Long-Term Prognostic Significance of Coronary Flow Velocity Reserve in Patients with Significant Coronary Artery Disease Not Involving the Left Anterior Descending Coronary Artery (Results from the SZEGED Study) (original) (raw)
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American Heart Journal, 2008
Doppler-derived coronary flow velocity reserve (CFVR) of left anterior descending (LAD) artery is an effective tool to predict overall mortality. The aim was to investigate the capability of CFVR to predict outcome in an unselected cohort of patients older than 80 years having stress echo negative by wall motion criteria. Methods and results The study group refers to 369 patients aged .80 years (156 men; mean age 83 + 2 years) who had undergone dipyridamole stress echocardiography with CFVR assessment of LAD artery of known (n ¼ 144) or suspected (n ¼ 225) coronary artery disease. Stress echocardiography was negative for wall motion criteria in all cases. Mean CFVR was 2.07 + 0.53. During a median follow-up of 21 months, there were 62 major adverse cardiac events (MACEs; 45 deaths and 17 non-fatal myocardial infarctions). With a receiver operating characteristic analysis, a CFVR of ≤1.93 was the best cutoff for predicting mortality and MACE. At individual patient analysis, 152 (41%) subjects had a CFVR of ,1.93. Annual mortality was 9.8% in patients with CFVR ,1.93 and 3.7% in those with CFVR .1.93 (P ¼ 0.001); an annual MACE rate was 14.8% in the former and 4.5% in the latter (P , 0.0001). Of 15 clinical and echocardiographic parameters analysed, CFVR ≤1.93 [hazard ratio (HR) ¼ 2.17, 95% CI 1.14-4.10] and resting wall motion abnormality (RWMA; HR ¼ 2.60; 95% CI 1.35-5.00) were multivariable indicators of mortality. Moreover, CFVR ≤1.93 (HR ¼ 2.69, 95% CI 1.56-4.67), and RWMA (HR ¼ 2.38; 95% CI 1.31-4.33) were also strong independent predictors of MACEs. At incremental analysis, CFR ≤1.93 added prognostic information over clinical evaluation and RWMA when both mortality and MACE were taken as clinical end points. Conclusions A reduced CFVR of LAD artery is a strong and independent indicator of both mortality and MACE, adding prognostic information over clinical evaluation and RWMA. Conversely, a preserved CFVR predicts a favourable outcome particularly in subjects with no RWMA.
The American Journal of Cardiology, 2009
In patients with angiographically normal coronary arteries and chest pain, pharmacologic stress echocardiography can identify a subgroup of patients with a less benign prognosis. Coronary flow reserve (CFR) in the left anterior descending artery (LAD) can currently be combined with wall motion analysis during vasodilator stress echocardiography. The aim of this study was to assess the prognostic value of CFR response in patients with normal coronary arteries and normal wall motion during stress. We selected 394 patients (171 men, 61 ؎ 11 years of age) who underwent dipyridamole stress echocardiography (0.84 mg/kg over 6 minutes) with 2-dimensional echocardiography and CFR evaluation of the LAD by Doppler. All had angiographically nonsignificant (<50% quantitatively assessed) stenosis in any major vessel, normal left ventricular function (wall motion score index 1), and test negativity for conventional wall motion criteria. Images were independently read by a core laboratory for wall motion and a core laboratory for CFR. Mean CFR was 2.5 ؎ 0.6 and 87 patients (22%) had an abnormal CFR <2.
Clinical Physiology and Functional Imaging, 2009
Introduction: Coronary flow velocity reserve (CFR) is markedly reduced in severe aortic valve stenosis (AS). Independent prognostic value of pulsed-wave Doppler echocardiography-derived CFR was seen in a variety of diseases. However, the prognostic significance of CFR by pulsed-wave Doppler echocardiography has never been evaluated in patients with AS. Methods: A total of 49 AS patients (mean age: 63 ± 9 years, 26 men) were enrolled in this prospective follow-up study; they all had undergone standard transthoracic Doppler-echo study, coronary angiography and dipyridamole stress transoesophageal echocardiography as CFR measurement. Results: During a mean follow-up of 82 ± 38 months, 18 patients suffered cardiovascular death and one patient had non-fatal stroke. Other two patients underwent reoperation of dysfunctional prosthetic aortic valve. Using receiver operator curve (ROC) analysis, CFR <2AE13 had the highest accuracy in predicting cardiovascular outcome (sensitivity 90%, specificity 46%, area under the curve 66%, P = 0AE02). By univariable analysis, diabetes mellitus, hypertension, presence of coronary artery disease and lower CFR were significant predictors of cardiovascular morbidity and mortality. Multivariable regression analysis showed that only lower CFR [hazard ratio (HR) 1AE67, 95% CI of HR: 1AE05-4AE29, P < 0AE05] was independent predictor of cardiovascular outcome. Discussion: Long-term prognostic significance of CFR for prediction of cardiovascular morbidity and mortality has been demonstrated during a 9-year follow-up in patients with AS. Despite a relatively small number of patients were followed, CFR was found to be an independent predictor for future cardiovascular events in AS patients.
