RESUMEN
OBJECTIVE: To assess long-term clinical outcomes and factors associated with target vessel revascularisation in patients with deferred revascularisation based on negative fractional flow reserve and negative instantaneous wave-free ratio. METHODS: The longitudinal, retrospective study was conducted from July 1, 2020, to January 1, 2022, at the Aga Khan University Hospital, Karachi, and comprised medical records from January 2012 to January 2020 of patients with deferred revascularisation having intermediate to severe coronary lesions on coronary angiogram and had negative fractional flow reserve >0.80 or instantaneous wave-free ratio >0.89 and had not undergone immediate or planned revascularisation on the basis of negative physiological assessment. Data was collected from the institutional records, while final follow-up was taken by reviewing the medical records or telephonic interviews regarding any major adverse cardiac event after the index procedure. Data was analysed using Stata 14.2. RESULTS: Of the 345 patients, 245(71%) were males. The overall mean age was 62±11 years. There were 194(56%) patients who presented with stable angina and 151(44%) presented with acute coronary syndrome. Mean fractional flow reserve was 0.87±0.04 and mean instantaneous wave-free ratio was 0.93±0.03. Multivessel disease was present in 223(65%) patients. Median follow-up period was 29 months (IQR: 24-36 months). Major adverse cardiovascular events occurred in 22(6%) patients, and target vessel revascularisation was required in 11(3%). Diabetes and percentage of stenosis were found to be independent predictors of major adverse cardiovascular events (p<0.05). CONCLUSIONS: Deferral of revascularisation and opting for medical treatment for coronary artery stenosis with higher fractional flow reserve or instantaneous wave-free ratio could be considered a safe and reasonable strategy.
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Angiografía Coronaria , Reserva del Flujo Fraccional Miocárdico , Revascularización Miocárdica , Humanos , Reserva del Flujo Fraccional Miocárdico/fisiología , Masculino , Femenino , Persona de Mediana Edad , Pakistán/epidemiología , Estudios Retrospectivos , Anciano , Revascularización Miocárdica/métodos , Revascularización Miocárdica/estadística & datos numéricos , Enfermedad de la Arteria Coronaria/cirugía , Enfermedad de la Arteria Coronaria/fisiopatología , Estudios Longitudinales , Estenosis Coronaria/fisiopatología , Estenosis Coronaria/cirugía , Síndrome Coronario Agudo/cirugía , Síndrome Coronario Agudo/fisiopatología , Angina Estable/cirugía , Angina Estable/fisiopatología , Resultado del Tratamiento , Intervención Coronaria Percutánea/métodosRESUMEN
BACKGROUND: Clinical events such as angina pectoris, acute coronary syndrome, and sudden death caused by myocardial bridge (MB) have attracted increasing attention. It is still a challenge to diagnose whether MB can cause the symptoms of patients with MB. For most MB patients, medication remains the primary treatment. CASE PRESENTATION: This article reports a case of chest pain in a patient with MB in the middle segment of the left anterior descending artery (LADm) with moderate stenosis in the proximal segment (LADp). Through functional assessment, we found that neither MB nor fixed stenosis had sufficient effect on coronary blood flow to cause myocardial ischemia, but their synergistic effect resulted in myocardial ischemia. Finally, a stent was implanted in LADp and good clinical results were achieved. CONCLUSIONS: For symptomatic patients with MB combined with fixed stenosis, functional evaluation may be necessary, which has significant guiding significance for treatment strategy selection. For asymptomatic patients, early detection of myocardial ischemia may also improve the prognosis of patients.
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Estenosis Coronaria , Puente Miocárdico , Humanos , Estenosis Coronaria/fisiopatología , Estenosis Coronaria/diagnóstico por imagen , Estenosis Coronaria/terapia , Estenosis Coronaria/etiología , Puente Miocárdico/complicaciones , Puente Miocárdico/fisiopatología , Puente Miocárdico/diagnóstico por imagen , Resultado del Tratamiento , Masculino , Stents , Angiografía Coronaria , Persona de Mediana Edad , Isquemia Miocárdica/fisiopatología , Isquemia Miocárdica/etiología , Isquemia Miocárdica/terapia , Isquemia Miocárdica/diagnóstico por imagen , Intervención Coronaria Percutánea/instrumentación , Anciano , Índice de Severidad de la EnfermedadAsunto(s)
Estenosis Coronaria , Intervención Coronaria Percutánea , Humanos , Intervención Coronaria Percutánea/métodos , Estenosis Coronaria/diagnóstico por imagen , Estenosis Coronaria/cirugía , Estenosis Coronaria/fisiopatología , Masculino , Femenino , Persona de Mediana Edad , Anciano , Velocidad del Flujo Sanguíneo/fisiologíaRESUMEN
