Korean Circ J.  2018 Jan;48(1):16-23. 10.4070/kcj.2017.0177.

Ischemia-based Coronary Revascularization: Beyond Anatomy and Fractional Flow Reserve

Affiliations
  • 1Department of Cardiology, Ajou University School of Medicine, Suwon, Korea. sjtahk@ajou.ac.kr

Abstract

Treatment strategies for patients with coronary artery disease (CAD) should be based on objective evidence of inducible ischemia in the subtended myocardium to improve clinical outcomes, symptoms, and cost-effectiveness. Fractional flow reserve (FFR) is the most verified index to-date for invasively evaluating lesion-specific myocardial ischemia. Favorable results from large clinical trials that applied FFR-guided percutaneous coronary intervention (PCI) prompted changes in coronary revascularization guidelines to emphasize the importance of this ischemia-based strategy using invasive coronary physiology. However, the frequency of functional evaluations is lacking in daily practice, and visual assessment still dominates treatment decisions in CAD patients. Despite recent efforts to integrate functional and anatomical assessments for coronary stenosis, there is considerable discordance between the 2 modalities, and the diagnostic accuracy of simple parameters obtained from current imaging tools is not satisfactory to determine functional significance. Although evidence that supports or justifies anatomy-guided PCI is more limited, and FFR-guided PCI is currently recommended, it is important to be aware of conditions and factors that influence FFR for accurate interpretation and application. In this article, we review the limitations of the current anatomy-derived evaluation of the functional significance of coronary stenosis, detail considerations for the clinical utility of FFR, and discuss the importance of an integrated physiologic approach to determine treatment strategies for CAD patients.

Keyword

Coronary artery disease; Coronary angiography; Intravascular ultrasonography; Fractional flow reserve

MeSH Terms

Coronary Angiography
Coronary Artery Disease
Coronary Stenosis
Humans
Ischemia
Myocardial Ischemia
Myocardium
Percutaneous Coronary Intervention
Physiology
Ultrasonography, Interventional

Cited by  1 articles

Coronary Microvascular Dysfunction: Is It Distinct Clinical Entity or Common Physiologic Pathway?
Jung-Min Ahn
Korean Circ J. 2020;50(10):904-906.    doi: 10.4070/kcj.2020.0352.


