Catheterization Cardiovascular Interventions, Martin-Reyes et al [2] measured baseline Pd/Pa, Pd/Pa after 0.2 mg intracoronary (IC) nitroglycerin (NTG), and FFR using intravenous adenosine in 283 patients (335 lesions). They found that the optimal cutoff values of resting Pd/Pa and Pd/ Pa-NTG to predict FFR>0.80 were >0.96 and >0.88, respectively.…”

mentioning

confidence: 99%

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On the search for an “easy” FFR: Submaximal hyperemia and NTG‐induced translesional pressure drop (Pd/Pa‐NTG)

Kern

Seto

2016

Cathet Cardio Intervent

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Key PointsEstimators of FFR that do not require adenosine hyperemia may increase the use of hemodynamic lesion assessment. This study shows that Pd/Pa of >0.88 after nitroglycerin bolus had a 95% sensitivity for an FFR >0.80, and could avoid adenosine in half of cases. Nitroglycerin hyperemia is novel but requires more study to be a surrogate for adenosine.Considered a standard in the cath lab for objective lesion assessment where angiography is known to be frequently inadequate, fraction flow reserve (FFR) remains underutilized. Barriers to FFR use have been addressed in numerous print and presentation forums. A consistent theme, often emphasized by those seeking to make FFR more "user-friendly" is the supposed dark side of adenosine. If only adenosine were not so (name your downside): difficult to mix, costly, time consuming, uncomfortable for the patient, and (rarely) potentially dangerous, FFR would be easier to perform and therefore would be used more often.The search for an easier FFR began several years ago with the introduction of adenosine-free, resting indices of lesion hemodynamics such as the instantaneous wave free ratio, iFR [1] and continued with discussions of basal stenosis resistance and resting Pd/Pa. The ability of resting Pd/Pa ratios or some variant thereof to accurately reflect FFR is controversial. Resting (and for iFR) purportedly minimal coronary resistance will decrease with even a mild degree of hyperemia producing a new value reducing confidence in their use. This expected physiologic response has led to investigations of sub-maximal hyperemic translesional pressure ratios as a step away from resting ratios and a step closer to the unvarnished FFR without requiring adenosine (Fig. 1).In this issue of Catheterization Cardiovascular Interventions, Martin-Reyes et al.[2] measured baseline Pd/Pa, Pd/Pa after 0.2 mg intracoronary (IC) nitroglycerin (NTG), and FFR using intravenous adenosine in 283 patients (335 lesions). They found that the optimal cutoff values of resting Pd/Pa and Pd/ Pa-NTG to predict FFR>0.80 were >0.96 and >0.88, respectively. Pd/Pa-NTG had high negative predictive value and sensitivity (96% and 95% for FFR>0.80).

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“…Hyperemic effects of these agents have long been known. Two encouraging studies demonstrated that measurement of the significance of intermediate stenoses was feasible by using contrast medium instead of adenosine [8, 9]. …”

Section: Introductionmentioning

confidence: 99%

Efficacy of coronary fractional flow reserve using contrast medium compared to adenosine

Topçu

Tanboğa

Aksakal

et al. 2016

pwki

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IntroductionCoronary fractional flow reserve (FFR) is recommended as the gold standard method in evaluating intermediate coronary stenoses. However, there are significant debates concerning the agents and the timing of the measurement.AimTo compare the contrast medium induced Pd/Pa ratio (CMR) with the FFR.Material and methodsWe enrolled 28 consecutive patients with 34 intermediate lesions who underwent coronary FFR measurement by intracoronary (i.c.) adenosine. After baseline Pd/Pa was calculated, a single contrast medium (Iomeron) injection of 6 ml (3 ml/s) was performed manually. Within 10 s after the contrast medium injection, the CMR was calculated. Bolus injection of i.c. adenosine was performed to induce maximal hyperemia (from 60 µg to 600 µg), and when it was ≤ 0.80, the intermediate lesion was considered as significant.ResultsAfter bolus i.c. adenosine, 12 lesions of 34 (35.3%) were identified as significant. The CMR value was 0.86 ±0.06 (range: 0.71–0.97). There were no significant differences between FFR and CMR values (p = 0.108). A substantial positive correlation between adenosine and contrast values was detected (0.886 and p < 0.001). Good agreement in Bland-Altman analysis was revealed (mean bias was 0.027, 95% confidence interval 0.038–0.092). Receiver operating characteristics curve analysis showed 90.9% sensitivity and 91.7% specificity for a cut-off value of 0.85 for the CMR compared to FFR (≤ 0.80).ConclusionsOur study showed that measuring the CMR is a feasible method compared to FFR. The CMR may be used in situations where adenosine cannot be administered.

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The use of the acute Pd/Pa drop after intracoronary nitroglycerin infusion to rule out significant FFR: CANICA (Can intracoronary nitroglycerin predict fractional flow reserve without adenosine?) multicenter study

Abstract: The cutoff value of acute Pd/Pa-NTG > 0.88 has a high NPV meaning adenosine-FFR can be avoided in almost half of lesions.

Cited by 12 publications

References 16 publications

Fractional flow reserve (FFR)-based therapy in patients presenting with acute coronary syndrome: Current data and everyday practice

Fractional flow reserve (FFR)-based therapy in patients presenting with acute coronary syndrome: Current data and everyday practice

On the search for an “easy” FFR: Submaximal hyperemia and NTG‐induced translesional pressure drop (Pd/Pa‐NTG)

Efficacy of coronary fractional flow reserve using contrast medium compared to adenosine

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