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Ullrich-Daub H, Olschewski M, Schnorbus B, Belhadj KA, Köhler T, Vosseler M, Münzel T, Gori T. Quantitative flow ratio or angiography for the assessment of non-culprit lesions in acute coronary syndromes, a randomized trial. Clin Res Cardiol 2025; 114:729-737. [PMID: 38980329 PMCID: PMC12089241 DOI: 10.1007/s00392-024-02484-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Accepted: 06/20/2024] [Indexed: 07/10/2024]
Abstract
BACKGROUND Patients undergoing percutaneous coronary intervention for acute coronary syndromes often have multivessel disease (MVD). Quantitative flow ratio (QFR) is an angiography-based technology that may help quantify the functional significance of non-culprit lesions, with the advantage that measurements are possible also once the patient is discharged from the catheterization laboratory. AIM Our two-center, randomized superiority trial aimed to test whether QFR, as compared to angiography, modifies the rate of non-culprit lesion interventions (primary functional endpoint) and improves the outcomes of patients with acute coronary syndromes and MVD (primary clinical endpoint). METHODS In total, 202 consecutive patients (64 [56-71] years of age, 160 men) with STEMI (n = 69 (34%)), NSTEMI (n = 94 (47%)), or unstable angina (n = 39 (19%)) and MVD who had undergone successful treatment of all culprit lesions were randomized 1:1 to angiography- vs. QFR-guided delayed revascularization of 246 non-culprit stenoses (1.2/patient). RESULTS The proportion of patients assigned to percutaneous intervention was not different between groups (angiography group: 45 (45%) vs. QFR: 56 (55%), P = 0.125; relative risk = 0.80 (0.60-1.06)). At 12 months, a primary clinical endpoint event (composite of death, nonfatal myocardial infarction, revascularization, and significant angina) occurred in 24 patients (angiography-guided) and 23 patients (QFR-guided; P = 0.637, HR = 1.16 [0.63-2.15]). None of its components was different between groups. DISCUSSION QFR guidance based on analysis of images from the primary intervention was not associated with a difference in the rate of non-culprit lesion staged revascularization nor in the 12-month incidence of clinical events in patients with acute coronary syndromes and multivessel disease. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Registry (NCT04808310).
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Affiliation(s)
- Helen Ullrich-Daub
- Department of Cardiology, Cardiology I, University Medical Center Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
- German Centre for Cardiovascular Research (DZHK), Standort RheinMain, Frankfurt, Germany
| | - Maximilian Olschewski
- Department of Cardiology, Cardiology I, University Medical Center Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
- German Centre for Cardiovascular Research (DZHK), Standort RheinMain, Frankfurt, Germany
| | | | - Khelifa-Anis Belhadj
- Department of Cardiology, Cardiology I, University Medical Center Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
- German Centre for Cardiovascular Research (DZHK), Standort RheinMain, Frankfurt, Germany
| | - Till Köhler
- Cardiopraxis Mainz and Ingelheim, Mainz, Germany
| | - Markus Vosseler
- Department of Cardiology, Cardiology I, University Medical Center Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Thomas Münzel
- Department of Cardiology, Cardiology I, University Medical Center Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
- German Centre for Cardiovascular Research (DZHK), Standort RheinMain, Frankfurt, Germany
| | - Tommaso Gori
- Department of Cardiology, Cardiology I, University Medical Center Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany.
- German Centre for Cardiovascular Research (DZHK), Standort RheinMain, Frankfurt, Germany.
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Xie Y, Cen H, Wang L, Cheng K, Huang L, Lu H, Ji L, Chen Y, Zhou Z, Yang Z, Jing S, Zhu H, Chen K, Chen S, He W. Relationships Between Inflammatory Parameters Derived From Complete Blood Count and Quantitative Flow Ratio in Patients With Stable Coronary Artery Disease. Angiology 2025; 76:51-57. [PMID: 37632217 DOI: 10.1177/00033197231197804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/27/2023]
Abstract
To investigate the relationships between inflammatory parameters, including neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), monocyte-to-lymphocyte ratio (MLR) and systemic immune-inflammation index (SII), and quantitative flow ratio (QFR) in stable coronary artery disease (CAD) patients (n = 450) enrolled in this cross-sectional study. Logistic regression was performed to evaluate the associations of NLR, PLR, MLR, and SII evaluated as continuous and binary variables with QFR ≤0.80. When treated as continuous variables, lnNLR was associated with QFR ≤0.80 with borderline significance in univariable (odds ratio (OR) = 1.60, p = .05) and multivariable analysis (OR = 1.72, p = .05), while lnMLR was associated with QFR ≤0.80 significantly in univariable analysis (OR = 1.87, p = .03) and with borderline significance in multivariable analysis (OR = 1.91, p = .05). When treated as binary variables, high levels of MLR and SII were significantly associated with QFR ≤0.80 in univariable (MLR: OR = 1.91, p = .02; SII: OR = 2.42, p = .006) and multivariable analysis (MLR: OR = 1.83, p = .04; SII: OR = 2.19, p = .02). NLR, MLR, and SII, but not PLR, were significantly associated with the severity of coronary physiology in stable CAD patients.
