Ganzorig Nandine, Pompei Graziella, Jenkins Kenny, Wang Wanqi, Rubino Francesca, Gill Kieran, Kunadian Vijay
Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom.
Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Cona, Italy.
AsiaIntervention. 2024 Sep 27;10(3):157-168. doi: 10.4244/AIJ-D-24-00051. eCollection 2024 Sep.
Multivessel coronary artery disease (CAD), defined as ≥50% stenosis in 2 or more epicardial arteries, is associated with a high burden of morbidity and mortality in acute coronary syndrome (ACS) patients. A salient challenge for managing this cohort is selecting the optimal revascularisation strategy, for which the use of coronary physiology has been increasingly recognised. Fractional flow reserve (FFR) is an invasive, pressure wire-based, physiological index measuring the functional significance of coronary lesions. Understanding this can help practitioners evaluate which lesions could induce myocardial ischaemia and, thus, decide which vessels require urgent revascularisation. Non-hyperaemic physiology-based indices, such as instantaneous wave-free ratio (iFR), provide valid alternatives to FFR. While FFR and iFR are recommended by international guidelines in stable CAD, there is ongoing discussion regarding the role of physiology in patients with ACS and multivessel disease (MVD); growing evidence supports FFR use in the latter. Compelling findings show FFR-guided complete percutaneous coronary intervention (PCI) can reduce adverse cardiovascular events, mortality, and repeat revascularisations in ACS and MVD patients compared to angiography-based PCI. However, FFR is limited in identifying non-flow-limiting vulnerable plaques, which can disadvantage high-risk patients. Here, integrating coronary physiology assessment with intracoronary imaging in decision-making can improve outcomes and quality of life. Further research into novel physiology-based tools in ACS and MVD is needed. This review aims to highlight the key evidence surrounding the role of FFR and other functional indices in guiding PCI strategy in ACS and MVD patients.
多支冠状动脉疾病（CAD）定义为两支或更多支心外膜动脉狭窄≥50%，与急性冠状动脉综合征（ACS）患者的高发病率和死亡率负担相关。管理这一群体的一个突出挑战是选择最佳的血运重建策略，为此，冠状动脉生理学的应用越来越受到认可。血流储备分数（FFR）是一种基于压力导丝的有创生理指标，用于测量冠状动脉病变的功能意义。了解这一点有助于医生评估哪些病变可能诱发心肌缺血，从而决定哪些血管需要紧急血运重建。基于非充血生理学的指标，如瞬时无波比值（iFR），为FFR提供了有效的替代方案。虽然国际指南推荐在稳定型CAD中使用FFR和iFR，但关于生理学在ACS和多支血管疾病（MVD）患者中的作用仍在进行讨论；越来越多的证据支持在后者中使用FFR。令人信服的研究结果表明，与基于血管造影的PCI相比，FFR指导下的完全经皮冠状动脉介入治疗（PCI）可以减少ACS和MVD患者的不良心血管事件、死亡率和再次血运重建。然而，FFR在识别非血流限制性易损斑块方面存在局限性，这可能对高危患者不利。在此，在决策过程中将冠状动脉生理学评估与冠状动脉内成像相结合可以改善预后和生活质量。需要对ACS和MVD中基于新型生理学的工具进行进一步研究。本综述旨在强调围绕FFR和其他功能指标在指导ACS和MVD患者PCI策略中作用的关键证据。
