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Impact of Percutaneous Revascularization on Exercise Hemodynamics in Patients With Stable Coronary Disease.

ABSTRACT: BACKGROUND:Recently, the therapeutic benefits of percutaneous coronary intervention (PCI) have been challenged in patients with stable coronary artery disease (SCD). OBJECTIVES:The authors examined the impact of PCI on exercise responses in the coronary circulation, the microcirculation, and systemic hemodynamics in patients with SCD. METHODS:A total of 21 patients (mean age 60.3 ± 8.4 years) with SCD and single-vessel coronary stenosis underwent cardiac catheterization. Pre-PCI, patients exercised on a supine ergometer until rate-limiting angina or exhaustion. Simultaneous trans-stenotic coronary pressure-flow measurements were made throughout exercise. Post-PCI, this process was repeated. Physiological parameters, rate-limiting symptoms, and exercise performance were compared between pre-PCI and post-PCI exercise cycles. RESULTS:PCI reduced ischemia as documented by fractional flow reserve value (pre-PCI 0.59 ± 0.18 to post-PCI 0.91 ± 0.07), instantaneous wave-free ratio value (pre-PCI 0.61 ± 0.27 to post-PCI 0.96 ± 0.05) and coronary flow reserve value (pre-PCI 1.7 ± 0.7 to post-PCI 3.1 ± 1.0; p < 0.001 for all). PCI increased peak-exercise average peak coronary flow velocity (p < 0.0001), coronary perfusion pressure (distal coronary pressure; p < 0.0001), systolic blood pressure (p = 0.01), accelerating wave energy (p < 0.001), and myocardial workload (rate-pressure product; p < 0.01). These changes observed immediately following PCI resulted from the abolition of stenosis resistance (p < 0.0001). PCI was also associated with an immediate improvement in exercise time (+67 s; 95% confidence interval: 31 to 102 s; p < 0.0001) and a reduction in rate-limiting angina symptoms (81% reduction in rate-limiting angina symptoms post-PCI; p < 0.001). CONCLUSIONS:In patients with SCD and severe single-vessel stenosis, objective physiological responses to exercise immediately normalize following PCI. This is seen in the coronary circulation, the microcirculation, and systemic hemodynamics.

SUBMITTER: Cook CM

PROVIDER: S-EPMC6580361 | biostudies-other | 2018 Aug

REPOSITORIES: biostudies-other

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Impact of Percutaneous Revascularization on Exercise Hemodynamics in Patients With Stable Coronary Disease.

Cook Christopher M CM Ahmad Yousif Y Howard James P JP Shun-Shin Matthew J MJ Sethi Amarjit A Clesham Gerald J GJ Tang Kare H KH Nijjer Sukhjinder S SS Kelly Paul A PA Davies John R JR Malik Iqbal S IS Kaprielian Raffi R Mikhail Ghada G Petraco Ricardo R Al-Janabi Firas F Karamasis Grigoris V GV Mohdnazri Shah S Gamma Reto R Al-Lamee Rasha R Keeble Thomas R TR Mayet Jamil J Sen Sayan S Francis Darrel P DP Davies Justin E JE

Journal of the American College of Cardiology 20180801 9

<h4>Background</h4>Recently, the therapeutic benefits of percutaneous coronary intervention (PCI) have been challenged in patients with stable coronary artery disease (SCD).<h4>Objectives</h4>The authors examined the impact of PCI on exercise responses in the coronary circulation, the microcirculation, and systemic hemodynamics in patients with SCD.<h4>Methods</h4>A total of 21 patients (mean age 60.3 ± 8.4 years) with SCD and single-vessel coronary stenosis underwent cardiac catheterization. Pr ...[more]

PMID: 30139442

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Project description:Aims:Coronary flow reserve (CFR) is an integrated measure of the entire coronary vasculature, and is a powerful prognostic marker in coronary artery disease (CAD). The extent to which coronary revascularization can improve CFR is unclear. This study aimed to evaluate the impact of percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) on CFR in patients with stable CAD. Methods and results:In a prospective, multicentre observational study, CFR was measured by 15O-water positron emission tomography as the ratio of stress to rest myocardial blood flow at baseline and 6?months after optimal medical therapy (OMT) alone, PCI, or CABG. Changes in the SYNTAX and Leaman scores were angiographically evaluated as indicators of completeness of revascularization. Follow-up was completed by 75 (25 OMT alone, 28 PCI, and 22 CABG) out of 82 patients. The median SYNTAX and Leaman scores, and baseline CFR were 14.5 [interquartile range (IQR): 8-24.5], 5.5 (IQR: 2.5-12.5), and 1.94 (IQR: 1.67-2.66), respectively. Baseline CFR was negatively correlated with the SYNTAX (??=?-0.40, P?<?0.001) and Leaman scores (??=?-0.33, P?=?0.004). Overall, only CABG was associated with a significant increase in CFR [1.67 (IQR: 1.14-1.96) vs. 1.98 (IQR: 1.60-2.39), P?<?0.001]. Among patients with CFR <2.0 (n?=?41), CFR significantly increased in the PCI [1.70 (IQR: 1.42-1.79) vs. 2.21 (IQR: 1.78-2.49), P?=?0.002, P?<?0.001 for interaction between time and CFR] and CABG groups [1.28 (IQR: 1.13-1.80) vs. 1.86 (IQR: 1.57-2.22), P?<?0.001]. The reduction in SYNTAX or Leaman scores after PCI or CABG was independently associated with the percent increase in CFR after adjusting for baseline characteristics (P?=?0.012 and P?=?0.011, respectively). Conclusion:Coronary revascularization ameliorated reduced CFR in patients with obstructive CAD. The degree of improvement in angiographic CAD burden by revascularization was correlated with magnitude of improvement in CFR.