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Affiliation(s)
- Yanqing Xie
- Department of Cardiology, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
- Institute of Geriatrics, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Han Cen
- Institute of Geriatrics, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
- Clinical Research Centre, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Li Wang
- Department of Cardiology, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Keai Cheng
- Department of Cardiology, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Li Huang
- Department of Emergency Intensive Care Unit, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Haoxuan Lu
- Department of Cardiology, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Lili Ji
- Department of Cardiology, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Yudan Chen
- Department of Cardiology, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Zhong Zhou
- Department of Cardiology, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Zhuo Yang
- Department of Cardiology, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Sheng Jing
- Department of Cardiology, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Haibo Zhu
- Department of Cardiology, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Kan Chen
- Department of Cardiology, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Si Chen
- Department of Cardiology, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Wenming He
- Department of Cardiology, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
- Institute of Geriatrics, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
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Grib A, Abras M, Surev A, Grib L. Fractional Flow Reserve Implications for Clinical Decision Making in Coronary Artery Disease. Life (Basel) 2024; 14:1326. [PMID: 39459626 PMCID: PMC11509863 DOI: 10.3390/life14101326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2024] [Revised: 10/13/2024] [Accepted: 10/15/2024] [Indexed: 10/28/2024] Open
Abstract
Fractional flow reserve (FFR) is regarded as the gold standard for assessing the functional significance of coronary artery lesions. However, its utilization in clinical practice remains limited. This study aims to determine whether FFR results can influence treatment decisions for coronary artery disease compared to visual assessments of angiographic images. We conducted a retrospective study involving 63 patients diagnosed with either chronic coronary syndrome (n = 39, 61.9%) or acute coronary syndrome (n = 24, 38.1%) who underwent an FFR assessment. Three experienced interventional cardiologists (>300 PCI procedures/year) reevaluated 105 ambiguous coronary lesions in these patients, blinded to the FFR results. The objective was to assess lesion significance and determine the treatment strategy based on a visual angiographic evaluation. The three operators reached concordant agreement (≥two operators) to perform PCI in 60 (57.1%) of the evaluated lesions based on the angiographic assessment. Of these, nine lesions (15%) were deemed functionally non-significant by FFR (FFR > 0.80). Conversely, they agreed to defer PCI in 45 (42.9%) lesions, but 4 lesions (8.9%) were found to be functionally significant (FFR ≤ 0.80) and required a re-evaluation for PCI. Visual-guided decision making by interventional cardiologists shows variability and does not always align with the functional significance of coronary lesions as determined by FFR. Incorporating FFR into routine decision making could enhance treatment accuracy and patient outcomes.
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Affiliation(s)
- Andrei Grib
- Discipline of Cardiology, State University of Medicine and Pharmacy “Nicolae Testemitanu”, MD 2004 Chisinau, Moldova (L.G.)
| | - Marcel Abras
- Discipline of Cardiology, State University of Medicine and Pharmacy “Nicolae Testemitanu”, MD 2004 Chisinau, Moldova (L.G.)
| | - Artiom Surev
- Institute of Cardiology, MD 2025 Chisinau, Moldova
| | - Livi Grib
- Discipline of Cardiology, State University of Medicine and Pharmacy “Nicolae Testemitanu”, MD 2004 Chisinau, Moldova (L.G.)
