Verna Edoardo, Lattanzio Mariangela, Ghiringhelli Sergio, Provasoli Stefano, Caico Salvatore Ivan
Department of Cardiology, Cardiac Catheterization Lab., Ospedale di Circolo e Fondazione Macchi, University Hospital, Varese, Italy.
J Cardiovasc Med (Hagerstown). 2006 Mar;7(3):169-75. doi: 10.2459/01.JCM.0000215270.24649.de.
The present study aimed to prospectively evaluate whether application of the concept of fractional flow reserve (FFR) guides the immediate decision to perform or to defer coronary angioplasty in unselected consecutive patients with one or more angiographically intermediate (50-70%) stenoses and non-conclusive or lacking non-invasive testing.
We studied 112 patients (81 males and 31 females, aged 31-81 years) including 71 multivessel disease patients (63%) and 30 patients (27%) with unstable symptoms. FFR was measured with the use of a pressure-wire after adenosine-induced hyperaemia and compared with quantitative coronary angiography in 171 stenoses. Coronary angioplasty was performed in the presence of an FFR < 0.75 and deferred if FFR was > or = 0.75. Cardiac events including death, myocardial infarction, recurrent angina or symptoms requiring repeated hospitalization and target vessel revascularization (TVR) were recorded during a median period of 34 months (interquartile range 9-54 months).
Coronary angioplasty was deferred based on FFR results in 54 patients (group I). In the remaining 58 patients, angioplasty was performed in one or more stenoses that were significant by FFR and deferred in non-significant stenoses (group II). Overall, coronary angioplasty was performed in 71 vessels (41%) and deferred in 100 (59%). Cumulative cardiac events occurred in 12.9% of group I patients and in 24.1% of group II patients (chi-squared = 1.57, P = 0.20). TVR was required in 5% of the stenoses untreated based on FFR result in both groups and in 12.6% of stenoses that underwent coronary angioplasty (chi-squared = 3.25, P = 0.07; relative risk = 2.5, 95% confidence interval = 0.88-8.61).
In patients with angiographically intermediate stenoses, functional evaluation by FFR to select lesions that do not need to be treated invasively is safe. Unnecessary angioplasty and stenting may be saved in more than one half of individual coronary stenoses. The risk of major cardiac events and TVR of functionally non-significant stenoses is lower than the risk associated with coronary angioplasty. Our observations further support the use of pressure wire for physiological assessment of coronary artery stenosis in the catheterization room.
本研究旨在前瞻性评估对于未选择的连续性患者，应用血流储备分数（FFR）概念是否能指导立即进行或推迟冠状动脉血管成形术的决策，这些患者有一处或多处血管造影显示为中度（50 - 70%）狭窄且无创检查结果不明确或缺乏。
我们研究了112例患者（81例男性和31例女性，年龄31 - 81岁），其中包括71例多支血管病变患者（63%）和30例有不稳定症状的患者（27%）。在腺苷诱发充血后，使用压力导丝测量FFR，并与171处狭窄的定量冠状动脉造影结果进行比较。当FFR < 0.75时进行冠状动脉血管成形术，若FFR > 或 = 0.75则推迟手术。在中位时间34个月（四分位间距9 - 54个月）内记录心脏事件，包括死亡、心肌梗死、复发性心绞痛或需要再次住院的症状以及靶血管血运重建（TVR）。
基于FFR结果，54例患者（I组）推迟了冠状动脉血管成形术。在其余58例患者中，对一处或多处FFR显示为有意义的狭窄进行了血管成形术，对无意义的狭窄则推迟手术（II组）。总体而言，71处血管（41%）进行了冠状动脉血管成形术，100处（59%）推迟了手术。I组患者中累积心脏事件发生率为12.9%，II组患者中为24.1%（卡方检验 = 1.57，P = 0.20）。两组中基于FFR结果未治疗的狭窄中有5%需要进行TVR，而进行冠状动脉血管成形术的狭窄中有12.6%需要进行TVR（卡方检验 = 3.25，P = 0.07；相对风险 = 2.5，95%置信区间 = 0.88 - 8.61）。
对于血管造影显示为中度狭窄的患者，通过FFR进行功能评估以选择无需进行侵入性治疗的病变是安全的。超过一半的个体冠状动脉狭窄可能避免不必要的血管成形术和支架置入术。功能上无意义的狭窄发生主要心脏事件和TVR的风险低于冠状动脉血管成形术相关风险。我们的观察结果进一步支持在导管室使用压力导丝对冠状动脉狭窄进行生理评估。