BACKGROUND: AccuFFRct (ArteryFlow Technology) is a novel noninvasive method for calculating fractional flow reserve (FFR) from coronary computed tomography angiography (CCTA). The accuracy of AccuFFRct has not been adequately assessed. OBJECTIVES: This study sought to evaluate the diagnostic performance of AccuFFRct in detecting lesion-specific ischemia. METHODS: This prospective study enrolled 339 patients with 404 vessels. CCTA-derived FFR was calculated using an on-site computational fluid dynamics-based method and compared with invasive FFR. The performance of AccuFFRct was comprehensively analyzed in all lesions and subgroups, including "gray zone" lesions, various lesion classifications, clinical presentations, stenosis severities, and lesion locations. RESULTS: Using FFR ≤0.80 as a reference standard, the overall diagnostic accuracy, sensitivity, specificity, positive predictive value, and negative predictive value for AccuFFRct were 90.6% (95% CI: 87.3%-93.3%), 90.9% (95% CI: 85.1%-94.9%), 90.4% (95% CI: 86.1%-93.8%), 85.3% (95% CI: 79.8%-89.5%), and 94.2% (95% CI: 90.8%-96.4%), respectively. Good correlation and agreement were found between the computed AccuFFRct and measured FFR. AccuFFRct showed superior discrimination ability to CCTA (AUC: 0.93 [95% CI: 0.89-0.95] vs 0.77 [95% CI: 0.72-0.81]; P < 0.001) and quantitative coronary angiography (AUC: 0.93 [95% CI: 0.89-0.95] vs 0.89 [95% CI: 0.85-0.92]; P = 0.048) for identifying functionally significant stenosis. Notably, AccuFFRct maintained high diagnostic accuracy across the spectrum of lesion classifications, clinical presentations, stenosis severities, lesion locations, and in the "gray zone". Furthermore, in the cohort with ≥70% stenosis, AccuFFRct could significantly reduce the rate of un-necessary invasive tests (33.1% vs 6.6%; P < 0.001). CONCLUSIONS: The study confirms the potential of AccuFFRct as a noninvasive alternative to invasive FFR for detecting ischemia in coronary artery disease and to risk stratify patients. The results highlight AccuFFRct's robust diagnostic ability across a wide range of lesion classifications, clinical presentations, stenosis severities, lesion locations, and in the "gray zone". (Diagnostic Performance of Fractional Flow Reserve Derived From Coronary CT Angiography [ACCURATE-CT]; NCT04426396).
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Angiografía por Tomografía Computarizada , Angiografía Coronaria , Enfermedad de la Arteria Coronaria , Estenosis Coronaria , Vasos Coronarios , Reserva del Flujo Fraccional Miocárdico , Valor Predictivo de las Pruebas , Índice de Severidad de la Enfermedad , Humanos , Estudios Prospectivos , Femenino , Masculino , Persona de Mediana Edad , Anciano , Estenosis Coronaria/fisiopatología , Estenosis Coronaria/diagnóstico por imagen , Reproducibilidad de los Resultados , Enfermedad de la Arteria Coronaria/fisiopatología , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Vasos Coronarios/diagnóstico por imagen , Vasos Coronarios/fisiopatología , Tomografía Computarizada Multidetector , Cateterismo Cardíaco , Interpretación de Imagen Radiográfica Asistida por ComputadorRESUMEN
AIM: To study clinical and demographic characteristics, treatment options, and clinical outcomes in patients with myocardial infarction with non-obstructive coronary arteries (MINOCA) compared with patients with myocardial infarction with obstructive coronary arteries (MIOCA). MATERIAL AND METHODS: This single-center prospective observational study included 712 successive patients diagnosed with acute myocardial infarction (MI), who routinely underwent direct coronary angiography. Based on the presence of stenosing coronary atherosclerosis, the patients were divided into two groups: MIOCA (coronary stenosis ≥50%) and MINOCA (coronary stenosis <50% without other, alternative causes). Clinical outcomes included in-hospital and long-term overall mortality, and cardiovascular rehospitalization. The median follow-up was 1.5 years. RESULTS: MINOCA was diagnosed in 73 (10.3%) patients, 37 (50%) of whom were women. The median age of patients with MINOCA was 61 years and in the MIOCA group 65 years. No significant differences in cardiovascular risk factors were found between patients with MINOCA and MIOCA. In 53.4% of cases, the cause of MINOCA was a discrepancy between the myocardial oxygen demand and supply, and in 35.6% of cases, the cause was hypertensive crisis and pulmonary edema. The factors associated with MINOCA included an age ≤58 years, female gender, absence of the ST-segment elevation, absence of areas of impaired local contractility, and presence of aortic stenosis and bronchopulmonary infection. Patients with MINOCA were less likely to be prescribed acetylsalicylic acid, P2Y12 inhibitors, dual antiplatelet therapy, beta-blockers, and statins (p<0.05). Data on long-term outcomes were available for 87.5% of patients (n=623). The prognosis of patients with MIOCA was comparable for in-hospital mortality (1.5% vs. 6.2%; p=0.161) and long-term overall mortality (6.1% vs. 14.7%; p=0.059). Cardiovascular rehospitalizations were more frequent in the MINOCA group (33.3% vs. 21.5%; p=0.042). CONCLUSION: The prevalence of MINOCA in our study was 10.3% among all patients with acute MI. MINOCA patients had comparable generally recognized cardiovascular risk factors with MIOCA patients. MINOCA patients had a comparable prognosis for in-hospital and long-term mortality and more often required cardiovascular rehospitalization.