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Kobayashi Y, Lønborg J, Jong A, Nishi T, De Bruyne B, Høfsten DE, Kelbæk H, Layland J, Nam CW, Pijls NH, Tonino PA, Warnøe J, Oldroyd KG, Berry C, Engstrøm T, Fearon WF. Prognostic Value of the Residual SYNTAX Score After Functionally Complete Revascularization in ACS. J Am Coll Cardiol 2018; 72:1321-1329. [DOI: 10.1016/j.jacc.2018.06.069] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 06/17/2018] [Accepted: 06/20/2018] [Indexed: 11/29/2022]
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Ahmed N, Layland J, Carrick D, Petrie MC, McEntegart M, Eteiba H, Hood S, Lindsay M, Watkins S, Davie A, Mahrous A, Carberry J, Teng V, McConnachie A, Curzen N, Oldroyd KG, Berry C. Safety of guidewire-based measurement of fractional flow reserve and the index of microvascular resistance using intravenous adenosine in patients with acute or recent myocardial infarction. Int J Cardiol 2016; 202:305-10. [PMID: 26418191 PMCID: PMC4669307 DOI: 10.1016/j.ijcard.2015.09.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Revised: 07/27/2015] [Accepted: 09/14/2015] [Indexed: 12/19/2022]
Abstract
AIMS Coronary guidewire-based diagnostic assessments with hyperemia may cause iatrogenic complications. We assessed the safety of guidewire-based measurement of coronary physiology, using intravenous adenosine, in patients with an acute coronary syndrome. METHODS We prospectively enrolled invasively managed STEMI and NSTEMI patients in two simultaneously conducted studies in 6 centers (NCT01764334; NCT02072850). All of the participants underwent a diagnostic coronary guidewire study using intravenous adenosine (140 μg/kg/min) infusion for 1-2 min. The patients were prospectively assessed for the occurrence of serious adverse events (SAEs) and symptoms and invasively measured hemodynamics were also recorded. RESULTS 648 patients (n=298 STEMI patients in 1 hospital; mean time to reperfusion 253 min; n=350 NSTEMI in 6 hospitals; median time to angiography from index chest pain episode 3 (2, 5) days) were included between March 2011 and May 2013. Two NSTEMI patients (0.3% overall) experienced a coronary dissection related to the guidewire. No guidewire dissections occurred in the STEMI patients. Chest symptoms were reported in the majority (86%) of patient's symptoms during the adenosine infusion. No serious adverse events occurred during infusion of adenosine and all of the symptoms resolved after the infusion ceased. CONCLUSIONS In this multicenter analysis, guidewire-based measurement of FFR and IMR using intravenous adenosine was safe in patients following STEMI or NSTEMI. Self-limiting symptoms were common but not associated with serious adverse events. Finally, coronary dissection in STEMI and NSTEMI patients was noted to be a rare phenomenon.
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Affiliation(s)
- Nadeem Ahmed
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow G12 8QQ, Scotland, UK; Department of Cardiology, Golden Jubilee National Hospital, Glasgow G81 4DY, Scotland, UK
| | - Jamie Layland
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow G12 8QQ, Scotland, UK; Department of Cardiology, Golden Jubilee National Hospital, Glasgow G81 4DY, Scotland, UK
| | - David Carrick
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow G12 8QQ, Scotland, UK; Department of Cardiology, Golden Jubilee National Hospital, Glasgow G81 4DY, Scotland, UK
| | - Mark C Petrie
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow G12 8QQ, Scotland, UK; Department of Cardiology, Golden Jubilee National Hospital, Glasgow G81 4DY, Scotland, UK
| | - Margaret McEntegart
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow G12 8QQ, Scotland, UK; Department of Cardiology, Golden Jubilee National Hospital, Glasgow G81 4DY, Scotland, UK
| | - Hany Eteiba
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow G12 8QQ, Scotland, UK; Department of Cardiology, Golden Jubilee National Hospital, Glasgow G81 4DY, Scotland, UK
| | - Stuart Hood
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow G12 8QQ, Scotland, UK; Department of Cardiology, Golden Jubilee National Hospital, Glasgow G81 4DY, Scotland, UK
| | - Mitchell Lindsay
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow G12 8QQ, Scotland, UK; Department of Cardiology, Golden Jubilee National Hospital, Glasgow G81 4DY, Scotland, UK
| | - Stuart Watkins
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow G12 8QQ, Scotland, UK; Department of Cardiology, Golden Jubilee National Hospital, Glasgow G81 4DY, Scotland, UK
| | - Andrew Davie
- Department of Cardiology, Golden Jubilee National Hospital, Glasgow G81 4DY, Scotland, UK
| | - Ahmed Mahrous
- Department of Cardiology, Golden Jubilee National Hospital, Glasgow G81 4DY, Scotland, UK
| | - Jaclyn Carberry
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow G12 8QQ, Scotland, UK
| | - Vannesa Teng
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow G12 8QQ, Scotland, UK
| | - Alex McConnachie
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, Scotland, UK
| | - Nick Curzen
- University Hospital Southampton Foundation Trust, Southampton, UK; Faculty of Medicine, University of Southampton, Southampton, UK
| | - Keith G Oldroyd
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow G12 8QQ, Scotland, UK; Department of Cardiology, Golden Jubilee National Hospital, Glasgow G81 4DY, Scotland, UK
| | - Colin Berry
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow G12 8QQ, Scotland, UK; Department of Cardiology, Golden Jubilee National Hospital, Glasgow G81 4DY, Scotland, UK.
