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Interventional Diagnostic Procedure: A Practical Guide for the Assessment of Coronary Vascular Function
Published on: March 15, 2022
Combined Anatomic and Functional Testing Identifies Patients With Obstructive Coronary Artery Disease Who Benefit
Oliver Buchhave Pedersen1, Laust Dupont Rasmussen2,3, Jacob Hartmann Søby2
1Department of Cardiology, Aalborg University Hospital, Denmark (O.B.P.).
Insights
Revascularization improves angina in some patients with single-vessel coronary artery disease, particularly those with significant myocardial perfusion defects. Nuclear myocardial perfusion imaging (nMPI) can identify patients who benefit most from this intervention.
Area of Science:
- Cardiology
- Nuclear Cardiology
- Interventional Cardiology
Background:
- Early revascularization in obstructive coronary artery disease (CAD) does not improve overall outcomes but can alleviate angina symptoms.
- The study investigates if myocardial perfusion defects and improvements predict health status changes after revascularization.
Purpose of the Study:
- To determine if the extent of myocardial perfusion defects and improvements in myocardial perfusion explain health status outcome changes after revascularization.
- To identify patients with single-vessel CAD who are most likely to benefit symptomatically from revascularization.
Main Methods:
- Analysis of two trials (ISCHEMIA and Dan-NICAD) involving stable patients with suspected obstructive CAD undergoing nuclear myocardial perfusion imaging (nMPI).
- Inclusion of patients with single-vessel CAD who underwent nMPI.
- Primary outcome measured was the change in the Seattle Angina Questionnaire angina frequency score.
Main Results:
- Revascularization was linked to improved angina frequency in 25% (summed difference score 5-10) and 26% (summed difference score ≥10) of patients.
- No symptom improvement was observed in patients with a summed difference score <5.
- Increased hyperemic myocardial blood flow post-revascularization was associated with freedom from angina (OR, 2.89).
Conclusions:
- Nuclear myocardial perfusion imaging (nMPI) can help identify patients with single-vessel CAD who may experience symptom relief from revascularization.
- Improved myocardial perfusion appears to be a key factor in the symptomatic benefit derived from revascularization.
Background:
In patients with obstructive coronary artery disease, early revascularization does not improve outcomes but may reduce angina symptoms. The objective of this study was to examine whether changes in health status outcomes following revascularization are explained by the extent of myocardial perfusion defects and improvement in myocardial perfusion.
Methods:
Two trials enrolling stable patients with new-onset chest pain suggestive of obstructive coronary artery disease, the ISCHEMIA (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches) and the Dan-NICAD (Danish Study of Noninvasive Testing in Coronary Artery Disease) trials, were analyzed. Patients with single-vessel coronary artery disease who underwent nuclear myocardial perfusion imaging (nMPI) were included. In the ISCHEMIA trial, patients with moderate/severe ischemia were randomized to either optimal medical therapy alone or optimal medical therapy and invasive angiography. The Dan-NICAD trial enrolled patients with suspected stenosis on coronary computed tomographic angiography undergoing nMPI. Test-guided revascularization blinded to nMPI was performed, and patients with initially abnormal nMPI were reassessed after 12 months. The primary outcome was the change in the Seattle Angina Questionnaire angina frequency score.
Results:
In total, 584 patients were eligible. In patients with a summed difference score of 5≤10 (n=149 [25%]) and ≥10 (n=152 [26%]), revascularization was associated with an improved angina frequency score (mean change ±SD: 16.4±20.9 and 19.0±24.1). No improvement was demonstrated in patients with a summed difference score <5. In multivariable logistic regression analysis (n=91), an increase in hyperemic myocardial blood flow at follow-up was associated with freedom from angina (odds ratio, 2.89 [95% CI, 1.04-8.70]).
Conclusions:
In patients with single-vessel coronary artery disease, nMPI may identify patients more likely to experience improved symptoms from revascularization, potentially reflecting enhanced myocardial perfusion.
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