Reference

1. Hachamovitch R, Berman DS, Shaw LJ, et al. Incremental prognostic value of myocardial perfusion single photon emission computed tomography for the prediction of cardiac death: differential stratification for risk of cardiac death and myocardial infarction. Circulation. 1998; 97:535–543.
2. Shaw LJ, Berman DS, Maron DJ, et al. Optimal medical therapy with or without percutaneous coronary intervention to reduce ischemic burden: results from the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial nuclear substudy. Circulation. 2008; 117:1283–1291.
3. Pijls NH, van Schaardenburgh P, Manoharan G, et al. Percutaneous coronary intervention of functionally nonsignificant stenosis: 5-year follow-up of the DEFER Study. J Am Coll Cardiol. 2007; 49:2105–2111.
4. Tonino PA, De Bruyne B, Pijls NH, et al. Fractional flow reserve versus angiography for guiding percutaneous coronary intervention. N Engl J Med. 2009; 360:213–224.
Article
5. Fearon WF, Bornschein B, Tonino PA, et al. Economic evaluation of fractional flow reserve-guided percutaneous coronary intervention in patients with multivessel disease. Circulation. 2010; 122:2545–2550.
Article
6. Pijls NH, Fearon WF, Tonino PA, et al. Fractional flow reserve versus angiography for guiding percutaneous coronary intervention in patients with multivessel coronary artery disease: 2-year follow-up of the FAME (Fractional Flow Reserve Versus Angiography for Multivessel Evaluation) study. J Am Coll Cardiol. 2010; 56:177–184.
7. Kim YH, Park SJ. Ischemia-guided percutaneous coronary intervention for patients with stable coronary artery disease. Circ J. 2013; 77:1967–1974.
Article
8. Patel MR, Dehmer GJ, Hirshfeld JW, Smith PK, Spertus JA. ACCF/SCAI/STS/AATS/AHA/ASNC/HFSA/SCCT 2012 Appropriate use criteria for coronary revascularization focused update: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, American Association for Thoracic Surgery, American Heart Association, American Society of Nuclear Cardiology, and the Society of Cardiovascular Computed Tomography. J Am Coll Cardiol. 2012; 59:857–881.
9. Nallamothu BK, Tommaso CL, Anderson HV, et al. ACC/AHA/SCAI/AMA-Convened PCPI/NCQA 2013 performance measures for adults undergoing percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures, the Society for Cardiovascular Angiography and Interventions, the American Medical Association-Convened Physician Consortium for Performance Improvement, and the National Committee for Quality Assurance. J Am Coll Cardiol. 2014; 63:722–745.
10. Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery. Guidelines on myocardial revascularization. Eur Heart J. 2010; 31:2501–2555.
11. Montalescot G, Sechtem U, Achenbach S, et al. 2013 ESC guidelines on the management of stable coronary artery disease: the Task Force on the Management of Stable Coronary Artery Disease of the European Society of Cardiology. Eur Heart J. 2013; 34:2949–3003.
12. Toth GG, Toth B, Johnson NP, et al. Revascularization decisions in patients with stable angina and intermediate lesions: results of the international survey on interventional strategy. Circ Cardiovasc Interv. 2014; 7:751–759.
13. Jang JS, Han KR, Moon KW, et al. The current status of percutaneous coronary intervention in Korea: based on year 2014 cohort of Korean Percutaneous Coronary Intervention (K-PCI) Registry. Korean Circ J. 2017; 47:328–340.
Article
14. Koo BK, Yang HM, Doh JH, et al. Optimal intravascular ultrasound criteria and their accuracy for defining the functional significance of intermediate coronary stenoses of different locations. JACC Cardiovasc Interv. 2011; 4:803–811.
Article
15. Han JK, Koo BK, Park KW, et al. Optimal intravascular ultrasound criteria for defining the functional significance of intermediate coronary stenosis: an international multicenter study. Cardiology. 2014; 127:256–262.
Article
16. Ahn JM, Kang SJ, Mintz GS, et al. Validation of minimal luminal area measured by intravascular ultrasound for assessment of functionally significant coronary stenosis comparison with myocardial perfusion imaging. JACC Cardiovasc Interv. 2011; 4:665–671.
17. Kang SJ, Lee JY, Ahn JM, et al. Validation of intravascular ultrasound-derived parameters with fractional flow reserve for assessment of coronary stenosis severity. Circ Cardiovasc Interv. 2011; 4:65–71.
Article
18. D'Ascenzo F, Barbero U, Cerrato E, et al. Accuracy of intravascular ultrasound and optical coherence tomography in identifying functionally significant coronary stenosis according to vessel diameter: a meta-analysis of 2,581 patients and 2,807 lesions. Am Heart J. 2015; 169:663–673.
19. Seo KW, Lim HS, Yoon MH, et al. The impact of microvascular resistance on the discordance between anatomical and functional evaluations of intermediate coronary disease. EuroIntervention. 2017; 13:e185–e192.
Article
20. Topol EJ, Nissen SE. Our preoccupation with coronary luminology. The dissociation between clinical and angiographic findings in ischemic heart disease. Circulation. 1995; 92:2333–2342.
21. Fischer JJ, Samady H, McPherson JA, et al. Comparison between visual assessment and quantitative angiography versus fractional flow reserve for native coronary narrowings of moderate severity. Am J Cardiol. 2002; 90:210–215.
Article
22. Fearon WF. Assessing intermediate coronary lesions: more than meets the eye. Circulation. 2013; 128:2551–2553.
23. Cho HO, Nam CW, Cho YK, et al. Characteristics of function-anatomy mismatch in patients with coronary artery disease. Korean Circ J. 2014; 44:394–399.
Article