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Berry C, Corcoran D, Hennigan B, Watkins S, Layland J, Oldroyd KG. Fractional flow reserve-guided management in stable coronary disease and acute myocardial infarction: recent developments. Eur Heart J 2015; 36:3155-64. [PMID: 26038588 PMCID: PMC4816759 DOI: 10.1093/eurheartj/ehv206] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 04/09/2015] [Accepted: 05/03/2015] [Indexed: 01/10/2023] Open
Abstract
Coronary artery disease (CAD) is a leading global cause of morbidity and mortality, and improvements in the diagnosis and treatment of CAD can reduce the health and economic burden of this condition. Fractional flow reserve (FFR) is an evidence-based diagnostic test of the physiological significance of a coronary artery stenosis. Fractional flow reserve is a pressure-derived index of the maximal achievable myocardial blood flow in the presence of an epicardial coronary stenosis as a ratio to maximum achievable flow if that artery were normal. When compared with standard angiography-guided management, FFR disclosure is impactful on the decision for revascularization and clinical outcomes. In this article, we review recent developments with FFR in patients with stable CAD and recent myocardial infarction. Specifically, we review novel developments in our understanding of CAD pathophysiology, diagnostic applications, prognostic studies, clinical trials, and clinical guidelines.
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Affiliation(s)
- Colin Berry
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, UK BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, Glasgow G12 8TA, UK
| | - David Corcoran
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, UK BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, Glasgow G12 8TA, UK
| | - Barry Hennigan
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, UK
| | - Stuart Watkins
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, UK
| | | | - Keith G Oldroyd
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, UK
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Li S, Tang X, Peng L, Luo Y, Dong R, Liu J. The diagnostic performance of CT-derived fractional flow reserve for evaluation of myocardial ischaemia confirmed by invasive fractional flow reserve: a meta-analysis. Clin Radiol 2015; 70:476-86. [DOI: 10.1016/j.crad.2014.12.013] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Revised: 12/12/2014] [Accepted: 12/18/2014] [Indexed: 11/28/2022]
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Buch AN, Chen C, Ferguson TB. Revascularization for stable ischemic heart disease: are there new parallels between percutaneous coronary intervention and coronary artery bypass grafting? Interv Cardiol 2015. [DOI: 10.2217/ica.14.76] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
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Ruparelia N, Kharbanda RK. Role of coronary physiology in the contemporary management of coronary artery disease. World J Clin Cases 2015; 3:148-155. [PMID: 25685761 PMCID: PMC4317608 DOI: 10.12998/wjcc.v3.i2.148] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2014] [Revised: 10/19/2014] [Accepted: 10/29/2014] [Indexed: 02/05/2023] Open
Abstract
Coronary artery disease (CAD) remains the leading cause of death worldwide with approximately 1 in 30 patients with stable CAD experiencing death or acute myocardial infarction each year. The presence and extent of resultant myocardial ischaemia has been shown to confer an increased risk of adverse outcomes. Whilst, optimal medical therapy (OMT) forms the cornerstone of the management of patients with stable CAD, a significant number of patients present with ischaemia refractory to OMT. Historically coronary angiography alone has been used to determine coronary lesion severity in both stable and acute settings. It is increasingly clear that this approach fails to accurately identify the haemodynamic significance of lesions; especially those that are visually “intermediate” in severity. Revascularisation based upon angiographic appearances alone may not reduce coronary events above OMT. Technological advances have enabled the measurement of physiological indices including the fractional flow reserve, the index of microcirculatory resistance and the coronary flow reserve. The integration of these parameters into the routine management of patients presenting to the cardiac catheterization laboratory with CAD represents a critical adjunctive tool in the optimal management of these patients by identifying patients that would most benefit from revascularisation and importantly also highlighting patients that would not gain benefit and therefore reducing the likelihood of adverse outcomes associated with coronary revascularisation. Furthermore, these techniques are applicable to a broad range of patients including those with left main stem disease, proximal coronary disease, diabetes mellitus, previous percutaneous coronary intervention and with previous coronary artery bypass grafting. This review will discuss current concepts relevant to coronary physiology assessment, its role in the management of both stable and acute patients and future applications.
