Age-related changes in the coronary microcirculation influencing the diagnostic performance of invasive pressure-based indices and long-term patient prognosis
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Daniel Faria1,2, Hernan Mejia-Renteria1, Joo Myung Lee3
1Interventional Cardiology, Hospital Clinico San Carlos IDISCC, Complutense University of Madrid, Madrid, Spain.
Insights
Aging impacts coronary microvascular function, decreasing vasodilation and affecting stenosis assessment. In older patients, coronary flow reserve (CFR) and resting Pd/Pa predict outcomes after FFR-guided PCI deferral.
Area of Science:
- Cardiology
- Vascular Physiology
- Geriatric Medicine
Background:
- Limited evidence exists on how aging affects coronary microvascular function and its impact on stenosis assessment using fractional flow reserve (FFR) and resting pressure ratios.
- Microcirculatory dysfunction is a key component of cardiovascular disease, particularly in older populations.
Purpose of the Study:
- To investigate age-related changes in coronary microvascular function.
- To determine the effect of age on hyperemic and non-hyperemic indices of stenosis relevance.
- To explore the prognostic implications of these age-related changes in patients undergoing coronary angiography.
Main Methods:
- A post hoc analysis of a prospective international registry (NCT03690713) involving 1134 patients and 1326 coronary vessels.
- Interrogation of coronary stenoses using pressure and flow guidewires to assess FFR, resting Pd/Pa, and coronary flow reserve (CFR).
- Analysis of age-dependent correlations with functional indices and 5-year follow-up for vessel-oriented composite outcomes (VOCO) after FFR-guided percutaneous coronary intervention (PCI) deferral.
Main Results:
- Age positively correlated with FFR but not with resting Pd/Pa.
- Coronary flow reserve (CFR) showed a negative correlation with age, primarily due to reduced maximal hyperemic flow in older individuals.
- In patients over 60 with deferred PCI (FFR > 0.80), abnormal resting Pd/Pa or CFR significantly increased the risk of VOCO.
Conclusions:
- Aging is associated with impaired microcirculatory vasodilation, as indicated by reduced CFR.
- In older patients (>60 years) with FFR-guided deferred PCI, both CFR and resting Pd/Pa provide incremental prognostic value for predicting future adverse events.
Objectives:
Investigate age-related changes in coronary microvascular function, its effect on hyperemic and non-hyperemic indices of stenosis relevance, and its prognostic implications.
Background:
Evidence assessing the effect of age on fractional flow reserve (FFR), resting mean distal intracoronary pressure/mean aortic pressure (Pd/Pa), and microcirculatory function remains scarce.
Methods:
This is a post hoc study of a large prospective international registry (NCT03690713) including 1134 patients (1326 vessels) with coronary stenoses interrogated with pressure and flow guidewires. Age-dependent correlations with functional indices were analyzed. Prevalences of FFR, resting Pd/Pa, and coronary flow reserve (CFR) classification agreement were assessed. At 5 years follow-up, the relation between resting Pd/Pa, CFR, and their age-dependent implications on FFR-guided percutaneous coronary intervention (PCI) deferral (deferred if FFR > 0.80) were investigated using vessel-oriented composite outcomes (VOCO) composed of death, myocardial infarction, and repeated revascularization.
Results:
Age correlated positively with FFR (r = 0.08, 95% confidence interval [CI]: 0.03 to 0.13, p = 0.005), but not with resting Pd/Pa (r = -0.03, 95% CI:-0.09 to 0.02, p = 0.242). CFR correlated negatively with age (r = -0.15, 95% CI: -0.21 to -0.10, p < 0.001) due to a significant decrease in maximal hyperemic flow in older patients. Patients over 60 years of age with FFR-guided deferred-PCI abnormal resting Pd/Pa or abnormal CFR had increased risk of VOCO (hazard ratio [HR]: 2.10, 95% CI: 1.15 to 4.36, p = 0.048; HR: 2.46, 95% CI:1.23 to 4.96, p = 0.011; respectively).
Conlusions:
Aging is associated with decrease in microcirculatory vasodilation, as assessed with adenosine-based methods like CFR. In patients older than 60 years in whom PCI is deferred according to FFR > 0.80, CFR and resting Pd/Pa have an incremental value in predicting future vessel-oriented patient outcomes.
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