Author + information
- Received January 26, 2015
- Revision received April 27, 2015
- Accepted May 7, 2015
- Published online November 1, 2015.
- Tim P. van de Hoef, MD, PhD∗,†∗ (, )
- Mauro Echavarría-Pinto, MD†,‡,
- Martijn A. van Lavieren, MSc∗,
- Martijn Meuwissen, MD, PhD§,
- Patrick W.J.C. Serruys, MD, PhD‡,‖,
- Jan G.P. Tijssen, PhD∗,
- Stuart J. Pocock, PhD†,¶,
- Javier Escaned, MD, PhD†,# and
- Jan J. Piek, MD, PhD∗
- ∗AMC Heartcenter, Academic Medical Center—University of Amsterdam, Amsterdam, the Netherlands
- †Cardiovascular Institute, Hospital Clínico San Carlos, and Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain
- ‡ThoraxCenter, Erasmus Medical Center, Rotterdam, the Netherlands
- §Department of Cardiology, Amphia Hospital, Breda, the Netherlands
- ‖Department of Cardiology, Imperial College, London, United Kingdom
- ¶Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
- #Faculty of Medicine, Complutense University, Madrid, Spain
- ↵∗Reprint requests and correspondence:
Dr. Tim P. van de Hoef, Academic Medical Center, AMC Heartcenter, Room B2-213, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands.
Objectives The purpose of this study is to evaluate whether coronary flow capacity (CFC) improves discrimination of patients at risk for major adverse cardiac events (MACE) compared with coronary flow reserve (CFR) alone, and to study the diagnostic and prognostic implications of CFC in relation to contemporary diagnostic tests for ischemic heart disease (IHD), including fractional flow reserve (FFR).
Background Although IHD results from a combination of focal obstructive, diffuse, and microcirculatory involvement of the coronary circulation, its diagnosis remains focused on focal obstructive causes. CFC comprehensively documents flow impairment in IHD, regardless of its origin, by interpreting CFR in relation to maximal flow (hyperemic average peak flow velocity [hAPV]), and overcomes the limitations of using CFR alone. This is governed by the understanding that ischemia occurs in vascular beds with substantially reduced hAPV and CFR, whereas ischemia is unlikely when hAPV or CFR is high.
Methods Intracoronary pressure and flow were measured in 299 vessels (228 patients), where revascularization was deferred in 154. Vessels were stratified as having normal, mildly reduced, moderately reduced, or severely reduced CFC using CFR thresholds derived from published data and corresponding hAPV percentiles. The occurrence of MACE after deferral of revascularization was recorded during 11.9 years of follow-up (quartile 1: 10.0 years, quartile 3: 13.4 years).
Results Combining CFR and hAPV improved the prediction of MACE over CFR alone (p = 0.01). After stratification in CFC, MACE rates throughout follow-up were strongly associated with advancing impairment of CFC (p = 0.002). After multivariate adjustment, mildly and moderately reduced CFC were associated with a 2.1-fold (95% confidence interval: 1.1 to 4.0; p = 0.017), and 7.1-fold (95% confidence interval: 2.9 to 17.1; p < 0.001) increase in MACE hazard, respectively, compared with normal CFC. Severely reduced CFC was identified by FFR ≤0.80 in 90% of cases, although ≥40% of vessels with normal or mildly reduced CFC still had an FFR ≤0.80.
Conclusions CFC provides a cross-modality platform for the diagnosis and risk-stratification of IHD and enriches the interpretation of contemporary diagnostic tests in IHD.
- coronary flow reserve
- coronary microcirculation
- fractional flow reserve
- microvascular ischemia
- nonobstructive flow impairment
This study was funded, in part, by the European Community’s Seventh Framework Programme (FP7/2007–2013) under grant agreement no. 224495 (euHeart project) and by grants from the Dutch Heart Foundation (2006B186, and D96.020). Dr. van de Hoef has served as a speaker at educational events organized by St. Jude Medical, Boston Scientific, and Volcano Corporation. Dr. Echavarría-Pinto has received a clinical scholarship from Fundación Interhospitalaria Investigacion Cardiovascular; and has served as a speaker at educational events organized by St. Jude Medical and Volcano Corporation. Drs. Meuwissen and Piek have served as speakers at educational events organized by Volcano Corporation. Dr. Escaned has served as a consultant and as a speaker at educational events for Volcano Corporation and St. Jude Medical. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. Drs. van de Hoef and Echavarría-Pinto contributed equally to this work.
- Received January 26, 2015.
- Revision received April 27, 2015.
- Accepted May 7, 2015.
- American College of Cardiology Foundation