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Objective Identification of Intermediate Lesions Inducing Myocardial Ischemia Using Sequential Intracoronary Pressure
Valérie E Stegehuis1, Gilbert W M Wijntjens1, Sukhjinder S Nijjer2
1Department of Interventional Cardiology Amsterdam Cardiovascular Sciences Heart Center Amsterdam UMC-location AMC University of Amsterdam The Netherlands.
Insights
A sequential approach combining pressure and flow measurements identified flow abnormalities in 20% of intermediate coronary lesions. Coronary flow reserve (CFR) offers additional value when instantaneous wave-free ratio (iFR) is borderline, challenging pressure-based assessments.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Diagnostic Imaging
Background:
- Ischemic heart disease diagnosis often relies on pressure-derived indexes for focal obstructive disease.
- Coronary flow's prognostic relevance suggests perfusion abnormalities are key for revascularization decisions.
- Invasive physiology techniques are critical for identifying patients who benefit from coronary revascularization.
Purpose of the Study:
- To evaluate the diagnostic utility of a sequential approach using pressure-derived indexes and flow measurements.
- To determine the prevalence of flow abnormalities in intermediate coronary lesions after initial pressure assessments.
Main Methods:
- Simultaneous intracoronary pressure and flow velocity measurements were performed on 366 intermediate lesions.
- Standard clinical cut points for instantaneous wave-free ratio (iFR), fractional flow reserve (FFR), and coronary flow reserve (CFR) were applied.
- A sequential pressure and flow velocity assessment strategy was employed.
Main Results:
- 32% of lesions were positive for FFR (FFR+) and 37% for iFR (iFR+).
- Subsequent CFR assessment revealed 25% FFR+/CFR+ and 30% iFR+/CFR+ lesions.
- A combined iFR, FFR, and invasive flow velocity approach identified 20% (74/366) of lesions as ischemic.
Conclusions:
- 20% of intermediate coronary lesions exhibit flow abnormalities when assessed sequentially using pressure and flow velocity.
- Coronary flow reserve (CFR) provides significant additional diagnostic value when instantaneous wave-free ratio (iFR) is borderline.
- These findings question the exclusive reliance on pressure-based approaches as the gold standard for detecting myocardial ischemia.
Abstract:
Background Although ischemic heart disease has a complex and multilevel origin, the diagnostic approach is mainly focused on focal obstructive disease as assessed by pressure-derived indexes. The prognostic relevance of coronary flow over coronary pressure has been suggested and implies that identification of relevant perfusion abnormalities by invasive physiology techniques is critical for the correct identification of patients who benefit from coronary revascularization. The purpose of this study was to evaluate the diagnostic potential of a sequential approach using pressure-derived indexes instantaneous wave-free ratio (iFR), fractional flow reserve (FFR), and coronary flow reserve (CFR) measurements to determine the number of intermediate lesions associated with flow abnormalities after initial pressure measurements. Methods and Results A total of 366 intermediate lesions were assessed with simultaneous intracoronary pressure and flow velocity measurements. Contemporary clinical iFR, FFR, and CFR cut points for myocardial ischemia were applied. A total of 118 (32%) lesions were FFR+ and 136 (37%) lesions were iFR+. Subsequent CFR assessment resulted for FFR in a total of 91 (25%) FFR+/CFR+ and for iFR a total of 111 (30%) iFR+/CFR+ lesions. An iFR, FFR, and invasive flow velocity assessment approach would have yielded 20% of lesions (74 of 366) as ischemic. Conclusions Ultimately, 20% of intermediate lesions are associated with flow abnormalities after applying a pressure and flow velocity sequential approach. If iFR is borderline, FFR has limited additional value, in contrast with CFR. These results emphasize the use of coronary physiology in assessing stenosis severity but may also further question the contemporary reputation of a pressure-based approach as a gold standard for the detection of myocardial ischemia in ischemic heart disease.