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Corcoran D, Berry C, Oldroyd K. Current frontiers in the clinical research of coronary physiology. Interv Cardiol 2015. [DOI: 10.2217/ica.14.68] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
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Layland J, Oldroyd KG, Curzen N, Sood A, Balachandran K, Das R, Junejo S, Ahmed N, Lee MMY, Shaukat A, O'Donnell A, Nam J, Briggs A, Henderson R, McConnachie A, Berry C. Fractional flow reserve vs. angiography in guiding management to optimize outcomes in non-ST-segment elevation myocardial infarction: the British Heart Foundation FAMOUS-NSTEMI randomized trial. Eur Heart J 2015; 36:100-11. [PMID: 25179764 PMCID: PMC4291317 DOI: 10.1093/eurheartj/ehu338] [Citation(s) in RCA: 230] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Revised: 07/18/2014] [Accepted: 08/01/2014] [Indexed: 12/17/2022] Open
Abstract
AIM We assessed the management and outcomes of non-ST segment elevation myocardial infarction (NSTEMI) patients randomly assigned to fractional flow reserve (FFR)-guided management or angiography-guided standard care. METHODS AND RESULTS We conducted a prospective, multicentre, parallel group, 1 : 1 randomized, controlled trial in 350 NSTEMI patients with ≥1 coronary stenosis ≥30% of the lumen diameter assessed visually (threshold for FFR measurement) (NCT01764334). Enrolment took place in six UK hospitals from October 2011 to May 2013. Fractional flow reserve was disclosed to the operator in the FFR-guided group (n = 176). Fractional flow reserve was measured but not disclosed in the angiography-guided group (n = 174). Fractional flow reserve ≤0.80 was an indication for revascularization by percutaneous coronary intervention (PCI) or coronary artery bypass surgery (CABG). The median (IQR) time from the index episode of myocardial ischaemia to angiography was 3 (2, 5) days. For the primary outcome, the proportion of patients treated initially by medical therapy was higher in the FFR-guided group than in the angiography-guided group [40 (22.7%) vs. 23 (13.2%), difference 95% (95% CI: 1.4%, 17.7%), P = 0.022]. Fractional flow reserve disclosure resulted in a change in treatment between medical therapy, PCI or CABG in 38 (21.6%) patients. At 12 months, revascularization remained lower in the FFR-guided group [79.0 vs. 86.8%, difference 7.8% (-0.2%, 15.8%), P = 0.054]. There were no statistically significant differences in health outcomes and quality of life between the groups. CONCLUSION In NSTEMI patients, angiography-guided management was associated with higher rates of coronary revascularization compared with FFR-guided management. A larger trial is necessary to assess health outcomes and cost-effectiveness.
