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Author Spotlight: Enhancing Coronary Artery Revascularization
Published on: September 15, 2023
Diffuse coronary artery disease leads to deferral of both surgical and percutaneous coronary artery revascularisation
Daniek P J Slegers1, Roberto Bova2, Samuel F M Heuts3
1Department of Cardiology, Maastricht University Medical Centre, Maastricht, the Netherlands.
Insights
Intracoronary pullback measurements reveal lesion morphology significantly impacts treatment decisions in stable coronary artery disease (CAD), often prioritizing morphology over functional severity for interventions.
Area of Science:
- Cardiology
- Interventional Cardiology
- Medical Imaging
Background:
- Accurate assessment of coronary artery disease (CAD) lesion severity and distribution is crucial for optimal treatment selection.
- Intracoronary pullback measurements are increasingly used, but their impact on clinical decision-making remains unclear.
Purpose of the Study:
- To investigate the influence of intracoronary pullback-derived lesion morphology on treatment strategies in stable CAD.
- To determine if lesion morphology independently affects treatment decisions beyond functional severity.
Main Methods:
- Retrospective single-centre cohort study of 303 patients with stable CAD undergoing intracoronary pullback measurement.
- Classification of lesions as focal or diffuse based on pullback data.
- Analysis of treatment strategies (optimal medical therapy, percutaneous coronary intervention, coronary artery bypass grafting) and one-year clinical outcomes.
Main Results:
- Diffuse disease (71%) was more common than focal disease (29%).
- Focal lesions were more likely treated with percutaneous coronary intervention (PCI), while diffuse lesions often received optimal medical therapy (OMT), even with significant ischemia (FFR ≤0.75).
- Lesion morphology, fractional flow reserve (FFR), and symptom burden independently predicted treatment decisions.
Conclusions:
- Intracoronary pullback-derived lesion morphology is an independent factor influencing treatment decisions in stable CAD.
- Diffuse coronary artery disease morphology frequently leads to deferral of revascularization, irrespective of functional severity.
- Lesion morphology can outweigh functional severity in guiding treatment choices for stable CAD.
Background:
Accurate assessment of lesion severity and distribution is essential for selecting the optimal treatment strategy in stable coronary artery disease (CAD). Clinicians increasingly use pullback measurements to assess disease patterns and improve percutaneous interventions, but the influence on clinical decision-making in practice is unknown.
Methods:
We conducted a retrospective, single-centre cohort study of patients with functionally significant stable CAD and who received intracoronary pullback measurement. Lesion morphology was classified as focal or diffuse based on intracoronary pressure pullback. The primary outcome was the final treatment strategy: optimal medical therapy (OMT), percutaneous coronary intervention (PCI), or coronary artery bypass grafting (CABG).
Results:
A total of 303 patients were included, of whom 29 % had focal and 71 % had diffuse disease. Patients with focal disease were more frequently treated with PCI, while those with diffuse disease more often received OMT, even in the presence of physiologically very significant ischemia (FFR ≤0.75). In multinomial regression analysis, lesion morphology, FFR value, and symptom burden independently predicted treatment decision. No difference in one-year clinical outcomes was observed between treatment groups.
Conclusions:
Lesion morphology from intracoronary pullback independently influences treatment in stable CAD, alongside severity and symptoms. PCI is typically chosen for focal lesions, whereas diffuse disease often results in deferring revascularization, even with significant ischemia (FFR ≤0.75). This shows that lesion morphology can take precedence over functional severity when deciding treatment.
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