24. Gonzalo N, Escaned J, Alfonso F, et al. Morphometric assessment of coronary stenosis relevance with optical coherence tomography: a comparison with fractional flow reserve and intravascular ultrasound. J Am Coll Cardiol. 2012; 59:1080–1089.
25. Jang JS, Shin HC, Bae JS, et al. Diagnostic performance of intravascular ultrasound-derived minimal lumen area to predict functionally significant non-left main coronary artery disease: a meta-analysis. Korean Circ J. 2016; 46:622–631.
Article
26. Biasco L, Pedersen F, Lønborg J, et al. Angiographic characteristics of intermediate stenosis of the left anterior descending artery for determination of lesion significance as identified by fractional flow reserve. Am J Cardiol. 2015; 115:1475–1480.
Article
27. Yang HM, Tahk SJ, Lim HS, et al. Relationship between intravascular ultrasound parameters and fractional flow reserve in intermediate coronary artery stenosis of left anterior descending artery: intravascular ultrasound volumetric analysis. Catheter Cardiovasc Interv. 2014; 83:386–394.
Article
28. Jin XJ, Tahk SJ, Yang HM, et al. The relationship between intravascular ultrasound-derived percent total atheroma volume and fractional flow reserve in the intermediate stenosis of proximal or middle left anterior descending coronary artery. Int J Cardiol. 2015; 185:56–61.
Article
29. Yoon MH, Tahk SJ, Lim HS, et al. Myocardial mass contributes to the discrepancy between anatomic stenosis severity assessed by intravascular ultrasound and fractional flow reserve in intermediate lesions of the coronary artery. [Epub ahead of print]. Catheter Cardiovasc Interv. 2017.
Article
30. Nahser PJ Jr, Brown RE, Oskarsson H, Winniford MD, Rossen JD. Maximal coronary flow reserve and metabolic coronary vasodilation in patients with diabetes mellitus. Circulation. 1995; 91:635–640.
Article
31. Krams R, Kofflard MJ, Duncker DJ, et al. Decreased coronary flow reserve in hypertrophic cardiomyopathy is related to remodeling of the coronary microcirculation. Circulation. 1998; 97:230–233.
Article
32. Lakatta EG, Levy D. Arterial and cardiac aging: major shareholders in cardiovascular disease enterprises: part I: aging arteries: a “set up” for vascular disease. Circulation. 2003; 107:139–146.
33. Lakatta EG, Levy D. Arterial and cardiac aging: major shareholders in cardiovascular disease enterprises: part II: the aging heart in health: links to heart disease. Circulation. 2003; 107:346–354.
34. Echavarría-Pinto M, van de Hoef TP, Serruys PW, Piek JJ, Escaned J. Facing the complexity of ischaemic heart disease with intracoronary pressure and flow measurements: beyond fractional flow reserve interrogation of the coronary circulation. Curr Opin Cardiol. 2014; 29:564–570.
35. Pijls NH, de Bruyne B. Coronary Pressure. 2nd ed. Dordrecht: Kluwer Academic;2000.
36. Spaan JA, Piek JJ, Hoffman JI, Siebes M. Physiological basis of clinically used coronary hemodynamic indices. Circulation. 2006; 113:446–455.
Article
37. Pijls NH, van Son JA, Kirkeeide RL, De Bruyne B, Gould KL. Experimental basis of determining maximum coronary, myocardial, and collateral blood flow by pressure measurements for assessing functional stenosis severity before and after percutaneous transluminal coronary angioplasty. Circulation. 1993; 87:1354–1367.
Article
38. Fearon WF. Percutaneous coronary intervention should be guided by fractional flow reserve measurement. Circulation. 2014; 129:1860–1870.
Article
39. Uren NG, Crake T, Lefroy DC, de Silva R, Davies GJ, Maseri A. Reduced coronary vasodilator function in infarcted and normal myocardium after myocardial infarction. N Engl J Med. 1994; 331:222–227.
Article
40. Ragosta M, Powers ER, Samady H, Gimple LW, Sarembock IJ, Beller GA. Relationship between extent of residual myocardial viability and coronary flow reserve in patients with recent myocardial infarction. Am Heart J. 2001; 141:456–462.
Article
41. De Bruyne B, Pijls NH, Kalesan B, et al. Fractional flow reserve-guided PCI versus medical therapy in stable coronary disease. N Engl J Med. 2012; 367:991–1001.
Article
42. Lee JM, Jung JH, Hwang D, et al. Coronary flow reserve and microcirculatory resistance in patients with intermediate coronary stenosis. J Am Coll Cardiol. 2016; 67:1158–1169.
Article
43. Kim HY, Lim HS, Doh JH, et al. Physiological severity of coronary artery stenosis depends on the amount of myocardial mass subtended by the coronary artery. JACC Cardiovasc Interv. 2016; 9:1548–1560.
44. Taylor CA, Fonte TA, Min JK. Computational fluid dynamics applied to cardiac computed tomography for noninvasive quantification of fractional flow reserve: scientific basis. J Am Coll Cardiol. 2013; 61:2233–2241.
45. Ha J, Kim JS, Lim J, et al. Assessing computational fractional flow reserve from optical coherence tomography in patients with intermediate coronary stenosis in the left anterior descending artery. Circ Cardiovasc Interv. 2016; 9:e003613.
Article
46. Park JB, Choi G, Chun EJ, et al. Computational fluid dynamic measures of wall shear stress are related to coronary lesion characteristics. Heart. 2016; 102:1655–1661.
Article
47. Tu S, Westra J, Yang J, et al. Diagnostic accuracy of fast computational approaches to derive fractional flow reserve from diagnostic coronary angiography: the International Multicenter FAVOR Pilot Study. JACC Cardiovasc Interv. 2016; 9:2024–2035.
Full Text Links
  • KCJ
Actions
Cited
CITED
export Copy
Close
Share
  • Twitter
  • Facebook
Similar articles
Copyright © 2024 by Korean Association of Medical Journal Editors. All rights reserved.     E-mail: koreamed@kamje.or.kr