Amsterdam UMC, University of Amsterdam, Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands; Department of Cardiology, Toho University Medical Center, Ohashi Hospital, Tokyo, Japan.
Amsterdam UMC, University of Amsterdam, Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands.
JACC Cardiovasc Interv. 2020 Jul 27;13(14):1617-1638. doi: 10.1016/j.jcin.2020.04.040.
Physiological assessment of coronary artery disease (CAD) has become one of the cornerstones of decision making for myocardial revascularization, with a large body of evidence supporting the benefits of using fractional flow reserve and other pressure-based indexes for functional assessment of coronary stenoses. Furthermore, physiology allows the identification of specific vascular dysfunction mechanisms in patients without obstructive CAD. Currently, more than 10 modalities of functional coronary assessment are available, although the overall adoption of these physiological tools, of either intracoronary or image-based nature, is still low. In this paper the authors review these modalities of functional coronary assessment according to their timing of use: outside the catheterization laboratory, in the catheterization laboratory prior to the percutaneous coronary intervention (PCI), and in the catheterization laboratory during or after PCI. The authors discuss how the information obtained can be used in setting the indication for PCI, in planning and guiding the procedure, and in documenting the final functional result of the intervention. The advantages and limitations of each modality in each setting are discussed. Furthermore, the key value of intracoronary physiology in diagnosing mechanisms of microcirculatory dysfunction, which account for the presence of ischemia in many patients without obstructive CAD, is revisited. On the basis of the opportunities generated by the multiplicity of diagnostic tools described, the authors propose an algorithmic approach to physiological coronary investigations in clinical practice, with the key aims of: 1) avoiding unneeded revascularization procedures; 2) improving procedural PCI and long-term outcomes in patients with obstructive CAD; and 3) diagnosing vascular dysfunction mechanisms that can be effectively treated in patients with NOCAD. The authors believe that such structured approach may also contribute to the wider adoption of available technologies for functional assessment of patients with CAD.
对冠状动脉疾病（CAD）的生理学评估已成为血运重建决策的基石之一，大量证据支持使用血流储备分数和其他压力为基础的指标对冠状动脉狭窄进行功能评估。此外，生理学还可以识别无阻塞性 CAD 患者的特定血管功能障碍机制。目前，有超过 10 种功能型冠状动脉评估的方法，但这些生理学工具（无论是基于腔内还是影像学）的总体应用仍然较低。本文作者根据这些功能型冠状动脉评估方法的使用时机对其进行了回顾：在导管室外、在经皮冠状动脉介入治疗（PCI）前的导管室中和在 PCI 期间或之后的导管室中。作者讨论了如何将获得的信息用于确定 PCI 的适应证，规划和指导手术，并记录介入治疗的最终功能结果。讨论了每种方法在每种情况下的优缺点。此外，还重新审视了腔内生理学在诊断微循环功能障碍机制中的重要价值，这些机制解释了许多无阻塞性 CAD 患者存在缺血的原因。基于所描述的多种诊断工具带来的机会，作者提出了一种在临床实践中进行生理学冠状动脉研究的算法方法，主要目标是：1）避免不必要的血运重建手术；2）改善有阻塞性 CAD 患者的手术 PCI 和长期预后；3）诊断可有效治疗 NOCAD 患者的血管功能障碍机制。作者认为，这种结构化的方法也可能有助于更广泛地采用现有的 CAD 患者功能评估技术。
