静息生理指标的生理和临床评估。
Physiological and Clinical Assessment of Resting Physiological Indexes.
机构信息
Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea (J.M.L., K.H.C., Y.B.S., J.-Y.H.).
Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, South Korea (Jonghanne Park, D.H., T.-M.R., B.-K.K.).
出版信息
Circulation. 2019 Feb 12;139(7):889-900. doi: 10.1161/CIRCULATIONAHA.118.037021.
BACKGROUND
Recently, resting pressure-derived indexes such as resting full-cycle ratio (RFR) and diastolic pressure ratio (dPR) have been introduced to assess the functional significance of epicardial coronary stenosis. The present study sought to investigate the agreement of RFR or dPR with other pressure-derived indexes (instantaneous wave-free ratio [iFR] or fractional flow reserve), the sensitivity of RFR or dPR for anatomic or hemodynamic stenosis severity, and the prognostic implications of RFR or dPR compared with iFR Methods: RFR and dPR were calculated from resting pressure tracings by an independent core laboratory in 1024 vessels (435 patients). The changes in resting physiological indexes according to diameter stenosis were compared among iFR, RFR, and dPR. Among 115 patients who underwent N-ammonia positron emission tomography, the changes in those indexes according to basal and hyperemic stenosis resistance and absolute hyperemic myocardial blood flow were compared. The association between resting physiological indexes and the risk of 2-year vessel-oriented composite outcomes (a composite of cardiac death, vessel-related myocardial infarction, and vessel-related ischemia-driven revascularization) was analyzed among 864 deferred vessels.
RESULTS
Both RFR and dPR showed a significant correlation with iFR ( R=0.979, P<0.001 for RFR; and R=0.985, P<0.001 for dPR), which was higher than that with fractional flow reserve ( R=0.822, P<0.001; and R=0.819, P<0.001, respectively). RFR and dPR showed a very high agreement with iFR (C index, 0.987 and 0.993). Percent difference of iFR, RFR, and dPR according to the increase in anatomic and hemodynamic severity was almost identical. The diagnostic performance of iFR, RFR, and dPR was not different in the prediction of myocardial ischemia defined by both low hyperemic myocardial blood flow and low coronary flow reserve by N-ammonia positron emission tomography. All resting physiological indexes showed significant association with the risk of 2-year vessel-oriented composite outcomes (iFR per 0.1 increase: hazard ratio, 0.514 [95% CI, 0.370-0.715], P<0.001; RFR per 0.1 increase: hazard ratio, 0.524 [95% CI, 0.378-0.725], P<0.001; dPR per 0.1 increase: hazard ratio, 0.587 [95% CI, 0.436-0.791], P<0.001) in deferred vessels.
CONCLUSIONS
All resting pressure-derived physiological indexes (iFR, RFR, and dPR) can be used as invasive tools to guide treatment strategy in patients with coronary artery disease.
CLINICAL TRIAL REGISTRATION
URL: https://www.clinicaltrials.gov . Unique identifier: NCT01621438.
背景
最近，静息压力衍生指标如静息全周期比（RFR）和舒张压力比（dPR）已被引入以评估心外膜冠状动脉狭窄的功能意义。本研究旨在探讨 RFR 或 dPR 与其他压力衍生指标（瞬时无波比 [iFR] 或血流储备分数）的一致性，RFR 或 dPR 对解剖学或血流动力学狭窄严重程度的敏感性，以及与 iFR 相比，RFR 或 dPR 的预后意义。
方法
由一个独立的核心实验室从 1024 个血管（435 例患者）的静息压力轨迹中计算 RFR 和 dPR。比较 iFR、RFR 和 dPR 中根据直径狭窄程度的静息生理指标的变化。在 115 例接受 N-氨正电子发射断层扫描的患者中，比较了这些指标根据基础和充血性狭窄阻力以及绝对充血性心肌血流的变化。在 864 个延迟血管中，分析了静息生理指标与 2 年血管导向复合结局（心脏死亡、血管相关心肌梗死和血管相关缺血驱动血运重建的复合）风险之间的关系。
结果
RFR 和 dPR 与 iFR 均呈显著相关（RFR：R=0.979，P<0.001；dPR：R=0.985，P<0.001），相关性高于与血流储备分数（RFR：R=0.822，P<0.001；dPR：R=0.819，P<0.001）。RFR 和 dPR 与 iFR 的一致性非常高（C 指数，0.987 和 0.993）。iFR、RFR 和 dPR 根据解剖学和血流动力学严重程度增加的百分比差异几乎相同。在预测由 N-氨正电子发射断层扫描定义的低充血性心肌血流和低冠状动脉血流储备引起的心肌缺血方面，iFR、RFR 和 dPR 的诊断性能没有差异。所有静息生理指标与 2 年血管导向复合结局的风险均有显著关联（iFR 每增加 0.1：风险比，0.514 [95%CI，0.370-0.715]，P<0.001；RFR 每增加 0.1：风险比，0.524 [95%CI，0.378-0.725]，P<0.001；dPR 每增加 0.1：风险比，0.587 [95%CI，0.436-0.791]，P<0.001）。
结论
所有静息压力衍生的生理指标（iFR、RFR 和 dPR）都可以用作指导冠状动脉疾病患者治疗策略的有创工具。
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