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      How to select patients requiring coronary revascularisation using coronary physiology

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          Abstract

          The coronary angiogram is an indicator of flow limiting coronary artery disease but coronary physiology at the time of angiography is vital in assessing the true functional significance of coronary artery disease. With advances in guidewire technology and the greater use of physiology within the catheter laboratory, there is now a slow evolution of physiological indices in being able to reliably assess the functional significance of individual lesions and also the adequacy of revascularization in a growing range of clinical scenarios. As co-registration of physiology with the angiogram and intravascular imaging will become easier, we will find ourselves increasingly in an era of ‘Precision PCI’.

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          Most cited references48

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          Fractional flow reserve versus angiography for guiding percutaneous coronary intervention.

          Pim A.L. Tonino, Bernard De Bruyne, Nico H.J. Pijls … (2009)
          In patients with multivessel coronary artery disease who are undergoing percutaneous coronary intervention (PCI), coronary angiography is the standard method for guiding the placement of the stent. It is unclear whether routine measurement of fractional flow reserve (FFR; the ratio of maximal blood flow in a stenotic artery to normal maximal flow), in addition to angiography, improves outcomes. In 20 medical centers in the United States and Europe, we randomly assigned 1005 patients with multivessel coronary artery disease to undergo PCI with implantation of drug-eluting stents guided by angiography alone or guided by FFR measurements in addition to angiography. Before randomization, lesions requiring PCI were identified on the basis of their angiographic appearance. Patients assigned to angiography-guided PCI underwent stenting of all indicated lesions, whereas those assigned to FFR-guided PCI underwent stenting of indicated lesions only if the FFR was 0.80 or less. The primary end point was the rate of death, nonfatal myocardial infarction, and repeat revascularization at 1 year. The mean (+/-SD) number of indicated lesions per patient was 2.7+/-0.9 in the angiography group and 2.8+/-1.0 in the FFR group (P=0.34). The number of stents used per patient was 2.7+/-1.2 and 1.9+/-1.3, respectively (P<0.001). The 1-year event rate was 18.3% (91 patients) in the angiography group and 13.2% (67 patients) in the FFR group (P=0.02). Seventy-eight percent of the patients in the angiography group were free from angina at 1 year, as compared with 81% of patients in the FFR group (P=0.20). Routine measurement of FFR in patients with multivessel coronary artery disease who are undergoing PCI with drug-eluting stents significantly reduces the rate of the composite end point of death, nonfatal myocardial infarction, and repeat revascularization at 1 year. (ClinicalTrials.gov number, NCT00267774.) 2009 Massachusetts Medical Society
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            Measurement of fractional flow reserve to assess the functional severity of coronary-artery stenoses.

            N. H. Pijls, B. De Bruyne, K Peels … (1996)
            The clinical significance of coronary-artery stenoses of moderate severity can be difficult to determine. Myocardial fractional flow reserve (FFR) is a new index of the functional severity of coronary stenoses that is calculated from pressure measurements made during coronary arteriography. We compared this index with the results of noninvasive tests commonly used to detect myocardial ischemia, to determine the usefulness of the index. In 45 consecutive patients with moderate coronary stenosis and chest pain of uncertain origin, we performed bicycle exercise testing, thallium scintigraphy, stress echocardiography with dobutamine, and quantitative coronary arteriography and compared the results with measurements of FFR. In all 21 patients with an FFR of less than 0.75, reversible myocardial ischemia was demonstrated unequivocally on at least one noninvasive test. After coronary angioplasty or bypass surgery was performed, all the positive test results reverted to normal. In contrast, 21 of the 24 patients with an FFR of 0.75 or higher tested negative for reversible myocardial ischemia on all the noninvasive tests. No revascularization procedures were performed in these patients, and none were required during 14 months of follow-up. The sensitivity of FFR in the identification of reversible ischemia was 88 percent, the specificity 100 percent, the positive predictive value 100 percent, the negative predictive value 88 percent, and the accuracy 93 percent. In patients with coronary stenosis of moderate severity, FFR appears to be a useful index of the functional severity of the stenoses and the need for coronary revascularization.
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              Optimal Medical Therapy with or without PCI for Stable Coronary Disease

              William E Boden, Robert O'Rourke, Koon Teo … (2007)
              New England Journal of Medicine, 356(15), 1503-1516
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                Author and article information

                Journal
                Journal ID (nlm-ta): JRSM Cardiovasc Dis
                Journal ID (iso-abbrev): JRSM Cardiovasc Dis
                Journal ID (publisher-id): CVD
                Journal ID (hwp): spcvd
                Title: JRSM Cardiovascular Disease
                Publisher: SAGE Publications (Sage UK: London, England )
                ISSN (Electronic): 2048-0040
                Publication date (Electronic): 3 February 2021
                Publication date Collection: Jan-Dec 2021
                Volume: 10
                Electronic Location Identifier: 2048004020979476
                Affiliations
                [1-2048004020979476]NIHR Biomedical Research Centre and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, St Thomas’ Campus, King’s College London, London, UK
                Author notes
                [*]Divaka Perera, Cardiovascular Division, Rayne Institute, St. Thomas’ Hospital, London SE1 7EH, UK. Email: Divaka.Perera@ 123456kcl.ac.uk
                Author information
                https://orcid.org/0000-0002-9413-8291
                Article
                Publisher ID: 10.1177_2048004020979476
                DOI: 10.1177/2048004020979476
                PMC ID: 7868490
                SO-VID: a9301436-7e4f-4f43-adb2-d335c6ee5514
                Copyright © © The Author(s) 2021
                License:

                Creative Commons CC-BY: This article is distributed under the terms of the Creative Commons Attribution 4.0 License ( https://creativecommons.org/licenses/by/4.0/) which permits any use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages ( https://us.sagepub.com/en-us/nam/open-access-at-sage).

                History
                Date received : 17 September 2020
                Date revision received : 29 October 2020
                Date accepted : 18 November 2020
                Categories
                Subject: A Vision of Percutaneous Coronary Revascularization in 2020
                Subject: Review Article
                Custom metadata
                cover-date January-December 2021
                typesetter ts2

                Keywords: catheter-based coronary interventions,stents,chronic ischemic heart disease,acute coronary syndromes
                Data availability:
                Keywords: catheter-based coronary interventions, stents, chronic ischemic heart disease, acute coronary syndromes

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