Project description:ObjectivesTo assess the perceptions of patients with stable coronary artery disease of the urgency and benefits of elective percutaneous coronary intervention and to examine how they vary across centers and by providers.DesignCross sectional study.Setting10 US academic and community hospitals performing percutaneous coronary interventions between 2009 and 2011.Participants991 patients with stable coronary artery disease undergoing elective percutaneous coronary intervention.Main outcome measuresPatients' perceptions of the urgency and benefits of percutaneous coronary intervention, assessed by interview. Multilevel hierarchical logistic regression models examined the variation in patients' understanding across centers and operators after adjusting for patient characteristics, using median odds ratios.ResultsThe most common reported benefits from percutaneous coronary intervention were to extend life (90%, n=892; site range 80-97%) and to prevent future heart attacks (88%, n=872; site range 79-97%). Although nearly two thirds of patients (n=661) reported improvement of symptoms as a benefit of percutaneous coronary intervention (site range 52-87%), only 1% (n=9) identified this as the only benefit. Substantial variability was noted in the ways informed consent was obtained at each site. After adjusting for patient and operator characteristics, the median odds ratios showed significant variation in patients' perceptions of percutaneous coronary intervention across sites (range 1.4-3.1) but not across operators within a site.ConclusionPatients have a poor understanding of the benefits of elective percutaneous coronary intervention, with significant variation across sites. No sites had a high proportion of patients accurately understanding the benefits. Coupled with the wide variability in the ways in which hospitals obtain informed consent, these findings suggest that hospital level interventions into the structure and processes of obtaining informed consent for percutaneous coronary intervention might improve patient comprehension and understanding.

Project description:ImportanceMany studies have compared outcomes for incomplete revascularization (IR) among patients undergoing percutaneous coronary interventions (PCI), but little is known about whether outcomes are related to the nature of the IR.ObjectiveTo determine whether some coronary vessel characteristics are associated with worse outcomes in patients with PCI with IR.Design, setting, and participantsNew York's PCI registry was used to examine mortality (median follow-up, 3.4 years) as a function of the number of vessels that were incompletely revascularized, the stenosis in those vessels, and whether the proximal left anterior descending artery was incompletely revascularized after controlling for other factors associated with mortality for patients with and without ST-elevation myocardial infarction (STEMI). This was a multicenter study (all nonfederal PCI hospitals in New York State) that included 41 639 New York residents with multivessel coronary artery disease undergoing PCI in New York State between January 1, 2010, and December 31, 2012.ExposuresPercutaneous coronary interventions, with complete and incomplete revascularization.Main outcomes and measuresMedium-term mortality.ResultsFor patients with STEMI, the mean age was 62.8 years; 26.2% were women, 11.9% were Hispanic, and 81.5% were white. For other patients, the mean age was 66.6 years, 29.1% were women, 11.3% were Hispanic, and 79.1% were white. Incomplete revascularization was very common (78% among patients with STEMI and 71% among other patients). Patients with IR in a vessel with at least 90% stenosis were at higher risk than other patients with IR. This was not significant among patients with STEMI (17.18% vs 12.86%; adjusted hazard ratio [AHR], 1.16; 95% CI, 0.99-1.37) and significant among patients without STEMI (17.71% vs 12.96%; AHR, 1.15; 95% CI, 1.07-1.24). Similarly, patients with IR in 2 or more vessels had higher mortality than patients with completely revascularization and higher mortality than other patients with IR among patients with STEMI (20.37% vs 14.39%; AHR, 1.35; 95% CI, 1.15-1.59) and among patients without STEMI (20.10% vs 12.86%; AHR, 1.17; 95% CI, 1.09-1.59). Patients with proximal left anterior descending artery vessel IR had higher mortality than other patients with IR (20.09% vs 14.67%; AHR, 1.31; 95% CI, 1.04-1.64 for patients with STEMI and 20.78% vs 15.62%; AHR, 1.11; 95% CI, 1.01-1.23 for patients without STEMI). More than 20% of all PCI patients had IR of 2 or more vessels and more than 30% had IR with more than 90% stenosis.Conclusions and relevancePatients with IR are at higher risk of mortality if they have IR with at least 90% stenosis, IR in 2 or more vessels, or proximal left anterior descending IR.

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Impact of Percutaneous Revascularization on Exercise Hemodynamics in Patients With Stable Coronary Disease.

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Impact of Percutaneous Revascularization on Exercise Hemodynamics in Patients With Stable Coronary Disease.

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