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Long-Term Clinical Outcomes of Nonhyperemic Pressure Ratios: Resting Full-Cycle Ratio, Diastolic Pressure Ratio, and Instantaneous Wave-Free Ratio.

ABSTRACT: Background Nonhyperemic pressure ratios (NHPRs) such as instantaneous wave-free ratio, resting full-cycle ratio, or diastolic pressure ratio have emerged as invasive physiologic indices precluding the need for hyperemic agents. The current study sought to evaluate the long-term prognostic implications of NHPRs compared with fractional flow reserve (FFR). Methods and Results NHPRs were calculated from resting pressure tracings by an independent core laboratory in 1024 vessels (435 patients). The association between NHPRs and the risk of 5-year vessel-oriented composite outcomes (VOCO, a composite of cardiac death, vessel-related myocardial infarction, and ischemia-driven revascularization) were analyzed among 864 deferred vessels. Lesions with positive NHPRs (instantaneous wave free ratio, resting full-cycle ratio, and diastolic pressure ratio ?0.89) or FFR (?0.80) showed significantly higher risk of VOCO at 5 years than those with negative NHPRs or FFR, respectively. Discriminant ability for 5-year VOCO was not different among NHPRs and FFR (C-index: 0.623-0.641, P for comparison=0.215). In comparison of VOCO among the groups with deferred concordant negative (NHPRs-/FFR-), deferred discordant (NHPRs+/FFR- or NHPRs-/FFR+), and revascularized vessels, the cumulative incidence of VOCO were 7.5%, 14.4%, and 14.8% (log-rank P<0.001), respectively. The deferred discordant group showed similar risk of VOCO with the revascularized vessel group (hazard ratio, 0.981; 95% CI 0.434-2.217, P=0.964). Conclusions Currently available invasive pressure-derived indices showed similar prognostic implications for vessel-related events at 5 years. Deferred lesions with discordant results between NHPRs and FFR did not show higher risk of vessel-related events at 5 years than revascularized vessels. Registration URL: https://www.clini?caltr?ials.gov; Unique identifiers: NCT01621438, NCT01621438.

SUBMITTER: Lee JM

PROVIDER: S-EPMC7726993 | biostudies-literature | 2020 Sep

REPOSITORIES: biostudies-literature

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Long-Term Clinical Outcomes of Nonhyperemic Pressure Ratios: Resting Full-Cycle Ratio, Diastolic Pressure Ratio, and Instantaneous Wave-Free Ratio.

Lee Joo Myung JM Lee Seung Hun SH Hwang Doyeon D Rhee Tae-Min TM Choi Ki Hong KH Kim Jinseob J Park Jinhyoung J Kim Hyung Yoon HY Jung Hae Won HW Cho Yun-Kyeong YK Yoon Hyuck-Jun HJ Song Young Bin YB Hahn Joo-Yong JY Nam Chang-Wook CW Shin Eun-Seok ES Doh Joon-Hyung JH Hur Seung-Ho SH Koo Bon-Kwon BK

Journal of the American Heart Association 20200911 18

Background Nonhyperemic pressure ratios (NHPRs) such as instantaneous wave-free ratio, resting full-cycle ratio, or diastolic pressure ratio have emerged as invasive physiologic indices precluding the need for hyperemic agents. The current study sought to evaluate the long-term prognostic implications of NHPRs compared with fractional flow reserve (FFR). Methods and Results NHPRs were calculated from resting pressure tracings by an independent core laboratory in 1024 vessels (435 patients). The ...[more]

