Barry Hennigan1, Keith G Oldroyd2, Colin Berry2, Nils Johnson2, John McClure2, Peter McCartney2, Margaret B McEntegart2, Hany Eteiba2, Mark C Petrie2, Paul Rocchiccioli2, Richard Good2, Martin M Lindsay2, Stuart Hood2, Stuart Watkins2. 1. From the University of Glasgow, United Kingdom (B.H., K.G.O., C.B., P.M., M.B.M., H.E., M.C.P., P.R., R.G., M.M.L., S.H., S.W.); Cardiology Department, Golden Jubilee National Hospital, Clydebank, Glasgow, United Kingdom (B.H., K.G.O., C.B., J.M.); and The Weatherhead PET Imaging Center, Houston, TX (N.J.). barryhennigan@physicians.ie. 2. From the University of Glasgow, United Kingdom (B.H., K.G.O., C.B., P.M., M.B.M., H.E., M.C.P., P.R., R.G., M.M.L., S.H., S.W.); Cardiology Department, Golden Jubilee National Hospital, Clydebank, Glasgow, United Kingdom (B.H., K.G.O., C.B., J.M.); and The Weatherhead PET Imaging Center, Houston, TX (N.J.).
Abstract
BACKGROUND: Distal coronary to aortic pressure ratio (Pd/Pa) and instantaneous wave-free ratio (iFR) are indices of functional significance of a coronary stenosis measured without hyperemia. It has been suggested that iFR has superior diagnostic accuracy to Pd/Pa when compared with fractional flow reserve (FFR).We hypothesized that in comparison with FFR, revascularization decisions based on either binary cutoff values for iFR and Pd/Pa or hybrid strategies incorporating iFR or Pd/Pa will result in similar levels of disagreement. METHODS AND RESULTS: This is a prospective study in consecutive patients undergoing FFR for clinical indications using proprietary software to calculate iFR. We measured Pd/Pa, iFR, FFR, and hyperemic iFR. Diagnostic accuracy versus FFR ≤0.80 was calculated using binary cutoff values of ≤0.90 for iFR and ≤0.92 for Pd/Pa, and adenosine zones for iFR of 0.86 to 0.93 and Pd/Pa of 0.87 to 0.94 in the hybrid strategy. One hundred ninety-seven patients with 257 stenoses (mean diameter stenosis 48%) were studied. Using binary cutoffs, diagnostic accuracy was similar for iFR and resting Pd/Pa with misclassification rates of 21% versus 20.2% (P=0.85). In the hybrid analysis, 54% of iFR cases and 53% of Pd/Pa cases were outside the adenosine zone and rates of misclassification were 9.4% versus 11.9% (P=0.55). CONCLUSIONS: Binary cutoff values for iFR and Pd/Pa result in misclassification of 1 in 5 lesions. Using a hybrid strategy, approximately half of the patients do not receive adenosine, but 1 in 10 lesions are still misclassified. The use of nonhyperemic indices of stenosis severity cannot be recommended for decision making in the catheterization laboratory. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT02377310.
BACKGROUND: Distal coronary to aortic pressure ratio (Pd/Pa) and instantaneous wave-free ratio (iFR) are indices of functional significance of a coronary stenosis measured without hyperemia. It has been suggested that iFR has superior diagnostic accuracy to Pd/Pa when compared with fractional flow reserve (FFR).We hypothesized that in comparison with FFR, revascularization decisions based on either binary cutoff values for iFR and Pd/Pa or hybrid strategies incorporating iFR or Pd/Pa will result in similar levels of disagreement. METHODS AND RESULTS: This is a prospective study in consecutive patients undergoing FFR for clinical indications using proprietary software to calculate iFR. We measured Pd/Pa, iFR, FFR, and hyperemic iFR. Diagnostic accuracy versus FFR ≤0.80 was calculated using binary cutoff values of ≤0.90 for iFR and ≤0.92 for Pd/Pa, and adenosine zones for iFR of 0.86 to 0.93 and Pd/Pa of 0.87 to 0.94 in the hybrid strategy. One hundred ninety-seven patients with 257 stenoses (mean diameter stenosis 48%) were studied. Using binary cutoffs, diagnostic accuracy was similar for iFR and resting Pd/Pa with misclassification rates of 21% versus 20.2% (P=0.85). In the hybrid analysis, 54% of iFR cases and 53% of Pd/Pa cases were outside the adenosine zone and rates of misclassification were 9.4% versus 11.9% (P=0.55). CONCLUSIONS: Binary cutoff values for iFR and Pd/Pa result in misclassification of 1 in 5 lesions. Using a hybrid strategy, approximately half of the patients do not receive adenosine, but 1 in 10 lesions are still misclassified. The use of nonhyperemic indices of stenosis severity cannot be recommended for decision making in the catheterization laboratory. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT02377310.
Authors: Nils P Johnson; Wenguang Li; Xi Chen; Barry Hennigan; Stuart Watkins; Colin Berry; William F Fearon; Keith G Oldroyd Journal: Eur Heart J Date: 2019-08-14 Impact factor: 29.983
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