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Angiografía Coronaria , Infarto del Miocardio , Humanos , Femenino , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Anciano , Infarto del Miocardio/epidemiología , Angiografía Coronaria/métodos , Prevalencia , Factores de Riesgo , Federación de Rusia/epidemiología , MINOCA/epidemiología , Vasos Coronarios/diagnóstico por imagen , Vasos Coronarios/fisiopatología , Estenosis Coronaria/epidemiología , Estenosis Coronaria/fisiopatologíaRESUMEN
BACKGROUND AND OBJECTIVE: Disturbed autonomic nervous system (ANS) may promote inflammatory, immune, and oxidative stress responses, which may increase the risk of acute coronary events. S100ß has been proposed as a biomarker of neuronal injury that would provide an insightful understanding of the crosstalk between the ANS, immune-inflammatory cells, and plaques that drive atherosclerosis. This study investigates the correlation between S100ß, and functional coronary stenosis as determined by quantitative flow ratio (QFR). METHODS: Patients with unstable angina pectoris (UAP) scheduled for coronary angiography and QFR were retrospectively enrolled. Serum S100ß levels were determined by enzyme-linked immunosorbent assay. The Gensini score was used to estimate the extent of atherosclerotic lesions and the cumulative sum of three-vessel QFR (3V-QFR) was calculated to estimate the total atherosclerotic burden. RESULTS: Two hundred thirty-three patients were included in this study. Receiver operator characteristic (ROC) curve indicated that S100ß>33.28 pg/mL predicted functional ischemia in patients with UAP. Multivariate logistic analyses showed that a higher level of S100ß was independently correlated with a functional ischemia-driven target vessel (QFR ≤0.8). This was also closely correlated with the severity of coronary lesions, as measured by the Gensini score (OR = 5.058, 95% CI: 2.912-8.793, p <0.001). According to 3V-QFR, S100ß is inversely associated with total atherosclerosis burden (B = -0.002, p <0.001). CONCLUSIONS: S100ß was elevated in the functional ischemia stages of UAP. It was independently associated with coronary lesion severity as assessed by Gensini score and total atherosclerosis burden as estimated by 3V-QFR in patients with UAP.
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Angina Inestable , Biomarcadores , Angiografía Coronaria , Subunidad beta de la Proteína de Unión al Calcio S100 , Humanos , Masculino , Femenino , Angina Inestable/sangre , Angina Inestable/fisiopatología , Angina Inestable/diagnóstico por imagen , Persona de Mediana Edad , Anciano , Subunidad beta de la Proteína de Unión al Calcio S100/sangre , Estudios Retrospectivos , Biomarcadores/sangre , Curva ROC , Estenosis Coronaria/sangre , Estenosis Coronaria/fisiopatología , Estenosis Coronaria/diagnóstico por imagenRESUMEN
BACKGROUND AND OBJECTIVE: Fractional Flow Reserve (FFR) is generally considered the gold standard in hemodynamics to assess the impact of a stenosis on the blood flow. The standard procedure to measure involves the displacement of a pressure guide along the circulatory system until it is placed next to the lesion to be analyzed. The main objective of the present study is to analyze the influence of the pressure guide on the invasive FFR measurements and its implications in clinical practice. METHODS: We studied the influence of pressure wires on the measurement of Fractional Flow Reserve (FFR) through a combination of Computational Fluid Dynamics (CFD) simulations using 45 clinical patient data with 58 lesions and ideal geometries. The analysis is conducted considering patients that were subjected to a computer tomography and also have direct measurements using a pressure guide. Influence of the stenosis severity, degree of occlusion and blood viscosity has also been studied. RESULTS: The influence of pressure wires specifically affects severe stenosis with a lumen diameter reduction of 50 % or greater. This type of stenosis leads to reduced hyperemic flow and increased coronary pressure drop. Thus, we identified that the placement of wires during FFR measurements results in partial obstruction of the coronary artery lumen, leading to increased pressure drop and subsequent reduction in blood flow. The severity of low FFR values associated with severe stenosis may be prone to overestimation when compared to stenosis without severe narrowing. These results have practical implications, particularly in the interpretation of lesions falling within the "gray zone" (0,75-0,80). CONCLUSIONS: The pressure wire's presence significantly alters the flow on severe lesions, which has an impact on the FFR calculation. In contrast, the impact of the pressure wire appears to be reduced when the FFR is larger than 0.8. The findings provide critical information for physicians, emphasizing the need for cautious interpretation of FFR values, particularly in severe stenosis. It also offers insights into improving the correlation between FFRct models and invasive measurements by incorporating the influence of pressure wires.
