探讨使用绝对心肌血流和冠状动脉压力评估狭窄病变时冠状动脉循环反应及其与有创生理学指标的相关性。
Exploring Coronary Circulatory Response to Stenosis and Its Association With Invasive Physiologic Indexes Using Absolute Myocardial Blood Flow and Coronary Pressure.
机构信息
From Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (J.M.L.); Department of Internal Medicine and Cardiovascular Center (D.H., J.P., J.Z., C.H.K., B.-K.K.) and Department of Nuclear Medicine (J.-I.B., M.S., J.C.P., G.J.C.), Seoul National University Hospital, Korea; Department of Cardiology, China-Japan Union Hospital of Jilin University, Changchun, China (Y.T.); and Institute on Aging, Seoul National University, Korea (G.J.C., B.-K.K.).
出版信息
Circulation. 2017 Nov 7;136(19):1798-1808. doi: 10.1161/CIRCULATIONAHA.117.029911. Epub 2017 Aug 29.
BACKGROUND
Although invasive physiological assessment for coronary stenosis has become a standard practice to guide treatment strategy, coronary circulatory response and changes in invasive physiological indexes, according to different anatomic and hemodynamic lesion severity, have not been fully demonstrated in patients with coronary artery disease.
METHODS
One hundred fifteen patients with left anterior descending artery stenosis who underwent both N-ammonia positron emission tomography and invasive physiological measurement were analyzed. Myocardial blood flow (MBF) measured with positron emission tomography and invasively measured coronary pressures were used to calculate microvascular resistance and stenosis resistance.
RESULTS
With progressive worsening of angiographic stenosis severity, both resting and hyperemic transstenotic pressure gradient and stenosis resistance increased (<0.001 for all) and hyperemic MBF (<0.001) and resting microvascular resistance (=0.012) decreased. Resting MBF (=0.383) and hyperemic microvascular resistance (=0.431) were not changed and maintained stable. Both fractional flow reserve and instantaneous wave-free ratio decreased as angiographic stenosis severity, stenosis resistance, and transstenotic pressure gradient increased and hyperemic MBF decreased (all <0.001). When the presence of myocardial ischemia was defined by both low hyperemic MBF and low coronary flow reserve, the diagnostic accuracy of fractional flow reserve and instantaneous wave-free ratio did not differ, regardless of cutoff values of hyperemic MBF and coronary flow reserve.
CONCLUSIONS
This study demonstrated how the coronary circulation changes in response to increasing coronary stenosis severity using N-ammonium positron emission tomography-derived MBF and invasively measured pressure data. Currently used resting and hyperemic pressure-derived invasive physiological indexes have similar patterns of relationships to the different anatomic and hemodynamic lesion severities.
CLINICAL TRIAL REGISTRATION
URL: https://www.clinicaltrials.gov. Unique identifier: NCT01366404.
背景
尽管对冠状动脉狭窄进行有创的生理评估已成为指导治疗策略的标准做法，但冠状动脉循环反应以及根据不同解剖和血流动力学病变严重程度改变的有创生理指标在冠状动脉疾病患者中尚未得到充分证实。
方法
分析了 115 例接受 N-氨正电子发射断层扫描和有创生理测量的左前降支狭窄患者。用正电子发射断层扫描测量心肌血流（MBF）和有创测量冠状动脉压力，以计算微血管阻力和狭窄阻力。
结果
随着血管造影狭窄严重程度的逐渐恶化，静息和充血跨狭窄压力梯度和狭窄阻力均增加（均<0.001），充血 MBF（<0.001）和静息微血管阻力（=0.012）降低。静息 MBF（=0.383）和充血微血管阻力（=0.431）未改变且保持稳定。随着血管造影狭窄严重程度、狭窄阻力和跨狭窄压力梯度的增加以及充血 MBF 的降低，分数流量储备和瞬时无波比均降低（均<0.001）。当通过低充血 MBF 和低冠状动脉血流储备来定义心肌缺血的存在时，无论充血 MBF 和冠状动脉血流储备的截值如何，分数流量储备和瞬时无波比的诊断准确性均无差异。
结论
本研究使用 N-氨正电子发射断层扫描衍生的 MBF 和有创测量的压力数据，证明了冠状动脉循环如何对冠状动脉狭窄严重程度的增加做出反应。目前使用的静息和充血压力衍生的有创生理指标与不同的解剖和血流动力学病变严重程度具有相似的关系模式。
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