Correlação entre medidas fisiológicas de isquemia no laboratório de hemodinâmica: índices de repouso e índices hiperêmicos em lesões intermediárias de artérias coronárias principais
Correlação entre medidas fisiológicas de isquemia no laboratório de hemodinâmica: índices de repouso e índices hiperêmicos em lesões intermediárias de artérias coronárias principais
Data
2023
Autores
Ribeiro, Marcelo Lemos
Journal Title
Journal ISSN
Volume Title
Publisher
Instituto Nacional de Cardiologia
Resumo
Introdução: A doença coronariana é a maior causa de morbidade e mortalidade no mundo. A fisiologia coronariana invasiva tem se mostrado cientificamente segura no diagnóstico de lesões ateroscleróticas que provocam isquemia considerável, tanto no paciente com doença estável, quanto no paciente a ser estratificado após um episódio de síndrome coronariana aguda (SCA). Entretanto, a verdadeira acurácia diagnóstica dos recém popularizados índices de repouso, versus o tradicional índice hiperêmico Reserva de Fluxo Fracionado (FFR) tem sido uma questão controversa. Objetivo: Interrogar fisiologicamente lesões ateroscleróticas coronarianas, utilizando dois métodos de avaliação invasiva obtidos em repouso, um deles a relação pressão média distal / pressão média proximal no ciclo cardíaco inteiro (Pd/Pa), e um índice diastólico, Instantaneous Wave-Free Ratio (IFR) ou Diastolic Hyperemia-Free Ratio (DFR); e dois métodos hiperêmicos, seja Reserva de Fluxo Fracionado por contraste (c-FFR ), e o método referência ou padrão ouro Reserva de Fluxo Fracionado (FFR). Métodos: Estudo transversal, que selecionou prospectivamente pacientes no Laboratório de Hemodinâmica do Instituto Nacional de Cardiologia, no período de maio de 2020 a maio de 2022. Foram admitidos pacientes com angina estável e lesão coronariana intermediária (40-80% de obstrução na angiografia), e pacientes com síndrome coronariana aguda estabilizada e lesão adicional em outra artéria não relacionada ao evento agudo, e finalmente pacientes com doença multi-vascular cuja presença ou origem da isquemia fosse incerta. Resultados: Incluídos 119 pacientes e realizadas 152 avaliações fisiológicas comparativas, sendo 67% homens. A média de idade foi 62,9 anos. Avaliação após (SCA) ocorreu em 36,8%, e avaliação por angina estável/isquemia silenciosa em 63,2%. O FFR teve resultado positivo (≤ 0.80) em 92/152 lesões (60 %). A área sob a curva ROC mostrou uma maior correlação do c-FFR com o FFR (0,95), seguida do IFR/DFR (0,86) e do Pd/Pa (0,85). Discordância entre o IFR ou DFR e o método referência (FFR) ocorreu em 23,8% dos casos (36/152). Na nossa amostra, a discordância foi FFR + (hiperemia)/ IFR/DFR – (repouso) em 83 % dos casos. Os principais fatores associados a essa discordância foram lesões ostiais ou proximais, e a presença de restenose intrastent. Conclusão: A sensibilidade do FFR com adenosina foi superior à dos métodos em repouso, na detecção de lesões funcionalmente significativas. Contraste-FFR foi o método livre de adenosina que mais se aproximou aos resultados do FFR. A utilização dos métodos
de repouso deve ser complementar, e não substituta à hiperemia com adenosina ou medicação equivalente, na avaliação fisiológica invasiva das lesões coronarianas epicárdicas.
Palavras-chave: Aterosclerose coronariana. Isquemia miocárdica. Avaliação fisiológica invasiva.
