Clinical Outcome in Patients with Intermediate Stenosis of Left Anterior Descending Coronary Artery after Deferral of Revascularization on the Basis of Noninvasive Coronary Flow Reserve Measurement (original) (raw)
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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 the American Society of Echocardiography, 2018
Background: The potential of angiography to evaluate the hemodynamic severity of a left main coronary artery (LM) stenosis is limited. Noninvasive transthoracic Doppler echocardiographic coronary flow velocity reserve (CFVR) evaluation of intermediate coronary stenosis has demonstrated remarkably high negative prognostic value. The aim of this study was to assess clinical outcomes in patients with angiographically intermediate LM stenosis and preserved CFVR (>2.0) as evaluated by transthoracic Doppler echocardiographic CFVR. Methods: The initial study population included 102 patients with intermediate coronary stenosis of the LM referred for transthoracic Doppler echocardiographic CFVR assessment. Peak diastolic CFVR measurements were performed in the distal segment of the left anterior descending coronary artery after intravenous adenosine (140 mg/kg/min), and CFVR was calculated as the ratio between maximal hyperemic and baseline coronary flow velocity. Nineteen patients had impaired CFVR (#2.0) and were excluded from further analysis, as well as two patients with poor acoustic windows. The final group consisted of 81 patients (mean age, 60 6 9 years; 76 men) evaluated for adverse cardiac events including death, myocardial infarction, and revascularization. Results: Mean follow-up duration was 62 6 26 months. Mean CFVR was 2.4 6 0.4. Total event-free survival was 75 of 81 (92.6%), as six patients were referred for revascularization (five patients with coronary artery bypass grafting, one patient with percutaneous coronary intervention). There were no documented myocardial infarctions or cardiovascular deaths in the follow-up period. Conclusions: In patients with angiographically intermediate and equivocal LM stenosis and preserved CFVR values of >2.0, revascularization can be safely deferred.
The American Journal of Cardiology, 2009
Multidetector computed tomography (MDCT) detects coronary artery disease. However, an overestimation of coronary artery stenosis and artifacts can prevent accurate identification of significant coronary narrowing. The combination of MDCT with coronary flow reserve (CFR), the hyperemic/baseline peak flow velocity ratio, measured by transthoracic Doppler echocardiography might be helpful. We studied 144 consecutive patients with CFR and quantitative coronary angiography, obtained using both MDCT and invasive coronary angiography (reference method). It was hypothesized that the CFR might provide an incremental value to MDCT in detecting significant (>70%) left anterior descending (LAD) coronary artery stenosis. A CFR cutoff of <2 was used to discriminate significant stenosis. CFR was feasible in 141 (98%) of 144 patients, and MDCT was feasible in 131 (91%) of 144 patients (p <0.02). In a univariate model, the prediction of significant LAD stenosis was slightly, but significantly (p <0.0001), better with CFR (sensitivity 90%, specificity 96%, positive predictive value 84%, negative predictive value 97%, and diagnostic accuracy 94%, chi-square ؍ 97.5) than with MDCT (sensitivity 80%, specificity 93%, positive predictive value 71%, negative predictive value 95%, diagnostic accuracy 90%, chi-square ؍ 63.2). When the findings from transthoracic Doppler echocardiography and MDCT agreed, the diagnostic accuracy increased (96%; chi-square ؍ 86.1, p <0.0001). In a multivariate prediction of significant LAD stenosis using a logistic neural network, CFR overshadowed MDCT, and the area under the receiver operating curve was 0.99. Of the 13 patients missed by MDCT, the diagnostic accuracy of transthoracic Doppler echocardiography to predict significant LAD stenosis was 100%. Thus, CFR could improve the diagnostic accuracy of MDCT to detect significant LAD stenosis.
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.
Echocardiography, 2010
Objective: Coronary flow velocity reserve (CFR) by pulsed Doppler echocardiography is a useful hemodynamic index to evaluate the coronary microcirculatory dysfunction in the left anterior descending coronary artery (LAD). The present study was designed to evaluate the long-term predictive value of CFR for mortality in patients with right (RC) and/or left circumflex coronary artery (CX) stenosis without epicardial LAD disease. Methods: A total of 49 patients with significant RC and/or CX stenosis were enrolled in this prospective follow-up study. All patients had undergone coronary angiography demonstrating significant RC and/or CX stenosis without LAD disease and dipyridamole stress transoesophageal echocardiography as CFR measurement. Results: The success rate of follow-up was 43 out of 49 (88%). During a mean follow-up of 97 ± 29 months, 14 patients suffered cardiovascular deaths (12 sudden cardiac deaths and 2 strokes), and 1 patient died of pulmonal tumor. Patients who died during the follow-up had significantly lower CFR values (1.85 ± 0.43 vs. 2.31 ± 0.57, P < 0.05). Using ROC analysis, CFR <2.09 had the highest accuracy in predicting cardiovascular survival (sensitivity 80%, specificity 57%, area under the curve 73%, P = 0.003). The logistic regression model identified only CFR as an independent predictor of survival (hazard ratio [HR] 6.26, 95% CI of HR 1.23-19.61, P = 0.024). Conclusions: Long-term prognostic significance of CFR for the prediction of mortality has been demonstrated during a 9-year follow-up in patients with significant coronary artery disease not involving the LAD. (Echocardiography 2010;27:306-310)