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Affiliation(s)
- Jamie Layland
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, UK BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, Glasgow G12 8TA, UK
| | - Keith G Oldroyd
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, UK
| | - Nick Curzen
- University Hospital Southampton Foundation Trust, Southampton, UK
| | | | | | - Raj Das
- Freeman Hospital, Newcastle, UK
| | - Shahid Junejo
- City Hospitals Sunderland Foundation Trust, Sunderland, UK
| | - Nadeem Ahmed
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, UK
| | - Matthew M Y Lee
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, UK
| | - Aadil Shaukat
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, UK
| | - Anna O'Donnell
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, UK
| | - Julian Nam
- Health Economics and Health Technology Assessment Unit, University of Glasgow, Glasgow, UK
| | - Andrew Briggs
- Health Economics and Health Technology Assessment Unit, University of Glasgow, Glasgow, UK
| | - Robert Henderson
- Trent Cardiac Centre, Nottingham University Hospitals, Nottingham, UK
| | | | - Colin Berry
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, UK BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, Glasgow G12 8TA, UK
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Elgendy IY, Conti CR, Bavry AA. Fractional flow reserve: an updated review. Clin Cardiol 2014; 37:371-380. [PMID: 24652785 PMCID: PMC6649528 DOI: 10.1002/clc.22273] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2013] [Revised: 02/18/2014] [Indexed: 01/10/2023] Open
Abstract
Revascularization of ischemia-producing coronary lesions is widely used in the management of coronary artery disease. However, some coronary lesions appear significant on the conventional angiogram when they are truly non-flow limiting. For this reason, it is becoming increasingly important to determine the coronary physiology. Fractional flow reserve (FFR) has emerged as a useful tool to determine the lesions that require revascularization. Measurement of FFR during invasive coronary angiography now has a class IA indication from the European Society of Cardiology for identifying hemodynamically significant coronary lesions when noninvasive evidence of myocardial ischemia is unavailable. Current data on FFR can be broadly classified into studies that compare the diagnostic accuracy of FFR measurement compared with other noninvasive modalities and studies that test treatment strategies of patients with intermediate coronary stenoses using a threshold value for FFR and that have clinical outcomes as endpoints. In this review, we will discuss the concept of FFR, current evidence supporting its usage, and future perspectives.
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Affiliation(s)
- Islam Y. Elgendy
- Department of MedicineUniversity of Florida College of MedicineGainesvilleFlorida
| | - C. Richard Conti
- Division of Cardiovascular MedicineUniversity of Florida College of MedicineGainesvilleFlorida
| | - Anthony A. Bavry
- Division of Cardiovascular MedicineUniversity of Florida College of MedicineGainesvilleFlorida
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13
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Curzen N, Rana O, Nicholas Z, Golledge P, Zaman A, Oldroyd K, Hanratty C, Banning A, Wheatcroft S, Hobson A, Chitkara K, Hildick-Smith D, McKenzie D, Calver A, Dimitrov BD, Corbett S. Does Routine Pressure Wire Assessment Influence Management Strategy at Coronary Angiography for Diagnosis of Chest Pain? Circ Cardiovasc Interv 2014; 7:248-55. [DOI: 10.1161/circinterventions.113.000978] [Citation(s) in RCA: 201] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Nick Curzen
- From University Hospitals Southampton NHS Foundation Trust, Southampton, United Kingdom (N.C., O.R., Z.N., P.G., A.C., S.C.); Faculty of Medicine, University of Southampton, Southampton, United Kingdom (N.C., B.D.D.); Freeman Hospital, Newcastle upon Tyne, and Newcastle University, Tyne and Wear, United Kingdom (A.Z.); Golden Jubilee Hospital, Glasgow, United Kingdom (K.O.); Belfast City Hospital, Belfast, United Kingdom (C.H.); John Radcliffe Hospital, Oxford, United Kingdom (A.B.); Leeds General
