在现实世界实践中使用微循环阻力指数和血流储备分数对缺血性心脏病进行综合生理评估：来自国际微循环阻力指数注册研究的见解
Integrated physiologic assessment of ischemic heart disease in real-world practice using index of microcirculatory resistance and fractional flow reserve: insights from the International Index of Microcirculatory Resistance Registry.
作者信息
Lee Joo Myung, Layland Jamie, Jung Ji-Hyun, Lee Hyun-Jung, Echavarria-Pinto Mauro, Watkins Stuart, Yong Andy S, Doh Joon-Hyung, Nam Chang-Wook, Shin Eun-Seok, Koo Bon-Kwon, Ng Martin K, Escaned Javier, Fearon William F, Oldroyd Keith G
机构信息
From the Department of Medicine, Seoul National University Hospital, Seoul, South Korea (J.M.L., J.-H.J., H.-J.L., B.-K.K.); Department of Cardiology, West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, United Kingdom (J.L., S.W., K.G.O.); BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (J.L., S.W., K.G.O.); Servicio de Cardiología, Hospital Clinico San Carlos, Faculty of Medicine Complutense University of Madrid, Madrid, Spain (M.E.-P., J.E.); Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (M.E.-P., J.E.); Department of Cardiovascular Medicine, Stanford University Medical Center, Stanford, CA (A.S.Y., W.F.F.); Department of Medicine, Inje University Ilsan Paik Hospital, Goyang, South Korea (J.-H.D.); Department of Medicine, Keimyung University Dongsan Medical Center, Daegu, South Korea (C.-W.N.); Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, South Korea (E.-S.S.); Institute on Aging, Seoul National University, Seoul, South Korea (B.K.K.); and Departments of Cardiology, Royal Prince Alfred and Concord Hospitals and University of Sydney, Sydney, Australia (M.K.N.).
出版信息
Circ Cardiovasc Interv. 2015 Nov;8(11):e002857. doi: 10.1161/CIRCINTERVENTIONS.115.002857.
BACKGROUND
The index of microcirculatory resistance (IMR) is a quantitative and specific index for coronary microcirculation. However, the distribution and determinants of IMR have not been fully investigated in patients with ischemic heart disease (IHD).
METHODS AND RESULTS
Consecutive patients who underwent elective measurement of both fractional flow reserve (FFR) and IMR were enrolled from 8 centers in 5 countries. Patients with acute myocardial infarction were excluded. To adjust for the influence of collateral flow, IMR values were corrected with Yong's formula (IMRcorr). High IMR was defined as greater than the 75th percentile in each of the major coronary arteries. FFR≤0.80 was defined as an ischemic value. 1096 patients with 1452 coronary arteries were analyzed (mean age 61.1, male 71.2%). Mean FFR was 0.84 and median IMRcorr was 16.6 U (Q1, Q3 12.4 U, 23.0 U). There was no correlation between IMRcorr and FFR values (r=0.01, P=0.62), and the categorical agreement of FFR and IMRcorr was low (kappa value=-0.04, P=0.10). There was no correlation between IMRcorr and angiographic % diameter stenosis (r=-0.03, P=0.25). Determinants of high IMR were previous myocardial infarction (odds ratio [OR] 2.16, 95% confidence interval [CI] 1.24-3.74, P=0.01), right coronary artery (OR 2.09, 95% CI 1.54-2.84, P<0.01), female (OR 1.67, 95% CI 1.18-2.38, P<0.01), and obesity (OR 1.80, 95% CI 1.31-2.49, P<0.01). Determinants of FFR ≤0.80 were left anterior descending coronary artery (OR 4.31, 95% CI 2.92-6.36, P<0.01), angiographic diameter stenosis ≥50% (OR 5.16, 95% CI 3.66-7.28, P<0.01), male (OR 2.15, 95% CI 1.38-3.35, P<0.01), and age (per 10 years, OR 1.21, 95% CI 1.01-1.46, P=0.04).
CONCLUSIONS
IMR showed no correlation with FFR and angiographic lesion severity, and the predictors of high IMR value were different from those for ischemic FFR value. Therefore, integration of IMR into FFR measurement may provide additional insights regarding the relative contribution of macro- and microvascular disease in patients with ischemic heart disease.
CLINICAL TRIAL REGISTRATION
URL: http://www.clinicaltrials.gov. Unique identifier: NCT02186093.
背景
微循环阻力指数（IMR）是冠状动脉微循环的一个定量且特异的指标。然而，缺血性心脏病（IHD）患者中IMR的分布及决定因素尚未得到充分研究。
方法与结果
从5个国家的8个中心纳入连续接受了血流储备分数（FFR）和IMR选择性测量的患者。排除急性心肌梗死患者。为校正侧支血流的影响，IMR值用Yong公式进行校正（IMRcorr）。高IMR定义为各主要冠状动脉中大于第75百分位数。FFR≤0.80定义为缺血值。对1096例患者的1452支冠状动脉进行了分析（平均年龄61.1岁，男性占71.2%）。平均FFR为0.84，IMRcorr中位数为16.6 U（四分位间距Q1、Q3分别为12.4 U、23.0 U）。IMRcorr与FFR值之间无相关性（r = 0.01，P = 0.62），FFR与IMRcorr的分类一致性较低（kappa值 = -0.04，P = 0.10）。IMRcorr与血管造影直径狭窄百分比之间无相关性（r = -0.03，P = 0.25）。高IMR的决定因素为既往心肌梗死（比值比[OR] 2.16，95%置信区间[CI] 1.24 - 3.74，P = 0.01）、右冠状动脉（OR 2.09，95% CI 1.54 - 2.84，P < 0.01）、女性（OR 1.67，95% CI 1.18 - 2.38，P < 0.01）和肥胖（OR 1.80，95% CI 1.31 - 2.49，P < 0.01）。FFR≤0.80的决定因素为左前降支冠状动脉（OR 4.31，95% CI 2.92 - 6.36，P < 0.01）、血管造影直径狭窄≥50%（OR 5.16，95% CI 3.66 - 7.28，P < 0.01）、男性（OR 2.15，95% CI 1.38 - 3.35，P < 0.01）和年龄（每10岁，OR 1.21，95% CI 1.01 - 1.46，P = 0.04）。
结论
IMR与FFR及血管造影病变严重程度无相关性，高IMR值的预测因素与缺血性FFR值的预测因素不同。因此，将IMR纳入FFR测量可能为缺血性心脏病患者大血管和微血管疾病的相对贡献提供更多见解。
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