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1.
Catheter Cardiovasc Interv ; 101(6): 1045-1052, 2023 05.
Article in English | MEDLINE | ID: mdl-36934387

ABSTRACT

OBJECTIVES: We aimed to evaluate the diagnostic accuracy of quantitative flow ratio (QFR) in left main (LM) coronary stenoses, using Fractional Flow Reserve (FFR) as reference. BACKGROUND: QFR has demonstrated a high accuracy in determining the functional relevance of coronary stenoses in non-LM. However, there is an important paucity of data regarding its diagnostic value in the specific anatomical subset of LM disease. METHODS: This is a retrospective, observational, multicenter, international, and blinded study including patients with LM stenoses. Cases with significant ostial LM disease were excluded. QFR was calculated from conventional angiograms at blinded fashion with respect to FFR. RESULTS: Sixty-seven patients with LM stenoses were analyzed. Overall, LM had intermediate severity, both from angiographic (diameter stenosis [%DS] 43.8 ± 11.1%) and functional perspective (FFR 0.756 ± 0.105). Mean QFR was 0.733 ± 0.159. Correlation between QFR and FFR was moderate (r = 0.590). Positive and negative predictive value, sensitivity and specificity were 85.4%, 64%, 85.4%, and 69.6% respectively. Classification agreement of QFR and FFR in terms of functional stenosis severity was 78.1%. Area under the receiver operating characteristics of QFR using FFR as reference was 0.82 [95% confidence interval [CI], 0.71-0.93], and significantly better than angiographic evaluation including %DS (area under the receiver-operating characteristic curve [AUC] 0.45 [95% CI, 0.32-0.58], p < 0.001) and minimum lumen diameter (AUC 0.60 [95% CI, 0.47-0.74], p < 0.001). CONCLUSIONS: Compared with FFR, QFR has acceptable diagnostic performance in determining the functional relevance of LM stenosis, being better than conventional angiographic assessment. Nonetheless, caution should be taken when applying functional angiography techniques for the assessment of LM stenosis given its particular anatomical characteristics.


Subject(s)
Coronary Artery Disease , Coronary Stenosis , Fractional Flow Reserve, Myocardial , Humans , Constriction, Pathologic , Coronary Angiography/methods , Coronary Vessels/diagnostic imaging , Severity of Illness Index , Reproducibility of Results , Treatment Outcome , Predictive Value of Tests
4.
J Am Heart Assoc ; 9(4): e014458, 2020 02 18.
Article in English | MEDLINE | ID: mdl-32063120

ABSTRACT

Background Sex-specific differences may influence prognosis after deferred revascularization following fractional flow reserve (FFR) measurement. This study sought to investigate the sex differences in long-term prognosis of patients with deferred revascularization following FFR assessment. Methods and Results A total of 879 patients (879 vessels) with deferred revascularization with FFR >0.75 who underwent FFR and coronary flow reserve measurements were enrolled from 3 countries (Korea, Japan, and Spain). Long-term outcomes were assessed in 649 men and 230 women by the patient-oriented composite outcome (POCO, a composite of any death, any myocardial infarction, and any revascularization). We applied inverse-probability weighting based on propensity scores to account for differences at baseline between women and men (age, hyperlipidemia, diabetes mellitus, diameter stenosis, lesion length, multivessel disease, FFR, coronary flow reserve. The median follow-up duration was 1855 days (745-1855 days). Median FFR values were 0.88 (0.83-0.93) in men and 0.89 (0.85-0.94) in women, respectively. The occurrences of POCO were significantly high in men compared with that in women (10.5% versus 4.2%, P=0.007). Kaplan-Meier analysis revealed that women had a significantly lower risk of POCO (χ2=7.2, P=0.007). Multivariate COX proportional hazards regression analysis revealed that age, male, diabetes mellitus, diameter stenosis, lesion length, and coronary flow reserve were independent predictors of POCO. After applying IPW, the hazard ratio of males for POCO was 2.07 (95% CI, 1.07-4.04, P=0.032). Conclusions This large multinational study reveals that long-term outcome differs between women and men in favor of women after FFR-guided revascularization deferral. Clinical Trial Registration URL: http://www.ClinicalTrials.gov. Unique identifier: NCT02186093.