| | - Omar Rana
- From University Hospitals Southampton NHS Foundation Trust, Southampton, United Kingdom (N.C., O.R., Z.N., P.G., A.C., S.C.); Faculty of Medicine, University of Southampton, Southampton, United Kingdom (N.C., B.D.D.); Freeman Hospital, Newcastle upon Tyne, and Newcastle University, Tyne and Wear, United Kingdom (A.Z.); Golden Jubilee Hospital, Glasgow, United Kingdom (K.O.); Belfast City Hospital, Belfast, United Kingdom (C.H.); John Radcliffe Hospital, Oxford, United Kingdom (A.B.); Leeds General
| | - Zoe Nicholas
- From University Hospitals Southampton NHS Foundation Trust, Southampton, United Kingdom (N.C., O.R., Z.N., P.G., A.C., S.C.); Faculty of Medicine, University of Southampton, Southampton, United Kingdom (N.C., B.D.D.); Freeman Hospital, Newcastle upon Tyne, and Newcastle University, Tyne and Wear, United Kingdom (A.Z.); Golden Jubilee Hospital, Glasgow, United Kingdom (K.O.); Belfast City Hospital, Belfast, United Kingdom (C.H.); John Radcliffe Hospital, Oxford, United Kingdom (A.B.); Leeds General
| | - Peter Golledge
- From University Hospitals Southampton NHS Foundation Trust, Southampton, United Kingdom (N.C., O.R., Z.N., P.G., A.C., S.C.); Faculty of Medicine, University of Southampton, Southampton, United Kingdom (N.C., B.D.D.); Freeman Hospital, Newcastle upon Tyne, and Newcastle University, Tyne and Wear, United Kingdom (A.Z.); Golden Jubilee Hospital, Glasgow, United Kingdom (K.O.); Belfast City Hospital, Belfast, United Kingdom (C.H.); John Radcliffe Hospital, Oxford, United Kingdom (A.B.); Leeds General
| | - Azfar Zaman
- From University Hospitals Southampton NHS Foundation Trust, Southampton, United Kingdom (N.C., O.R., Z.N., P.G., A.C., S.C.); Faculty of Medicine, University of Southampton, Southampton, United Kingdom (N.C., B.D.D.); Freeman Hospital, Newcastle upon Tyne, and Newcastle University, Tyne and Wear, United Kingdom (A.Z.); Golden Jubilee Hospital, Glasgow, United Kingdom (K.O.); Belfast City Hospital, Belfast, United Kingdom (C.H.); John Radcliffe Hospital, Oxford, United Kingdom (A.B.); Leeds General
| | - Keith Oldroyd
- From University Hospitals Southampton NHS Foundation Trust, Southampton, United Kingdom (N.C., O.R., Z.N., P.G., A.C., S.C.); Faculty of Medicine, University of Southampton, Southampton, United Kingdom (N.C., B.D.D.); Freeman Hospital, Newcastle upon Tyne, and Newcastle University, Tyne and Wear, United Kingdom (A.Z.); Golden Jubilee Hospital, Glasgow, United Kingdom (K.O.); Belfast City Hospital, Belfast, United Kingdom (C.H.); John Radcliffe Hospital, Oxford, United Kingdom (A.B.); Leeds General
| | - Colm Hanratty
- From University Hospitals Southampton NHS Foundation Trust, Southampton, United Kingdom (N.C., O.R., Z.N., P.G., A.C., S.C.); Faculty of Medicine, University of Southampton, Southampton, United Kingdom (N.C., B.D.D.); Freeman Hospital, Newcastle upon Tyne, and Newcastle University, Tyne and Wear, United Kingdom (A.Z.); Golden Jubilee Hospital, Glasgow, United Kingdom (K.O.); Belfast City Hospital, Belfast, United Kingdom (C.H.); John Radcliffe Hospital, Oxford, United Kingdom (A.B.); Leeds General
| | - Adrian Banning
- From University Hospitals Southampton NHS Foundation Trust, Southampton, United Kingdom (N.C., O.R., Z.N., P.G., A.C., S.C.); Faculty of Medicine, University of Southampton, Southampton, United Kingdom (N.C., B.D.D.); Freeman Hospital, Newcastle upon Tyne, and Newcastle University, Tyne and Wear, United Kingdom (A.Z.); Golden Jubilee Hospital, Glasgow, United Kingdom (K.O.); Belfast City Hospital, Belfast, United Kingdom (C.H.); John Radcliffe Hospital, Oxford, United Kingdom (A.B.); Leeds General
| | - Stephen Wheatcroft