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Estenosis Coronaria , Reserva del Flujo Fraccional Miocárdico , Humanos , Estenosis Coronaria/fisiopatología , Estenosis Coronaria/diagnóstico por imagen , Simulación por Computador , Hidrodinámica , Modelos Cardiovasculares , Hemodinámica , Masculino , Vasos Coronarios/fisiopatología , Vasos Coronarios/diagnóstico por imagen , Femenino , Persona de Mediana Edad , AncianoRESUMEN
BACKGROUND AND OBJECTIVES: Instantaneous wave-free ratio (iFR) is a new invasive indicator of myocardial ischaemia, and its diagnostic performance is as good as the "gold standard" of myocardial ischaemia diagnosis: fractional flow reserve (FFR). iFR can be approximated by iFRCT, which is calculated based on noninvasive coronary CT angiography (CTA) images and computational fluid dynamics (CFD). However, the existing methods for calculating iFRCT fail to accurately simulate the resting state of the coronary artery, resulting in low computational accuracy. Furthermore, the use of CFD technology limits its computational efficiency, making it difficult to meet clinical application needs. The role of coronary microcirculatory resistance compensation suggests that microcirculatory resistance can be adaptively reduced to compensate for increases in coronary stenotic resistance, thereby maintaining stable myocardial perfusion in the resting state. It is therefore necessary to consider this compensation mechanism to establish a high-fidelity microcirculation resistance model in the resting state in line with human physiology, and so to achieve accurate calculation of iFRCT. METHODS: In this study we successfully collected clinical data, such as FFR, in 205 stenotic vessels from 186 patients with coronary heart disease. A neural network model was established to predict coronary artery stenosis resistance. Based on the compensation mechanism of coronary microcirculation resistance, an iterative solution algorithm for microcirculation resistance in the resting state was developed. Combining the two methods, a simplified single-branch model combining coronary stenosis and microcirculation resistance was established, and the noninvasive and rapid numerical calculation of iFRCT was performed. RESULTS: The results showed that the mean squared error (MSE) between the pressure drop predicted by the neural network value for the coronary artery stenosis model and the ground truth in the test set was 0.053 %, and correlation analysis proved that there was a good correlation between them (r = 0.99, p < 0.001). With reference to clinical diagnosis of myocardial ischaemia (using FFR as the gold standard), the diagnostic accuracy of the iFRCT calculation model for the 205 cases was 88.29 % (r = 0.71, p < 0.001), and the total calculation time was < 8 s. CONCLUSIONS: The results of this study demonstrate the utility of a simplified single-branch model in an iFRCT calculation method based on haemodynamics and deep learning, which is important for noninvasive and rapid diagnosis of myocardial ischaemia.
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Angiografía Coronaria , Estenosis Coronaria , Aprendizaje Profundo , Reserva del Flujo Fraccional Miocárdico , Hemodinámica , Humanos , Estenosis Coronaria/fisiopatología , Estenosis Coronaria/diagnóstico por imagen , Estenosis Coronaria/diagnóstico , Femenino , Angiografía Coronaria/métodos , Masculino , Persona de Mediana Edad , Anciano , Vasos Coronarios/diagnóstico por imagen , Vasos Coronarios/fisiopatología , Angiografía por Tomografía Computarizada/métodos , Microcirculación , Isquemia Miocárdica/fisiopatología , Isquemia Miocárdica/diagnóstico por imagen , Isquemia Miocárdica/diagnóstico , Redes Neurales de la Computación , Modelos Cardiovasculares , Algoritmos , HidrodinámicaRESUMEN
BACKGROUND: T2*BOLD is based on myocardial deoxyhemoglobin content to reflect the state of myocardial oxygenation. Quantitative flow ratio is a tool for assessing coronary blood flow based on invasive coronary angiography. PURPOSE: This study aimed to evaluate the correlation between T2*BOLD and QFR in the diagnosis of stenotic coronary arteries in patients with multi-vessel coronary artery disease. METHODS: Fifty patients with MVCAD with at least 1 significant coronary artery stenosis (diameter stenosis > 50%) and 21 healthy control subjects underwent coronary angiography combined with QFR measurements and cardiovascular magnetic resonance (CMR). QFR ≤ 0.80 was considered to indicate the presence of hemodynamic obstruction. RESULTS: Totally 60 (54%) obstructive vessels had hemodynamic change. Between stenotic coronary arteries (QFR ≤ 0.8) and normal vessels, T2*BOLD showed AUCs of 0.97, 0.69, and 0.91 for left anterior descending (LAD), left circumflex (LCX) and right coronary (RCA) arteries and PI displayed AUCs of 0.89, 0.77 and 0.90 (all p > 0.05, except for LAD). The AUCs of T2*BOLD between stenotic coronary arteries (QFR > 0.8) and normal vessels were 0.86, 0.72, and 0.85 for LAD, LCX and RCA; while, PI showed AUCs of 0.93, 0.86, and 0.88, respectively (p > 0.05). Moreover, T2*BOLD displayed AUCs of 0.96, 0.74, and 0.91 for coronary arteries as before between coronary arteries with stenosis (QFR ≤ 0.8 and > 0.8), but the mean PI of LAD, LCX and RCA showed no significant differences between them. CONCLUSION: T2* BOLD and QFR have good correlation in diagnosing stenotic coronary arteries with hemodynamic changes in patients with stable multi-vessel CAD. T2* BOLD is superior to semi-quantitative perfusion imaging in analyzing myocardial ischemia without stress.