Echocardiography, 2013
Patients with moderate and severe aortic stenosis (AS) and without obstructive epicardial coronary disease have been shown to have an impairment of coronary flow reserve (CFR). We investigated the prognostic significance of CFR in predicting death during mid-to-long-term follow-up in asymptomatic patients with moderate/severe AS, preserved ejection fraction (EF), and with nonobstructed coronary arteries. Method and Result: A total of 127 patients with moderate or severe AS (effective orifice area of 1.5 cm 2 or less), mean age 66 AE 11 were enrolled in this prospective study. The median follow-up was 32 AE 7 months. All patients had standard Doppler echo study, coronary angiography, and adenosinestress transthoracic Doppler echo for CFR measurement. Univariate analysis showed that diabetes mellitus, CFR, aortic valve area (AVA), maximal velocity (V max), mean pressure gradient (P mean), energy loss index (ELI), aortic valve resistance (AVR), NT-proBNP, E/E′, valvulo-arterial impedance (Z va), and stroke work loss (SWL) were associated (P < 0.05) with death. Multivariable logistic regression analysis revealed that only Z va and CFR were independent predictors of death, with the CFR being the single strongest predictor (Table 2). Using receiver operating characteristics (ROC) analysis, the CFR value of 1.85 had the highest accuracy in predicting the death during mid-to-long-term follow-up (area under the curve; AUC 0.890, P = 0.009, sensitivity 96.3%, specificity 75%; 95% CI 0.287-0.946; Fig. 1). The Z va value of 5.52 Hg/mL per m had a sensitivity 70.0% and specificity 72.0% (AUC 0.766, 95% CI 0.587-0.946; P = 0.005). Conclusion: This study demonstrates that CFR has a prognostic value in patients with asymptomatic moderate or severe AS with preserved EF and nonobstructed coronary arteries.
European Journal of Echocardiography, 2009
Aims Prognostic value of transthoracic coronary flow reserve (T-CFR) is not established in patients with left anterior descending artery (LAD) stenosis of intermediate severity. Objective is to determine the prognosis value of T-CFR. 2 in medically treated patients with angiographically intermediate [50-70% QCA (quantitative coronary angiography)] proximal LAD stenosis. Methods and results Among 110 consecutive patients with intermediate LAD stenosis who underwent prospectively T-CFR in the distal part of the LAD after intravenous administration of adenosine to assess the functional significance of the stenosis, 80 patients had T-CFR. 2 and were treated medically without revascularization (Group 1). Among the 30 patients who had T-CFR , 2, an additional dobutamine stress echocardiography (DSE) was performed: 15 had a negative DSE; were treated medically and served as a comparative group (Group 2), and 15 had a positive DSE; underwent LAD revascularization, and were excluded from further analysis. All patients completed follow-up (16 + 10 months). During the follow-up period (range 6-45 months), 76 patients (95%) remained free of death or LAD-related event in Group 1, vs. 12 patients (80%) in Group 2. By Kaplan-Meier method, at 30 months the per cent estimated survival free from death or target vessel-related events was 92 + 4% in Group 1 and 44 + 22% in Group 2 (P , 0.01). By multivariate analysis, T-CFR remained the only independent predictor of death or LADrelated events. Conclusion In patients with proximal LAD stenosis of intermediate severity and T-CFR. 2, deferral of revascularization is associated with low event rate.
Journal of Cardiovascular Medicine, 2008
Background Transthoracic Doppler echocardiography is a valuable tool to measure coronary flow reserve (CFR) and detect in-stent restenosis (ISR) after percutaneous coronary angioplasty in selected series of patients. Objectives To assess the usefulness of coronary flow reserve measured by echocardiography in detecting significant (>-70%) ISR of the left anterior descending coronary artery in a large unselected population. Methods Two hundred and twenty-three patients (age 61 W 10 years; 168 men) treated with left anterior descending stenting underwent CFR measurement by transthoracic Doppler echocardiography and venous adenosine infusion 24-72 h before control coronary angiography. Coronary-active drugs were continued, and patients with multiple risk factors and old anterior-apical myocardial infarction were included. Results Significant ISR occurred in 56 patients (25%). Patients with ISR had higher basal coronary flow velocity (27 W 10 cm/s vs. 24 W 7 cm/s; P < 0.002) and lower CFR (1.5 W 0.5 vs. 2.7 W 0.6; P < 0.0001) than those without ISR. A linear relation was found between ISR and CFR (r U S0.73; P < 0.0001) and remained significant after adjustment for blood pressure and heart rate (r U S0.74; P < 0.0001). A CFR less than two identified significant ISR (sensitivity 88%, specificity 88%, area under the curve U 0.943; P < 0.001). In a multivariate model of CFR prediction, myocardial infarction and heart rate were slightly contributory (ß U S0.19, P < 0.01; ß U S0.16, P < 0.03, respectively), whereas ISR had a large influence (ß U S0.66; P < 0.0001). The inverse correlation between ISR and CFR persisted in patients with myocardial infarction (r U S0.64; P < 0.0001) and in those treated with b-blockers (r U S0. 71; P < 0.0001). Conclusion Echocardiographic measurement of CFR detects significant left anterior descending ISR in unselected patients with multiple risk factors, old anteriorapical myocardial infarction, and taking b-blockers.