- From University Hospitals Southampton NHS Foundation Trust, Southampton, United Kingdom (N.C., O.R., Z.N., P.G., A.C., S.C.); Faculty of Medicine, University of Southampton, Southampton, United Kingdom (N.C., B.D.D.); Freeman Hospital, Newcastle upon Tyne, and Newcastle University, Tyne and Wear, United Kingdom (A.Z.); Golden Jubilee Hospital, Glasgow, United Kingdom (K.O.); Belfast City Hospital, Belfast, United Kingdom (C.H.); John Radcliffe Hospital, Oxford, United Kingdom (A.B.); Leeds General
| | - Alex Hobson
- From University Hospitals Southampton NHS Foundation Trust, Southampton, United Kingdom (N.C., O.R., Z.N., P.G., A.C., S.C.); Faculty of Medicine, University of Southampton, Southampton, United Kingdom (N.C., B.D.D.); Freeman Hospital, Newcastle upon Tyne, and Newcastle University, Tyne and Wear, United Kingdom (A.Z.); Golden Jubilee Hospital, Glasgow, United Kingdom (K.O.); Belfast City Hospital, Belfast, United Kingdom (C.H.); John Radcliffe Hospital, Oxford, United Kingdom (A.B.); Leeds General
| | - Kam Chitkara
- From University Hospitals Southampton NHS Foundation Trust, Southampton, United Kingdom (N.C., O.R., Z.N., P.G., A.C., S.C.); Faculty of Medicine, University of Southampton, Southampton, United Kingdom (N.C., B.D.D.); Freeman Hospital, Newcastle upon Tyne, and Newcastle University, Tyne and Wear, United Kingdom (A.Z.); Golden Jubilee Hospital, Glasgow, United Kingdom (K.O.); Belfast City Hospital, Belfast, United Kingdom (C.H.); John Radcliffe Hospital, Oxford, United Kingdom (A.B.); Leeds General
| | - David Hildick-Smith
- From University Hospitals Southampton NHS Foundation Trust, Southampton, United Kingdom (N.C., O.R., Z.N., P.G., A.C., S.C.); Faculty of Medicine, University of Southampton, Southampton, United Kingdom (N.C., B.D.D.); Freeman Hospital, Newcastle upon Tyne, and Newcastle University, Tyne and Wear, United Kingdom (A.Z.); Golden Jubilee Hospital, Glasgow, United Kingdom (K.O.); Belfast City Hospital, Belfast, United Kingdom (C.H.); John Radcliffe Hospital, Oxford, United Kingdom (A.B.); Leeds General
| | - Dan McKenzie
- From University Hospitals Southampton NHS Foundation Trust, Southampton, United Kingdom (N.C., O.R., Z.N., P.G., A.C., S.C.); Faculty of Medicine, University of Southampton, Southampton, United Kingdom (N.C., B.D.D.); Freeman Hospital, Newcastle upon Tyne, and Newcastle University, Tyne and Wear, United Kingdom (A.Z.); Golden Jubilee Hospital, Glasgow, United Kingdom (K.O.); Belfast City Hospital, Belfast, United Kingdom (C.H.); John Radcliffe Hospital, Oxford, United Kingdom (A.B.); Leeds General
| | - Alison Calver
- From University Hospitals Southampton NHS Foundation Trust, Southampton, United Kingdom (N.C., O.R., Z.N., P.G., A.C., S.C.); Faculty of Medicine, University of Southampton, Southampton, United Kingdom (N.C., B.D.D.); Freeman Hospital, Newcastle upon Tyne, and Newcastle University, Tyne and Wear, United Kingdom (A.Z.); Golden Jubilee Hospital, Glasgow, United Kingdom (K.O.); Belfast City Hospital, Belfast, United Kingdom (C.H.); John Radcliffe Hospital, Oxford, United Kingdom (A.B.); Leeds General
| | - Borislav D. Dimitrov
- From University Hospitals Southampton NHS Foundation Trust, Southampton, United Kingdom (N.C., O.R., Z.N., P.G., A.C., S.C.); Faculty of Medicine, University of Southampton, Southampton, United Kingdom (N.C., B.D.D.); Freeman Hospital, Newcastle upon Tyne, and Newcastle University, Tyne and Wear, United Kingdom (A.Z.); Golden Jubilee Hospital, Glasgow, United Kingdom (K.O.); Belfast City Hospital, Belfast, United Kingdom (C.H.); John Radcliffe Hospital, Oxford, United Kingdom (A.B.); Leeds General
| | - Simon Corbett
- From University Hospitals Southampton NHS Foundation Trust, Southampton, United Kingdom (N.C., O.R., Z.N., P.G., A.C., S.C.); Faculty of Medicine, University of Southampton, Southampton, United Kingdom (N.C., B.D.D.); Freeman Hospital, Newcastle upon Tyne, and Newcastle University, Tyne and Wear, United Kingdom (A.Z.); Golden Jubilee Hospital, Glasgow, United Kingdom (K.O.); Belfast City Hospital, Belfast, United Kingdom (C.H.); John Radcliffe Hospital, Oxford, United Kingdom (A.B.); Leeds General
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