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Angiografía Coronaria , Estenosis Coronaria , Humanos , Masculino , Femenino , Estenosis Coronaria/diagnóstico por imagen , Estenosis Coronaria/fisiopatología , Persona de Mediana Edad , Angiografía Coronaria/métodos , Anciano , Estudios de Casos y Controles , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/fisiopatología , Circulación Coronaria , Imagen por Resonancia Magnética/métodosRESUMEN
INTRODUCTION: Revascularization of nonculprit arteries in patients with ST-Segment Elevation Myocardial Infarction (STEMI) is now recommended based on several trials. However, the optimal therapeutic strategy of nonculprit lesions remains unknown. Murray law-based Quantitative Flow Ratio (µQFR) is a novel, non-invasive, vasodilator-free method for evaluating the functional severity of coronary artery stenosis, which has potential applications for nonculprit lesion assessment in STEMI patients. MATERIAL AND METHODS: Patients with STEMI who received staged PCI before hospital discharge were enrolled retrospectively. µQFR analyses of nonculprit vessels were performed based on both acute and staged angiography. RESULTS: Eighty-four patients with 110 nonculprit arteries were included. The mean acute µQFR was 0.76 ± 0.18, and the mean staged µQFR was 0.75 ± 0.19. The average period between acute and staged evaluation was 8 days. There was a good correlation (r = 0.719, P < 0.001) between acute µQFR and staged µQFR. The classification agreement was 89.09%. The area under the receiver operator characteristic (ROC) curve for detecting staged µQFR ≤ 0.80 was 0.931. CONCLUSIONS: It is feasible to calculate the µQFR during the acute phase of STEMI patients. Acute µQFR and staged µQFR have a good correlation and agreement. The µQFR could be a valuable method for assessing functional significance of nonculprit arteries in STEMI patients.
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Angiografía Coronaria , Estenosis Coronaria , Vasos Coronarios , Intervención Coronaria Percutánea , Infarto del Miocardio con Elevación del ST , Índice de Severidad de la Enfermedad , Humanos , Infarto del Miocardio con Elevación del ST/fisiopatología , Infarto del Miocardio con Elevación del ST/diagnóstico , Infarto del Miocardio con Elevación del ST/diagnóstico por imagen , Infarto del Miocardio con Elevación del ST/terapia , Masculino , Femenino , Estudios Retrospectivos , Persona de Mediana Edad , Vasos Coronarios/diagnóstico por imagen , Vasos Coronarios/fisiopatología , Anciano , Estenosis Coronaria/fisiopatología , Estenosis Coronaria/diagnóstico por imagen , Estenosis Coronaria/diagnóstico , Valor Predictivo de las Pruebas , Circulación Coronaria , Curva ROC , Reproducibilidad de los Resultados , Velocidad del Flujo SanguíneoRESUMEN
BACKGROUND: Cardiovascular events still occur at intermediate stenosis with fractional flow reserve (FFR) ≥0.81, underscoring the additional measure to evaluate this residual risk. A reduction in distal coronary artery pressure/aortic pressure (Pd/Pa) from baseline to hyperemia (ie, change in Pd/Pa) reflects lipidic burden within vessel walls. We hypothesized that this physiological measure might stratify the risk of future cardiac events at deferrable lesions. METHODS: Lesion- (899 intermediate lesions) and patient-based (899 deferred patients) analyses in those with FFR ≥0.81 were conducted to investigate the association between change in Pd/Pa and target lesion failure (TLF) and major adverse cardiac events at 7 years, respectively. RESULTS: The occurrence of TLF and major adverse cardiac events was 6.7% and 13.4%, respectively. The incidence of target lesion-related nonfatal myocardial infarction was 0.6%. Lesions with TLF had a greater change in Pd/Pa (0.11±0.03 versus 0.09±0.04; P=0.002), larger diameter stenosis (51.0±9.2% versus 46.4±12.4%; P=0.048), and smaller FFR (0.84 [0.82-0.87] versus 0.86 [0.83-0.90]; P=0.02). Change in Pd/Pa (per 0.01 increase) predicted TLF (odds ratio, 1.16 [95% CI, 1.05-1.28]; P=0.002) and major adverse cardiac event (odds ratio, 1.08 [95% CI, 1.01-1.16]; P=0.03). Lesions with change in Pd/Pa ≥0.10 had 2.94- and 1.85-fold greater likelihood of TLF (95% CI, 1.30-6.69; P=0.01) and major adverse cardiac event (95% CI, 1.08-3.17; P=0.03), respectively. Lesions with FFR ≤0.85 had a substantially higher likelihood of TLF when there is a change in Pd/Pa ≥0.10 (12.4% versus 2.9%; hazard ratio, 3.60 [95% CI, 1.01-12.80]; P=0.04). However, change in Pd/Pa did not affect TLF risk in lesions with FFR ≥0.86 (3.8% versus 3.7%; hazard ratio, 0.56 [95% CI, 0.06-5.62]; P=0.62). CONCLUSIONS: Despite deferrable FFR values, lesions and patients with a change in Pd/Pa ≥0.10 had higher cardiovascular risk. Change in Pd/Pa might help stratify lesion- and patient-level risks of future cardiac events in those with FFR ≥0.81.