Subject(s)
Coronary Artery Disease/physiopathology , Coronary Artery Disease/surgery , Fractional Flow Reserve, Myocardial/physiology , Myocardial Revascularization , Registries , Coronary Artery Disease/diagnosis , Female , Humans , Japan , Male , Republic of Korea , Sex Factors , Spain , Survival Analysis , Time Factors , Treatment Outcome
5.
EuroIntervention ; 15(18): e1594-e1601, 2020 04 03.
Article in English | MEDLINE | ID: mdl-31543501

ABSTRACT

AIMS: Functional assessment of non-culprit lesions (NCL) in patients presenting with ST-elevation myocardial infarction (STEMI) and multivessel disease constitutes an unmet need. This study aimed to evaluate the diagnostic accuracy of quantitative flow ratio (QFR) in the functional assessment of NCL during the acute phase of STEMI. METHODS AND RESULTS: This was a retrospective, observational, multicentre study including patients with STEMI and staged fractional flow reserve (FFR) assessment of NCL. QFR in NCL was calculated from the coronary angiogram acquired during primary PCI in a blinded fashion with respect to FFR. The diagnostic value of QFR in the STEMI population was compared with a propensity score-matched population of stable angina patients. Eighty-two patients (91 NCL) were included. Target lesions were of both angiographic and functional (mean FFR 0.82±0.09) intermediate severity. The diagnostic performance of QFR was high (AUC 0.91 [95% CI: 0.85-0.97]) and similar to that observed in the matched control population (AUC 0.91 vs 0.94, p=0.5). The diagnostic accuracy of QFR was very high (>95%) in those vessels (61.5%) with QFR values out of a ROC-defined "grey zone" (0.75-0.85). A hybrid FFR/QFR approach (FFR only when QFR is in the grey zone) would adequately classify 96.7% of NCL, avoiding 58.5% of repeat diagnostic procedures. CONCLUSIONS: QFR has a good diagnostic accuracy in assessing the functional relevance of NCL during primary PCI, similar to the accuracy observed in stable patients.


Subject(s)
Coronary Stenosis/surgery , Coronary Vessels/diagnostic imaging , Fractional Flow Reserve, Myocardial , Percutaneous Coronary Intervention , ST Elevation Myocardial Infarction/surgery , Coronary Angiography , Coronary Stenosis/diagnostic imaging , Humans , Predictive Value of Tests , Reproducibility of Results , Retrospective Studies , ST Elevation Myocardial Infarction/therapy , Severity of Illness Index
6.
J Am Heart Assoc ; 8(16): e012906, 2019 08 20.
Article in English | MEDLINE | ID: mdl-31394987

ABSTRACT

Background Quantitative flow ratio (QFR), a novel functional angiography technique, computes fractional flow reserve (FFR) without pressure wires or adenosine. We investigated interindividual variations in the adenosine-induced hemodynamics during FFR assessment and their influence on QFR diagnostic performance. Methods and Results Patients with coronary stenoses who underwent intracoronary pressure and flow assessment were analyzed. Adenosine-induced hemodynamics during FFR measurement were determined by the percentage change in mean aortic pressure (%ΔPa) and the resistive reserve ratio (RRR). The diagnostic performance of QFR was evaluated and compared in each tertile of %ΔPa and RRR using FFR as reference. A total of 294 vessels (245 patients) were analyzed. Mean FFR was 0.80±0.11. Individuals showed a wide variation in the adenosine response in terms of %ΔPa (ranging from -75% to 43%; median, -9% [interquartile range, -3% to -17%]) and the RRR (ranging from 0.45 to 20.15; median, 3.1 [interquartile range, 2.1-4.9]). No significant differences for diagnostic efficiency of QFR were found between tertiles of %ΔPa (area under the curve for the receiver-operating characteristic analysis, 0.950 in tertile 1, 0.929 in tertile 2, and 0.910 in tertile 3; P=0.270) or between tertiles of the RRR (area under the curve for the receiver-operating characteristic analysis, 0.909 in tertile 1, 0.923 in tertile 2, and 0.959 in tertile 3; P=0.167). The classification agreement between QFR and FFR was not significantly modified by %ΔPa (tertile 1, 89%; tertile 2, 87%; and tertile 3, 86%; P=0.827) or by the RRR (tertile 1, 86%; tertile 2, 85%; and tertile 3, 91%; P=0.398). Conclusions Patients undergoing FFR assessment show large interindividual variations in the magnitude of adenosine-induced hemodynamics. However, such variations do not affect the diagnostic performance of QFR in assessing the functional relevance of observed stenoses.


