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Diagnostic and Prognostic Implications of Coronary Flow Capacity: A Comprehensive Cross-Modality Physiological
Tim P van de Hoef1, Mauro Echavarría-Pinto2, Martijn A van Lavieren3
1AMC Heartcenter, Academic Medical Center-University of Amsterdam, Amsterdam, the Netherlands; Cardiovascular Institute, Hospital Clínico San Carlos, and Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain.
Insights
Coronary flow capacity (CFC) better predicts major adverse cardiac events (MACE) than coronary flow reserve (CFR) alone. CFC provides a comprehensive diagnostic and prognostic tool for ischemic heart disease (IHD).
Area of Science:
- Cardiovascular Medicine
- Diagnostic Imaging
- Interventional Cardiology
Background:
- Ischemic heart disease (IHD) diagnosis traditionally focuses on focal obstructive causes, neglecting diffuse and microcirculatory involvement.
- Coronary flow capacity (CFC) integrates coronary flow reserve (CFR) and hyperemic average peak flow velocity (hAPV) for a comprehensive assessment of flow impairment.
- CFC addresses limitations of CFR alone by considering maximal flow, identifying ischemia in vessels with reduced hAPV and CFR.
Purpose of the Study:
- To evaluate if coronary flow capacity (CFC) improves the discrimination of patients at risk for major adverse cardiac events (MACE) compared to coronary flow reserve (CFR) alone.
- To investigate the diagnostic and prognostic implications of CFC in relation to contemporary tests like fractional flow reserve (FFR) for ischemic heart disease (IHD).
Main Methods:
- Intracoronary pressure and flow measurements were performed in 299 vessels from 228 patients, with revascularization deferred in 154.
- Vessels were stratified into normal, mildly, moderately, or severely reduced CFC categories based on CFR thresholds and hAPV percentiles.
- Major adverse cardiac events (MACE) were recorded over a median follow-up of 11.9 years in patients with deferred revascularization.
Main Results:
- Combining CFR and hAPV (CFC) significantly improved MACE prediction compared to CFR alone (p=0.01).
- Progressive impairment of CFC was strongly associated with increased MACE rates during follow-up (p=0.002).
- Mildly and moderately reduced CFC were linked to a 2.1-fold and 7.1-fold increase in MACE hazard, respectively, after multivariate adjustment.
Conclusions:
- Coronary flow capacity (CFC) offers a cross-modality platform for diagnosing and risk-stratifying patients with ischemic heart disease (IHD).
- CFC enhances the interpretation of established diagnostic tests for IHD, providing richer prognostic information.
- The study highlights CFC's value in identifying patients at risk for adverse cardiac events.
Objectives:
The purpose of this study is to evaluate whether coronary flow capacity (CFC) improves discrimination of patients at risk for major adverse cardiac events (MACE) compared with coronary flow reserve (CFR) alone, and to study the diagnostic and prognostic implications of CFC in relation to contemporary diagnostic tests for ischemic heart disease (IHD), including fractional flow reserve (FFR).
Background:
Although IHD results from a combination of focal obstructive, diffuse, and microcirculatory involvement of the coronary circulation, its diagnosis remains focused on focal obstructive causes. CFC comprehensively documents flow impairment in IHD, regardless of its origin, by interpreting CFR in relation to maximal flow (hyperemic average peak flow velocity [hAPV]), and overcomes the limitations of using CFR alone. This is governed by the understanding that ischemia occurs in vascular beds with substantially reduced hAPV and CFR, whereas ischemia is unlikely when hAPV or CFR is high.
Methods:
Intracoronary pressure and flow were measured in 299 vessels (228 patients), where revascularization was deferred in 154. Vessels were stratified as having normal, mildly reduced, moderately reduced, or severely reduced CFC using CFR thresholds derived from published data and corresponding hAPV percentiles. The occurrence of MACE after deferral of revascularization was recorded during 11.9 years of follow-up (quartile 1: 10.0 years, quartile 3: 13.4 years).
Results:
Combining CFR and hAPV improved the prediction of MACE over CFR alone (p = 0.01). After stratification in CFC, MACE rates throughout follow-up were strongly associated with advancing impairment of CFC (p = 0.002). After multivariate adjustment, mildly and moderately reduced CFC were associated with a 2.1-fold (95% confidence interval: 1.1 to 4.0; p = 0.017), and 7.1-fold (95% confidence interval: 2.9 to 17.1; p < 0.001) increase in MACE hazard, respectively, compared with normal CFC. Severely reduced CFC was identified by FFR ≤0.80 in 90% of cases, although ≥40% of vessels with normal or mildly reduced CFC still had an FFR ≤0.80.
Conclusions:
CFC provides a cross-modality platform for the diagnosis and risk-stratification of IHD and enriches the interpretation of contemporary diagnostic tests in IHD.
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