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Presión Arterial , Estenosis Coronaria , Vasos Coronarios , Reserva del Flujo Fraccional Miocárdico , Valor Predictivo de las Pruebas , Humanos , Masculino , Femenino , Anciano , Persona de Mediana Edad , Factores de Riesgo , Estenosis Coronaria/fisiopatología , Estenosis Coronaria/diagnóstico por imagen , Medición de Riesgo , Factores de Tiempo , Vasos Coronarios/fisiopatología , Vasos Coronarios/diagnóstico por imagen , Cateterismo Cardíaco , Pronóstico , Hiperemia/fisiopatología , Enfermedad de la Arteria Coronaria/fisiopatología , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Índice de Severidad de la Enfermedad , Angiografía Coronaria , Infarto del Miocardio/fisiopatología , IncidenciaRESUMEN
BACKGROUND: The prognostic impact of complete coronary revascularization relative to non-invasive testing methods is unknown. OBJECTIVES: To assess the association between completeness of revascularization defined by CTA-derived fractional flow reserve (FFRCT) and cardiovascular outcomes in patients with stable angina. METHODS: Multicenter 3-year follow-up study of patients with new onset stable angina and ≥ 30% stenosis by CTA. The lesion-specific FFRCT value (two cm-distal-to-stenosis) was registered in all vessels with stenosis and considered abnormal when ≤ 0.80. Patients with FFRCT ≤ 0.80 were categorized as: Completely revascularized (CR-FFRCT), all vessels with FFRCT ≤ 0.80 revascularized; incompletely revascularized (IR-FFRCT), ≥ 1 vessels with FFRCT ≤ 0.80 non-revascularized. Early revascularization (< 90 days from index CTA) categorized vessels as revascularized. The primary endpoint comprised cardiovascular death and non-fatal myocardial infarction; the secondary endpoint vessel-specific late revascularization and non-fatal myocardial infarction. RESULTS: Amongst 900 patients and 1759 vessels, FFRCT was ≤ 0.80 in 377 (42%) patients, 536 (30%) vessels; revascularization was performed in 244 (27%) patients, 340 (19%) vessels. Risk of the primary endpoint was higher for IR-FFRCT (15/210 [7.1%]) compared to CR-FFRCT (4/167 [2.4%]), RR: 2.98; 95% CI: 1.01-8.8, p â= â0.036, and to normal FFRCT (3/523 [0.6%]), RR: 12.45; 95% CI: 3.6-42.6, p â< â0.001. Incidence of the secondary endpoint was higher in non-revascularized vessels with FFRCT ≤ 0.80 (29/250 [12%]) compared to revascularized vessels with FFRCT ≤ 0.80 (5/286 [1.7%]), p â= â0.001, and to vessels with FFRCT > 0.80 (10/1223 [0.8%]), p â< â0.001. CONCLUSION: Incomplete revascularization of patients with lesion-specific FFRCT ≤ 0.80 is associated to unfavorable cardiovascular outcomes compared to those with complete revascularization or FFRCT > 0.80.
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Angina Estable , Angiografía por Tomografía Computarizada , Angiografía Coronaria , Estenosis Coronaria , Reserva del Flujo Fraccional Miocárdico , Valor Predictivo de las Pruebas , Humanos , Masculino , Femenino , Angina Estable/fisiopatología , Angina Estable/mortalidad , Angina Estable/diagnóstico por imagen , Angina Estable/cirugía , Angina Estable/terapia , Persona de Mediana Edad , Anciano , Resultado del Tratamiento , Factores de Riesgo , Factores de Tiempo , Estenosis Coronaria/diagnóstico por imagen , Estenosis Coronaria/fisiopatología , Estenosis Coronaria/mortalidad , Estenosis Coronaria/cirugía , Medición de Riesgo , Índice de Severidad de la Enfermedad , Vasos Coronarios/diagnóstico por imagen , Vasos Coronarios/fisiopatología , Revascularización Miocárdica , Infarto del Miocardio/mortalidad , Infarto del Miocardio/fisiopatología , Infarto del Miocardio/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/fisiopatología , Enfermedad de la Arteria Coronaria/mortalidad , Tomografía Computarizada MultidetectorRESUMEN
OBJECTIVES: The diagnostic performance of fractional flow reserve with computed tomography (FFR-CT) is affected by the presence of calcified plaque. Subtraction can remove the influence of calcification in coronary computed tomography angiography (CCTA) to increase confidence in the diagnosis of coronary artery stenosis. Our purpose is to investigate the accuracy of post-subtraction FFR-CT in predicting early revascularization. DESIGN: Based on CCTA data of 237 vessels from 79 patients with coronary artery disease, subtraction CCTA images were obtained at a local post-processing workstation, and the conventional and post-subtraction FFR-CT measurements and the difference in proximal and distal FFR-CT values of the narrowest segment of the vessel (ΔFFR-CT) were analyzed for their accuracy in predicting early coronary artery hemodynamic reconstruction. RESULTS: With FFR-CT ≤ 0.8 as the criterion, the accuracy of conventional and post-subtraction FFR-CT measurements in predicting early revascularization was 73.4% and 77.2% at the patient level, and 64.6% and 72.2% at the vessel level, respectively. The specificity of post-subtraction FFR-CT measurements was significantly higher than that of conventional FFR-CT at both the patient and vessel levels (P of 0.013 and 0.015, respectively). At the vessel level, the area under the curve of receiver operating characteristic was 0.712 and 0.797 for conventional and post-subtraction ΔFFR-CT, respectively, showing a difference (P = 0.047), with optimal cutoff values of 0.07 and 0.11, respectively. CONCLUSION: The post-subtraction FFR-CT measurements enhance the specificity in predicting early revascularization. The post-subtraction ΔFFR-CT value of the stenosis segment > 0.11 may be an important indicator for early revascularization.