PMID: 32914672

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Project description:Background Quantitative flow ratio ( QFR ) has a high diagnostic accuracy in assessing functional stenoses relevance, as judged by fractional flow reserve ( FFR ). However, its diagnostic performance has not been thoroughly evaluated using instantaneous wave-free ratio ( iFR ) or coronary flow reserve as the reference standard. This study sought to evaluate the diagnostic performance of QFR using other reference standards beyond FFR . Methods and Results We analyzed 182 patients (253 vessels) with stable ischemic heart disease and 82 patients (105 nonculprit vessels) with acute myocardial infarction in whom coronary stenoses were assessed with FFR , iFR, and coronary flow reserve. Contrast QFR analysis of interrogated vessels was performed in blinded fashion by a core laboratory, and its diagnostic performance was evaluated with respect to the other invasive physiological indices. Mean percentage diameter stenosis, FFR , iFR , coronary flow reserve, and QFR were 53.1±19.0%, 0.80±0.13, 0.88±0.12, 3.14±1.30, and 0.81±0.14, respectively. QFR showed higher correlation ( r=0.863 with FFR versus 0.740 with iFR , P<0.001), diagnostic accuracy (90.8% versus 81.3%, P<0.001), and discriminant function (area under the curve=0.953 versus 0.880, P<0.001) when FFR was used as a reference standard than when iFR was used as the reference standard. However, when coronary flow reserve was used as an independent reference standard, FFR , iFR , and QFR showed modest discriminant function (area under the curve=0.682, 0.765, and 0.677, respectively) and there were no significant differences in diagnostic accuracy among FFR , iFR , and QFR (65.4%, 70.6%, and 64.9%; all P values in pairwise comparisons >0.05, overall comparison P=0.061). Conclusions QFR has a high correlation and agreement with respect to both FFR and iFR , although it is better when FFR is used as the comparator. As a pressure-derived index not depending on wire or adenosine, QFR might be a promising tool for improving the adoption rate of physiology-based revascularization in clinical practice.

Project description:Background Post-percutaneous coronary intervention (PCI) fractional flow reserve ≥0.90 is an accepted marker of procedural success, and a cutoff of ≥0.95 has recently been proposed for post-PCI instantaneous wave-free ratio. However, stability of nonhyperemic pressure ratios (NHPRs) post-PCI is not well characterized, and transient reactive submaximal hyperemia post-PCI may affect their precision. We performed this study to assess stability and reproducibility of NHPRs post-PCI. Methods and Results Fifty-seven patients (age, 63.77±10.67 years; men, 71%) underwent hemodynamic assessment immediately post-PCI and then after a recovery period of 10, 20, and 30 minutes and repeated at 3 months. Manual offline analysis was performed to derive resting and hyperemic pressure indexes (Pd/Pa resting pressure gradient, mathematically derived instantaneous wave-free ratio, resting full cycle ratio, and fractional flow reserve) and microcirculatory resistances (basal microvascular resistance and index of microvascular resistance). Transient submaximal hyperemia occurring post-PCI was demonstrated by longer thermodilution time at 30 minutes compared with immediately post-PCI; mean difference of thermodilution time was 0.17 seconds (95% CI, 0.07-0.26 seconds; P=0.04). Basal microcirculatory resistance was also higher at 30 minutes than immediately post-PCI; mean difference of basal microvascular resistance was 10.89 mm Hg.s (95% CI, 2.25-19.52 mm Hg.s; P=0.04). Despite this, group analysis confirmed no significant differences in the values of resting whole cycle pressure ratios (Pd/Pa and resting full cycle ratio) as well as diastolic pressure ratios (diastolic pressure ratio and mathematically derived instantaneous wave-free ratio). Whole cardiac cycle NHPRs demonstrated the best overall stability post-PCI, and 1 in 5 repeated diastolic NHPRs crossed the clinical decision threshold. Conclusions Whole cycle NHPRs demonstrate better reproducibility and clinical precision post-PCI than diastolic NHPRs, possibly because of less perturbation from predominantly diastolic reactive hyperemia and left ventricular stunning. Registration URL: https://clinicaltrials.gov/ct2/show/NCT03502083; Unique identifier: NCT03502083 and URL: https://clinicaltrials.gov/ct2/show/NCT03076476; Unique identifier: NCT03076476.

Dataset Information

Long-Term Clinical Outcomes of Nonhyperemic Pressure Ratios: Resting Full-Cycle Ratio, Diastolic Pressure Ratio, and Instantaneous Wave-Free Ratio.

Publications

Long-Term Clinical Outcomes of Nonhyperemic Pressure Ratios: Resting Full-Cycle Ratio, Diastolic Pressure Ratio, and Instantaneous Wave-Free Ratio.

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