Felder L, Vassalli G, Vassalli F, Jiang Z, Grimm J, Krayenbuehl H P, Hess O M
Department of Internal Medicine, Cardiology, University Hospital, Zurich, Switzerland.
Coron Artery Dis. 1994 Apr;5(4):347-58. doi: 10.1097/00019501-199404000-00011.
The clinical significance of coronary flow reserve (CFR) was evaluated after pharmacological (papaverine) and physiological (exercise) vasodilation in patients with coronary artery disease (CAD).
CFR was determined using parametric imaging in 10 patients with normal coronary arteries (group 1) and in 10 with CAD (group 2). Contrast density and mean appearance time were measured (region of interest = 249 pixels) in the perfusion beds of the left circumflex and the left anterior descending coronary arteries at rest, 45 s after 10 mg intracoronary papaverine, and during supine bicycle exercise. CFR was calculated from coronary perfusion after papaverine divided by perfusion at rest and coronary perfusion during exercise divided by perfusion at rest. Perfusion zones in patients with CAD were subdivided into regions supplied by a non-stenosed (group 2a) and a stenosed (group 2b) coronary artery.
In control patients, heart rate increased from 75 beats/min at rest to 125 beats/min during exercise, and in patients with CAD from 63 to 107 beats/min, respectively. Mean aortic pressure showed a significant increase during exercise in both groups. Mean pulmonary artery pressure increased significantly during exercise from 19 to 28 mmHg in control patients and from 22 to 42 mmHg in the CAD group (P < 0.001). Coronary driving pressure (mean aortic minus diastolic pulmonary artery pressure) tended to increase during exercise in the control group (from 90 to 101 mmHg, NS) and remained nearly unchanged in patients with CAD (from 92 to 94 mmHg, NS). In the control group, CFR was significantly higher during exercise than after papaverine (4.0 versus 3.5, respectively; P < 0.01). However, coronary resistance (coronary driving pressure divided by coronary flow index) was similar after papaverine and during exercise. In patients with CAD, papaverine-dependent CFR was significantly reduced in the perfusion zone of the stenosed (2.1) but not of the non-stenosed coronary artery (3.0). In contrast, CFR during exercise was significantly decreased in both perfusion zones (2.5 in non-stenosed arteries and 1.5 in stenosed vessels).
In control patients, CFR is slightly but significantly larger during exercise than after papaverine because of the exercise-induced increase in coronary driving pressure. In contrast, CFR is smaller during exercise than after papaverine in patients with CAD, most probably as a result of secondary mechanisms such as exercise-induced narrowing of stenosed vessels or an increase in extravascular resistance. Thus, CFR based on papaverine appears to be of limited value for assessing the functional significance of a stenotic lesion.
在冠状动脉疾病（CAD）患者中，经药理学（罂粟碱）和生理学（运动）血管扩张后，评估了冠状动脉血流储备（CFR）的临床意义。
使用参数成像法测定了10例冠状动脉正常患者（第1组）和10例CAD患者（第2组）的CFR。在静息状态、冠状动脉内注射10 mg罂粟碱后45秒以及仰卧位自行车运动期间，测量左旋支和左前降支冠状动脉灌注床的对比剂密度和平均显影时间（感兴趣区域=249像素）。CFR通过罂粟碱注射后的冠状动脉灌注除以静息灌注以及运动期间的冠状动脉灌注除以静息灌注来计算。CAD患者的灌注区被细分为由非狭窄冠状动脉供血的区域（第2a组）和狭窄冠状动脉供血的区域（第2b组）。
在对照组患者中，心率从静息时的75次/分钟增加到运动时的125次/分钟，CAD患者的心率分别从63次/分钟增加到107次/分钟。两组患者运动期间平均主动脉压均显著升高。对照组患者运动期间平均肺动脉压从19 mmHg显著升高至28 mmHg，CAD组从22 mmHg升高至42 mmHg（P<0.001）。冠状动脉驱动压（平均主动脉压减去舒张期肺动脉压）在对照组运动期间趋于升高（从90 mmHg升至101 mmHg，无显著性差异），而CAD患者则几乎保持不变（从92 mmHg升至94 mmHg，无显著性差异）。在对照组中，运动期间的CFR显著高于罂粟碱注射后（分别为4.0和3.5；P<0.01）。然而，罂粟碱注射后和运动期间的冠状动脉阻力（冠状动脉驱动压除以冠状动脉血流指数）相似。在CAD患者中，狭窄冠状动脉灌注区罂粟碱依赖性CFR显著降低（2.1），而非狭窄冠状动脉灌注区则未降低（3.0）。相比之下，两个灌注区运动期间的CFR均显著降低（非狭窄动脉为2.5，狭窄血管为1.5）。
在对照组患者中，由于运动诱导冠状动脉驱动压升高，运动期间的CFR略高于罂粟碱注射后，但差异显著。相比之下，CAD患者运动期间的CFR低于罂粟碱注射后，这很可能是由于诸如运动诱导狭窄血管狭窄或血管外阻力增加等继发机制所致。因此，基于罂粟碱的CFR对于评估狭窄病变的功能意义似乎价值有限。