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Angiografía por Tomografía Computarizada , Angiografía Coronaria , Enfermedad de la Arteria Coronaria , Estenosis Coronaria , Reserva del Flujo Fraccional Miocárdico , Revascularización Miocárdica , Valor Predictivo de las Pruebas , Humanos , Masculino , Femenino , Persona de Mediana Edad , Anciano , Enfermedad de la Arteria Coronaria/fisiopatología , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/terapia , Estenosis Coronaria/diagnóstico por imagen , Estenosis Coronaria/fisiopatología , Estenosis Coronaria/terapia , Reproducibilidad de los Resultados , Vasos Coronarios/fisiopatología , Vasos Coronarios/diagnóstico por imagen , Calcificación Vascular/diagnóstico por imagen , Calcificación Vascular/fisiopatología , Calcificación Vascular/terapia , Estudios Retrospectivos , Tomografía Computarizada Multidetector , Índice de Severidad de la Enfermedad , Tiempo de Tratamiento , Angiografía de Substracción DigitalRESUMEN
Wellens syndrome, an ST Elevation Myocardial Infarction (STEMI) equivalent, is also known as T-wave left anterior descending (LAD) coronary artery disease. Wellens syndrome is characterized by a unique electrocardiogram (ECG) pattern that suggests a significant stenosis in the left anterior descending coronary artery that warrants immediate intervention. Hereby, we present a case report of Wellens syndrome in a patient with a history of hypertension and chronic obstructive pulmonary disease (COPD) that may be potentially mistaken for pseudo- Wellens syndrome because the ECG pattern mimics left ventricular strain pattern (LVSP) in left ventricular hypertrophy (LVH). Thus, cautious examination of recent chest pain and ECG is important to differentiate Wellens syndrome and LVSP in patients with hypertension and COPD to perform early detection and aggressive intervention since they may help to lessen the adverse results.
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Electrocardiografía , Hipertensión , Enfermedad Pulmonar Obstructiva Crónica , Humanos , Enfermedad Pulmonar Obstructiva Crónica/complicaciones , Enfermedad Pulmonar Obstructiva Crónica/fisiopatología , Hipertensión/complicaciones , Masculino , Infarto del Miocardio con Elevación del ST/diagnóstico , Infarto del Miocardio con Elevación del ST/fisiopatología , Infarto del Miocardio con Elevación del ST/complicaciones , Infarto del Miocardio con Elevación del ST/etiología , Persona de Mediana Edad , Hipertrofia Ventricular Izquierda/diagnóstico , Hipertrofia Ventricular Izquierda/fisiopatología , Hipertrofia Ventricular Izquierda/etiología , Diagnóstico Diferencial , Estenosis Coronaria/diagnóstico por imagen , Estenosis Coronaria/complicaciones , Estenosis Coronaria/diagnóstico , Estenosis Coronaria/fisiopatología , Dolor en el Pecho/etiología , Dolor en el Pecho/diagnóstico , Angiografía Coronaria , SíndromeRESUMEN
The quantification of stenosis severity from X-ray catheter angiography is a challenging task. Indeed, this requires to fully understand the lesion's geometry by analyzing dynamics of the contrast material, only relying on visual observation by clinicians. To support decision making for cardiac intervention, we propose a hybrid CNN-Transformer model for the assessment of angiography-based non-invasive fractional flow-reserve (FFR) and instantaneous wave-free ratio (iFR) of intermediate coronary stenosis. Our approach predicts whether a coronary artery stenosis is hemodynamically significant and provides direct FFR and iFR estimates. This is achieved through a combination of regression and classification branches that forces the model to focus on the cut-off region of FFR (around 0.8 FFR value), which is highly critical for decision-making. We also propose a spatio-temporal factorization mechanisms that redesigns the transformer's self-attention mechanism to capture both local spatial and temporal interactions between vessel geometry, blood flow dynamics, and lesion morphology. The proposed method achieves state-of-the-art performance on a dataset of 778 exams from 389 patients. Unlike existing methods, our approach employs a single angiography view and does not require knowledge of the key frame; supervision at training time is provided by a classification loss (based on a threshold of the FFR/iFR values) and a regression loss for direct estimation. Finally, the analysis of model interpretability and calibration shows that, in spite of the complexity of angiographic imaging data, our method can robustly identify the location of the stenosis and correlate prediction uncertainty to the provided output scores.
