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Comprehensive Angiography-Derived Functional Assessment of Epicardial and Microvascular Coronary Disease. Correlation
Francesco Della Mora1, Leonardo Portolan1, Dimitrios Terentes-Printzios2
1Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy.
Insights
Coronary angiography combined with microvascular assessment accurately identifies myocardial ischemia mechanisms. This approach improves diagnosis compared to epicardial assessment alone in patients with suspected coronary artery disease.
Area of Science:
- Cardiology
- Interventional Cardiology
- Physiology
Background:
- Coronary angiography (CA) shows poor correlation with non-invasive myocardial stress imaging (NSI).
- Myocardial ischemia is frequently observed in patients with unobstructed coronary arteries, suggesting limitations in current diagnostic methods.
- The diagnostic utility of combined epicardial and microcirculatory assessment using angiography remains unclear.
Purpose of the Study:
- To evaluate the diagnostic performance of combined quantitative flow ratio (QFR) and angiography-derived index of microcirculatory resistance (IMRangio).
- To assess the correlation of combined QFR/IMRangio with NSI findings.
- To determine the predominant mechanism of myocardial ischemia in patients with suspected coronary artery disease.
Main Methods:
- Retrospective analysis of 917 coronary vessels in 319 patients who underwent both CA and NSI.
- Quantitative flow ratio (QFR) for epicardial function and angiography-derived index of microcirculatory resistance (IMRangio) for microcirculatory function were calculated.
- Diagnostic accuracy was assessed using receiver operating characteristic (ROC) curves.
Main Results:
- NSI indicated myocardial ischemia in 76% of cases.
- IMRangio was significantly higher and QFR was significantly lower in vessels subtending ischemic territories.
- Combined QFR/IMRangio assessment demonstrated incremental diagnostic performance over isolated assessments and identified the predominant ischemia mechanism in 77% of patients with positive NSI.
Conclusions:
- Combined angiography-derived assessment of epicardial and microvascular function is valuable for defining myocardial ischemia mechanisms.
- This integrated approach enhances diagnostic accuracy in patients with suspected coronary artery disease.
- The study highlights the importance of evaluating both epicardial and microcirculatory function for comprehensive ischemia assessment.
Abstract:
Coronary angiography (CA) is poorly correlated with non-invasive myocardial stress imaging (NSI) and myocardial ischemia is often observed in patients with unobstructed coronary arteries. Moreover, the diagnostic performance of combined epicardial and microcirculatory angiography-derived physiological assessment and its correlation with NSI remains unknown. A total of 917 coronary vessels in 319 patients who underwent both CA and NSI were included in this multicenter observational retrospective analysis. Quantitative flow ratio (QFR) and angiography-derived index of microcirculatory resistance (IMRangio) analyses were performed to estimate coronary epicardial and microcirculatory function respectively. NSI demonstrated evidence of myocardial ischemia in 76% of the cases. IMRangio (36 [22 to 50] vs 29 [21 to 41], p <0.001) was significantly higher and QFR (0.92 [0.78 to 0.99] vs 0.97 [0.91 to 0.99], p <0.001) was significantly lower in vessels subtending ischemic territories. Overall, the diagnostic accuracy of QFR was moderate (area under the curve of receiver operating characteristic [AUCROC] 0.632 [95% confidence interval [CI] 0.589 to 0.674], p <0.0001) but it was higher in patients with normal microcirculatory function (AUCROC = 0.726 [95% CI 0.669 to 0.784], p <0.0001, p Value for AUCROC comparison = 0.009). Combined QFR/IMRangio assessment provided incremental diagnostic performance compared with the evaluation of epicardial or microcirculatory districts in isolation (p Value for AUC comparison <0.0001) and it was able to identify the predominant mechanism of myocardial ischemia in 77% of the patients with positive NSI. Our study suggests the value of a combined angiography-derived assessment of epicardial and microvascular function for the definition of the predominant mechanism of myocardial ischemia in patients with suspected coronary artery disease.
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