Subject(s)
Biological Variation, Individual , Coronary Stenosis/physiopathology , Fractional Flow Reserve, Myocardial/physiology , Hemodynamics/physiology , Acute Coronary Syndrome/physiopathology , Adenosine , Aged , Angina, Stable/physiopathology , Coronary Angiography , Coronary Stenosis/diagnosis , Female , Fractional Flow Reserve, Myocardial/drug effects , Hemodynamics/drug effects , Humans , Hyperemia , Male , Middle Aged , Vasodilator Agents
7.
Minerva Cardioangiol ; 67(4): 318-329, 2019 Aug.
Article in English | MEDLINE | ID: mdl-29687698

ABSTRACT

Coronary microcirculatory dysfunction (CMD) is a major cause of myocardial ischemia that influences the outcomes of patients with coronary artery disease. The mechanisms of CMD are heterogeneous and may result from a spectrum of biological and cardiovascular risk factors that may affect also the microcirculation of other vital organs. Microcirculatory dysfunction of the brain, known as cerebral small vessel disease, is increasingly being recognized as a cause of cognitive decline and neurodegenerative disorders. Despite microvascular dysfunction of the heart and the brain may share underlying pathophysiological mechanisms (endothelial dysfunction, thrombosis, vascular remodeling and capillary rarefaction), the evidence about the potential link between both pathological processes is scarce. In this paper we discuss the mechanisms of microvascular dysfunction of the heart and the brain, their clinical impact on cardiac events, cognitive decline and neurodegenerative disorders, and the potential link between both vascular target organs at the level of the microcirculation.


Subject(s)
Cerebral Small Vessel Diseases/physiopathology , Coronary Artery Disease/physiopathology , Microcirculation/physiology , Cerebrovascular Circulation/physiology , Cognitive Dysfunction/etiology , Cognitive Dysfunction/physiopathology , Coronary Circulation/physiology , Humans , Myocardial Ischemia/physiopathology , Neurodegenerative Diseases/physiopathology , Risk Factors
9.
JACC Cardiovasc Interv ; 11(8): 741-753, 2018 04 23.
Article in English | MEDLINE | ID: mdl-29673505