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Angiografía Coronaria , Estenosis Coronaria , Reserva del Flujo Fraccional Miocárdico , Humanos , Angiografía Coronaria/métodos , Reserva del Flujo Fraccional Miocárdico/fisiología , Estenosis Coronaria/diagnóstico por imagen , Estenosis Coronaria/fisiopatología , AlgoritmosRESUMEN
BACKGROUND: Due to insufficient near-field resolution and artifacts, it is challenging to evaluate the left ventricular apical perfusion with phased-array probes. By combining high-frequency linear probe and contrast-enhanced ultrasound (CEUS), imaging of apical myocardial perfusion could be improved. The study aims to evaluate the preliminary application of CEUS by high-frequency linear probes to assess the apical perfusion. METHODS: The study enrolled retrospectively 91 patients to test the feasibility of the novel method. In protocol 1, patients were stratified into a group with left anterior descending artery (LAD) stenosis (N = 40) and a group without LAD stenosis or coronary artery disease (N = 41) based on the degree of coronary artery narrowing, quantified by >50% stenosis in coronary angiography. Receiver operating characteristics (ROC) analysis was performed to test the diagnostic value of perfusion parameters. In protocol 2, the reproducibility of high-frequency linear probe in apical perfusion analysis was compared with the conventional phased-array probe in 30 patients. RESULTS: (1) The novel method is feasible in 81(89.01%) patients. (2) In protocol 1, to detect LAD stenosis, the best cut-off of ß, T, A, and MBF were 10.32, 3.28, 9.39, and 4.99, respectively. Area under the curve of ß, T, A, and MBF were .880, .881, .761, and .880, respectively. (3) In protocol 2, compared with phased-array probe, the quantitative analysis of high-frequency linear probe is of high reproducibility and could get good curve fitting (R2 = .29 vs. R2 = .71, P < .01). CONCLUSION: Observation of apical perfusion using this method is feasible and quantitative analysis allows an accurate and convenient identification of LAD stenosis. This method provides an alternative for patients who have difficulties in visualizing the apical region with a phased-array probe.
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Medios de Contraste , Estudios de Factibilidad , Humanos , Masculino , Femenino , Reproducibilidad de los Resultados , Estudios Retrospectivos , Persona de Mediana Edad , Imagen de Perfusión Miocárdica/métodos , Ecocardiografía/métodos , Aumento de la Imagen/métodos , Anciano , Sensibilidad y Especificidad , Ventrículos Cardíacos/diagnóstico por imagen , Ventrículos Cardíacos/fisiopatología , Estenosis Coronaria/fisiopatología , Estenosis Coronaria/diagnóstico por imagen , Diseño de EquipoRESUMEN
Coronary artery disease is the leading global cause of mortality and Fractional Flow Reserve (FFR) is widely regarded as the gold standard for assessing coronary artery stenosis severity. However, due to the limitations of invasive FFR measurements, there is a pressing need for a highly accurate virtual FFR calculation framework. Additionally, it's essential to consider local haemodynamic factors such as time-averaged wall shear stress (TAWSS), which play a critical role in advancement of atherosclerosis. This study introduces an innovative FFR computation method that involves creating five patient-specific geometries from two-dimensional coronary angiography images and conducting numerical simulations using computational fluid dynamics with a three-element Windkessel model boundary condition at the outlet to predict haemodynamic distribution. Furthermore, four distinct boundary condition methodologies are applied to each geometry for comprehensive analysis. Several haemodynamic features, including velocity, pressure, TAWSS, and oscillatory shear index are investigated and compared for each case. Results show that models with average boundary conditions can predict FFR values accurately and observed errors between invasive FFR and virtual FFR are found to be less than 5%.
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Angiografía Coronaria , Vasos Coronarios , Reserva del Flujo Fraccional Miocárdico , Humanos , Angiografía Coronaria/métodos , Vasos Coronarios/diagnóstico por imagen , Vasos Coronarios/fisiopatología , Modelos Cardiovasculares , Hemodinámica , Estenosis Coronaria/fisiopatología , Estenosis Coronaria/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/fisiopatología , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Masculino , Simulación por Computador , Femenino , Persona de Mediana EdadRESUMEN
Fractional flow reserve (FFR) has become the gold standard for evaluating coronary lesion-specific ischemia. However, FFR is an invasive method that may cause possible complications in the coronary artery and requires expensive equipment, which limits its use. Promising noninvasive diagnostic methods, such as computed tomography angiography-derived FFR (CT-FFR) and the quantitative flow ratio (QFR), have been proposed. In this study, we evaluated the diagnostic performance of the QFR and CT-FFR in predicting coronary lesion-specific ischemia, with the FFR serving as the reference standard. Patients with suspected or known coronary artery disease who underwent coronary CT angiography revealing 30-90% diameter stenosis in the main coronary artery (≥ 2.0 mm reference diameter) were enrolled. The FFR was measured during invasive coronary angiography (within 15 days after coronary CT angiography). An FFR ≤ 0.8 was the reference standard for coronary lesion-specific ischemia. A total of 103 vessels from 92 consecutive patients (aged 59.8 ± 9.2 years; 60.9% were men) were evaluated. The diagnostic performance of a QFR ≤ 0.80 for predicting coronary lesion-specific ischemia demonstrated good diagnostic accuracy, sensitivity, and specificity (92.2%, 87.2%, and 96.4%, respectively), with an area under the receiver operating characteristic curve (AUC) of 0.987 (P < 0.0001). The diagnostic performance of a CT-FFR ≤ 0.80 for predicting coronary lesion-specific ischemia also demonstrated good diagnostic accuracy, sensitivity, and specificity (96.1%, 95.7%, and 96.4%, respectively), with an AUC of 0.967 (P < 0.0001). However, there was no significant difference in the AUC between a QFR ≤ 0.80 and a CT-FFR ≤ 0.80 for predicting coronary lesion-specific ischemia (P = 0.319). There was an excellent correlation between the QFR and FFR (r = 0.856, P < 0.0001). The CT-FFR and FFR also showed a good direct correlation (r = 0.816, P < 0.0001). The QFR and CT-FFR are strongly correlated with the FFR and can provide excellent clinical diagnostic performance for coronary lesion-specific ischemia detection.