Department of Cardiology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA.
John L McClellan Memorial Veterans Hospital, Central Arkansas VA Healthy System, Little Rock, Arkansas, USA.
Catheter Cardiovasc Interv. 2022 Feb;99(3):714-722. doi: 10.1002/ccd.29790. Epub 2021 Jun 8.
Measurement of post-percutaneous coronary intervention (PCI) fractional flow reserve (FFR) demonstrates residual ischemia in a large percentage of cases deemed angiographically successful which, in turn, has been associated with worse long-term outcomes. It has recently been shown that a resting pressure index, Pd/Pa, has prognostic value post stenting, however, its diagnostic value relative to FFR post-PCI has not been evaluated.
The diagnostic accuracy of Pd/Pa in identifying ischemia (FFR≤0.80) pre- and post-PCI was evaluated. Three patient subsets were analyzed. A reference pre-PCI cohort of 1,255 patients (1,560 vessels) was used to measure the accuracy of pre-PCI Pd/Pa vs. FFR. A derivation post-PCI group of 574 patient (664 vessels) was then used to calculate the diagnostic accuracy of post-PCI Pd/Pa vs. FFR. A final prospective validation cohort of 230 patients (255 vessels) was used to test and validate the diagnostic performance of post-PCI Pd/Pa.
Median Pd/Pa and FFR were 0.90 (IQR 0.90-0.98) and 0.80 (IQR 0.71-0.88) in the reference pre-PCI model, 0.96 (IQR 0.93-1.00) and 0.87 (IQR 0.77-0.90) in the post-PCI derivation model, and 0.94 (IQR 0.89-0.97) and 0.84 (IQR 0.77-0.90) in the post-PCI validation model respectively. There was a strong linear correlation between Pd/Pa and FFR in all three models (p < 0.0001). Using ROC analysis, the optimal Pd/Pa cutoff value to predict a FFR ≤ 0.80 was ≤0.92 (AUC 0.87) in the pre-PCI model, ≤0.93 (AUC 0.85) in the post-PCI derivation model, and ≤ 0.90 (AUC 0.91) in the post-PCI validation model. Using a hybrid strategy of post-PCI Pd/Pa and post-PCI FFR when necessary (25% patients), overall diagnostic accuracy was improved to 95%.
Pd/Pa has excellent diagnostic accuracy for identifying ischemia post-intervention. Using a hybrid strategy of post-PCI Pd/Pa first, and FFR afterwards, if required, adenosine administration can be avoided in over 75% of physiologic assessments post intervention.
经皮冠状动脉介入治疗（PCI）后测量的分流量比值（FFR）显示，在被认为血管造影成功的大量病例中存在残余缺血，而这反过来又与长期预后较差有关。最近已经表明，静息压力指数 Pd/Pa 在支架置入后具有预后价值，然而，其在 PCI 后相对于 FFR 的诊断价值尚未得到评估。
评估了 Pd/Pa 在 PCI 前后识别缺血（FFR≤0.80）的诊断准确性。分析了三个患者亚组。使用参考的 PCI 前队列（1,255 例患者，1,560 支血管）来测量 PCI 前 Pd/Pa 与 FFR 的准确性。然后使用 574 例患者（664 支血管）的推导 PCI 后队列来计算 PCI 后 Pd/Pa 与 FFR 的诊断准确性。最后使用前瞻性验证队列（230 例患者，255 支血管）来测试和验证 PCI 后 Pd/Pa 的诊断性能。
参考 PCI 前模型中，Pd/Pa 和 FFR 的中位数分别为 0.90（IQR 0.90-0.98）和 0.80（IQR 0.71-0.88），PCI 后推导模型中分别为 0.96（IQR 0.93-1.00）和 0.87（IQR 0.77-0.90），而 PCI 后验证模型中分别为 0.94（IQR 0.89-0.97）和 0.84（IQR 0.77-0.90）。在所有三个模型中，Pd/Pa 和 FFR 之间均存在强线性相关性（p<0.0001）。使用 ROC 分析，预测 FFR≤0.80 的最佳 Pd/Pa 截断值在 PCI 前模型中为≤0.92（AUC 0.87），在 PCI 后推导模型中为≤0.93（AUC 0.85），在 PCI 后验证模型中为≤0.90（AUC 0.91）。使用 PCI 后 Pd/Pa 和必要时的 PCI 后 FFR 的混合策略（25%的患者），整体诊断准确性提高到 95%。
Pd/Pa 对识别介入后缺血具有出色的诊断准确性。使用 PCI 后 Pd/Pa 首先，如果需要，然后是 FFR 的混合策略，可以避免超过 75%的介入后生理性评估中使用腺苷。