ABSTRACT

OBJECTIVES: The authors sought to evaluate the influence of coronary microcirculatory dysfunction (CMD) on the diagnostic performance of the quantitative flow ratio (QFR). BACKGROUND: Functional angiographic assessment of coronary stenoses based on fluid dynamics, such as QFR, constitutes an attractive alternative to fractional flow reserve (FFR). However, it is unknown whether CMD affects the reliability of angiography-based functional indices. METHODS: FFR and the index of microcirculatory resistance (IMR) were measured in 300 vessels (248 patients) as part of a multicenter international registry. QFR was calculated at a blinded core laboratory. Vessels were classified into 2 groups according to microcirculatory status: low IMR (<23 U), and high IMR (≥23 U, CMD). The impact of CMD on the diagnostic performance of QFR, as well as on incremental value of QFR over quantitative angiography, was assessed using FFR as reference. RESULTS: Percent diameter stenosis (%DS) and FFR were similar in low- and high-IMR groups (%DS 51 ± 12% vs. 53 ± 11%; p = 0.16; FFR 0.80 ± 0.11 vs. 0.81 ± 0.11; p = 0.23, respectively). In the overall cohort, classification agreement (CA) between QFR and FFR and diagnostic efficiency of QFR (area under the receiver-operating characteristics curve [AUC]) were high (CA: 88%; AUC: 0.93 [95% confidence interval (CI): 0.90 to 0.96]). However, when assessed according to microcirculatory status, a significantly lower CA and AUC of QFR were found in the high-IMR group as compared with the low-IMR group (CA: 76% vs. 92%; p < 0.001; AUC: 0.88 [95% CI: 0.79 to 0.94] vs. 0.96 [95% CI: 0.92 to 0.98]; p < 0.05). Compared with angiographic assessment, QFR increased by 0.20 (p < 0.001) and by 0.16 (p < 0.001) the AUC of %DS in low- and high-IMR groups, respectively. Independent predictors of misclassification between QFR and FFR were high IMR and acute coronary syndrome. CONCLUSIONS: CMD decreases the diagnostic performance of QFR. However, even in the presence of CMD, QFR remains superior to angiography alone in ascertaining functional stenosis severity.


Subject(s)
Coronary Angiography , Coronary Stenosis/diagnostic imaging , Coronary Vessels/diagnostic imaging , Fractional Flow Reserve, Myocardial , Microcirculation , Aged , Cardiac Catheterization , Coronary Stenosis/physiopathology , Coronary Vessels/physiopathology , Europe , Female , Humans , Male , Middle Aged , Predictive Value of Tests , Prognosis , Registries , Reproducibility of Results , Retrospective Studies , Seoul , Severity of Illness Index
10.
Int J Hypertens ; 2011: 281240, 2011.
Article in English | MEDLINE | ID: mdl-21915370

ABSTRACT

Essential hypertension is characterized by increased peripheral vascular resistance to blood flow. The endothelium is a crucial regulator of vascular tone. Its function is impaired in patients with hypertension, with reduced vasodilation, increased vascular tone associated with a proinflammatory and prothrombotic state. Low-grade inflammation localized in vascular tissue is therefore recognized as an important contributor to the pathophysiology of hypertension, to the initiation and progression of atherosclerosis as well as to the development of cardiovascular diseases.

11.
Curr Opin Nephrol Hypertens ; 20(2): 125-32, 2011 Mar.
Article in English | MEDLINE | ID: mdl-21245762

ABSTRACT

PURPOSE OF REVIEW: The renin angiotensin system plays a key role in the development of hypertension-induced cardiovascular remodeling and cardiovascular damage. Angiotensin II (Ang II) exerts its effects by acting on two distinct subtypes of receptor, the angiotensin type 1 receptor (AT1R) and the angiotensin type 2 receptor (AT2R). Whereas AT1R mediates most of the recognized actions of Ang II, it appears that AT2R opposes, in part, the actions mediated by AT1R. As the AT2R is expressed in adult tissues in smaller numbers than AT1R, the actions and cell signaling of AT2R have been less well characterized than those of AT1R. RECENT FINDINGS: Current knowledge suggests that AT2R stimulation mediates vasodilation, antigrowth, proapoptotic and antiinflammatory effects. Hence, AT2R can modulate cardiovascular remodeling as well as the progression of atherosclerosis. A protective role of AT2R in the cardiovascular system has been also documented in humans, mainly during chronic AT1R inhibition. Furthermore, a new nonpeptide AT2R agonist has been developed, with potential future therapeutic applications in hypertensive conditions. SUMMARY: This article reviews the role of AT2R expression signaling and function in the pathogenesis of the functional and structural alterations induced by hypertension on the cardiovascular system.


Subject(s)
Cardiovascular Diseases/etiology , Hypertension/complications , Receptor, Angiotensin, Type 2/physiology , Animals , Cardiomegaly/etiology , Disease Models, Animal , Humans , Nitric Oxide/biosynthesis , Nitric Oxide Synthase Type III/metabolism , Vasculitis/etiology , Vasodilation
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