A Normal Reference Coronary Flow Reserve is Associated With a Lower Mortality in Patients With Stable Coronary Artery Disease

Transcription

1 A Normal Reference Coronary Flow Reserve is Associated With a Lower Mortality in Patients With Stable Coronary Artery Disease Tim van de Hoef, M.D. Steven AJ Chamuleau 2, Michiel Voskuil 2, Niels van Royen 1, Karel T Koch 1, Robbert J de Winter 1, Jan Baan Jr 1, Marije M Vis 1, Jan GP Tijssen 1, José PS Henriques 1, Jan J Piek 1, Martijn Meuwissen 1 1 Department of Cardiology, Academic Medical Center, University of Amsterdam, the Netherlands 2 Department of Cardiology University Medical Center Utrecht, The Netherlands 3 Department of Cardiology, Amphia Hospital Breda, The Netherlands No conflict of interest/financial disclosures

2 Background Both Myocardial Perfusion Scintigraphy (MPS) and intracoronary derived Fractional Flow Reserve (FFR) have shown predictive value for mortality and myocardial infarction There is no data regarding the prognostic value of MPS, FFR, Coronary Flow Reserve (CFR) and Reference CFR (RefCFR) in the same patient group with stable coronary artery disease

3 Hard Event Rate (%) Prognostic value MPS > 12,000 patients 7.4% % 1 0 Normal Abnormal Iskander et al. J Am Coll Cardiol 1998;32:57-62

4 Prognostic value FFR Pijls et al. J Am Coll Cardiol 2007;21:

5 Aim To investigate the prognostic value of MPS, FFR, CFR and RefCFR in the same patient group with stable coronary artery disease.

6 Methods: MPS Technetium Sestamibi (Cardiolite) Technetium Tetrofosmin (Myoview) Standard 2 Day Stress-Rest Protocol Stress: Pharmacological Exercise Adenosine Dipyridamole

7 Methods: Coronary hemodynamics FFR = Pdistal Paorta (during hyperaemia) Cut-off Value: 0.75 CFR= Hyperemic APV Baseline APV Cut-off Value: 2.0 RefCFR= Reference Hyperemic APV Reference Baseline APV Normal Value : 3.0 Kern et al. J Am Coll Cardiol 1996;28:

8 Patients Between April 1997 and December patients, including 408 coronary lesions FFR and CFR were determined for clinical reasons: 1. Presence of an intermediate coronary lesion (40-70% diameter stenosis) in multivessel disease 2. Non-diagnostic or negative exercise test in single vessel disease of intermediate severity (40-70%) 3.Presence of an intermediate lesion in case no noninvasive ischemic test was performed. Patients were enrolled in ongoing study protocols

9 Patients In 96 patients, including 140 coronary lesions, both FFR, CFR, RefCFR and MPS were assessed. 44 patients had double vessel disease and 52 patients had single vessel disease In patients with two-vessel disease, the coronary lesion in which the most severe Hyperemic Stenosis Resistance (HSR) was assessed, was used for further analysis Long term follow-up was performed to evaluate the occurrence of death using the Dutch National Registry.

10 Baseline Characteristics (N=96) Variable Age, yrs. ± SD 60 ± 10 Male Sex (%) 68 71% Hypertension (%) 38 40% Hyperlipidemia (%) 59 62% Family History (%) 44 46% Cigarette Smoking (%) 29 30% Diabetes Mellitus (%) 18 19% Prior Myocardial Infarction (%) 41 43% Prior PCI (%) 18 19% Normal Left Ventricular Function (%) 83 87% FFR ± SD 0,67 ± 0,18 CFR ± SD 2,1 ± 0,71 Ref CFR ± SD 2,9 ± 0,67 Diameter Stenosis % ± SD 59 ± 11

11 Results (1) Variable Alive At Follow Up: Yes Alive at Follow Up: No P-value Number of Patients (13,5%) Age, yrs ± SD 58 ± ± 6,5 0,03 Male Sex (%) 59 (71) 9 (69) NS Hypertension (%) 31 (37) 7 (54) NS Hyperlipidemia (%) 49 (60) 10 (77) NS Family History (%) 37 (45) 7 (54) NS Cigarette Smoking (%) 22 (27) 2 (15) NS Diabetes Mellitus (%) 16 (19) 2 (15) NS Prior MI (%) 33 (40) 8 (62) NS Prior PCI (%) 15 (18) 3 (23) NS Normal LVF (%) 74 (89) 9 (70) 0,07 LAD lesion (%) 48 (58) 6 (46) NS LCX lesion (%) 11 (13) 2 (15) NS RCA lesion (%) 24 (29) 5 (39) NS

12 Results (2) Diameter Stenosis MPS

13 Results: Coronary Hemodynamics Coronary Flow Reserve Fractional Flow Reserve

14 Results: Reference CFR

15 Results: Mortality Mean follow-up 8.3 yrs (range )

16 Survival

17 Survival (2)

18 Multivariate Analysis Univariate Analysis HR 95% CI P- value Multivariate Analysis HR 95% CI P- value Age 60 yrs 4, LVEF <50% ACE-inhibitor use FFR < Diameter Stenosis Pre-PCI Hyperlipidaemia <0.01 RefCFR < vessel disease

19 Conclusion A normal Reference CFR ( 3.0) is associated with a decreased long term mortality Reference CFR may be a better predictor for mortality compared to MPS, FFR and CFR in patients with intermediate coronary lesions An abnormal Reference CFR may be an expression of increased microvascular dysfunction in more diseased hearts that may be responsible for a worse clinical outcome

20 Additional Analysis Analysis of excluded cases MACE-follow up Reference Vessel Microvascular Resistance

21 Back-Up Slides

22 Pathofysiology FFR CFR RefCFR

23 Exclusion Only 96 of total 274 patients were used for further analysis (35%) No reference vessel was present (N=23) (3 vessel disease) Not all parameters were assessed (N=97) (on discretion of the operator) No MPS was performed (N=58)

24 Left Ventricular Function Dichotomized Left Ventricular Function Normal (LVEF >50%) Abnormal (LVEF >50%) Alive at Follow Up Yes Alive at Follow Up No 74 (89) 9 (70) 9 (11) 4 (30) P = 0.07 Quartiles Left Ventricular Function Alive at Follow Up Yes Alive at Follow Up No P-Value Normal 72 (87) 8 (62) 0.04 Mildly Impaired 4 (5) 2 (15) Impaired (LVEF 30 50%) Severely Impaired (LVEF <30%) 6 (7) 1 (8) (1) 2 (15) 0.05

25 HSR