Introduction: Coronary artery atherosclerosis is the leading cause of morbidity and mortality in the world. Since coronary invasive physiology in the catheterization laboratory has proved its value in diagnosing true ischemic coronary lesions, as in patients with stable disease or after an acute coronary syndrome (ACS), the true diagnostic accuracy of resting indexes versus the traditional hyperemic Fractional Flow Reserve (FFR) has been a matter of debate. Objective: The aim of this study was to evaluate physiologically intermediate atherosclerotic coronary lesions, by means of two resting indexes, one from the whole cardiac cycle as distal to aortic pressure ratio (Pd/Pa), and one diastolic resting index, Instantaneous Wave-Free Ratio (IFR) or Diastolic Hyperemia-Free Ratio (DFR), and two hyperemic indexes, contrast-based Fractional Flow Reserve (c-FFR) and the gold standard or reference method Fractional Flow Reserve (FFR).Methods: Cross-sectional study with selection of patients at the National Institute of Cardiology, from May 2020 to May 2022. The admission criteria included stable angina patients plus an intermediate coronary lesion (40-80% stenosis), as well as in-patients with ACS and intermediate lesions on a different, non-culpable artery, or multi arterial patients where the location of ischemia was not clearly identified. Results: 119 patients (152 lesions) were investigated. Male sex was present in 67% of cases. The mean age was 62.9 years. Physiologic evaluation after ACS occurred in 36.8% of cases, and 63.2% of patients presented with complaints of stable angina pectoris/silent ischemia. The FFR value was below ischemic threshold (FFR ≤ 0.80) in 92/152 lesions (60%). Compared with FFR, the AUC was 0.95 for c-FFR, 0.86 for IFR/DFR and 0.85 for PD/Pa. Discordance between the main resting diastolic index (IFR or DFR) and FFR occurred in 23.8% of cases (36/152), with the vast majority FFR +/IFR or DFR - (83%). The main factors associated with positive FFR discordant cases were ostial or proximal lesions, and the angiographic feature of intrastent restenosis. Conclusion: The sensitivity of FFR with adenosine to disclose functionally ischemic lesions was superior to that of resting physiologic indexes. Contrast-FFR results were the closest to intracoronary adenosine-FFR. The use of resting indexes to physiologically evaluate epicardial coronary lesions should be complementary to hyperemic evaluation with adenosine or equivalent agents. Keywords: Coronary Atherosclerosis. Myocardial Ischemia. Invasive Coronary Physiology.
Introduction: Coronary artery atherosclerosis is the leading cause of morbidity and mortality in the world. Since coronary invasive physiology in the catheterization laboratory has proved its value in diagnosing true ischemic coronary lesions, as in patients with stable disease or after an acute coronary syndrome (ACS), the true diagnostic accuracy of resting indexes versus the traditional hyperemic Fractional Flow Reserve (FFR) has been a matter of debate. Objective: The aim of this study was to evaluate physiologically intermediate atherosclerotic coronary lesions, by means of two resting indexes, one from the whole cardiac cycle as distal to aortic pressure ratio (Pd/Pa), and one diastolic resting index, Instantaneous Wave-Free Ratio (IFR) or Diastolic Hyperemia-Free Ratio (DFR), and two hyperemic indexes, contrast-based Fractional Flow Reserve (c-FFR) and the gold standard or reference method Fractional Flow Reserve (FFR).Methods: Cross-sectional study with selection of patients at the National Institute of Cardiology, from May 2020 to May 2022. The admission criteria included stable angina patients plus an intermediate coronary lesion (40-80% stenosis), as well as in-patients with ACS and intermediate lesions on a different, non-culpable artery, or multi arterial patients where the location of ischemia was not clearly identified. Results: 119 patients (152 lesions) were investigated. Male sex was present in 67% of cases. The mean age was 62.9 years. Physiologic evaluation after ACS occurred in 36.8% of cases, and 63.2% of patients presented with complaints of stable angina pectoris/silent ischemia. The FFR value was below ischemic threshold (FFR ≤ 0.80) in 92/152 lesions (60%). Compared with FFR, the AUC was 0.95 for c-FFR, 0.86 for IFR/DFR and 0.85 for PD/Pa. Discordance between the main resting diastolic index (IFR or DFR) and FFR occurred in 23.8% of cases (36/152), with the vast majority FFR +/IFR or DFR - (83%). The main factors associated with positive FFR discordant cases were ostial or proximal lesions, and the angiographic feature of intrastent restenosis. Conclusion: The sensitivity of FFR with adenosine to disclose functionally ischemic lesions was superior to that of resting physiologic indexes. Contrast-FFR results were the closest to intracoronary adenosine-FFR. The use of resting indexes to physiologically evaluate epicardial coronary lesions should be complementary to hyperemic evaluation with adenosine or equivalent agents. Keywords: Coronary Atherosclerosis. Myocardial Ischemia. Invasive Coronary Physiology.
Description
Palavras-chave
Aterosclerose coronariana, Isquemia miocárdica, Avaliação fisiológica invasiva, Coronary atherosclerosis, Myocardial ischemia, Invasive Coronary Physiology
Citação
Ribeiro ML. Correlação entre medidas fisiológicas de isquemia no laboratório de hemodinâmica: índices de repouso e índices hiperêmicos em lesões intermediárias de artérias coronárias principais. Rio de Janeiro. dissertação [Mestrado Profiossional em Ciências Cardiovasculares] Instituto Nacional de Cardiologia - INC; 2023.