Comparison of medical treatment and coronary revascularization in patients with moderate coronary lesions and borderline fractional flow reserve measurements

Objectives : (1) To evaluate the clinical outcomes of patients with moderate coronary lesions and borderline fractional flow reserve (FFR) measurements (between 0.75 and 0.80), comparing those who underwent coronary revascularization (CR) to those who had medical treatment (MT), and (2) to determine the predictive factors of major adverse cardiac events (MACE) at follow‐up. Methods : A total of 107 consecutive patients (mean age 62 ± 10 years) with at least one moderate coronary lesion (mean percent diameter stenosis 47 ± 12%) evaluated by coronary pressure wire with FFR measurement between 0.75 and 0.80 (mean 0.77 ± 0.02) were included in the study. MACE [CR, myocardial infarction (MI), cardiac death) and the presence of angina were evaluated at follow‐up. Results : Sixty‐three patients (59%) underwent CR and 44 patients (41%) had MT, with no clinical differences between groups. At a mean follow‐up of 13 ± 7 months, MACE related to the coronary lesion evaluated by FFR were higher in the MT group compared with CR group (23% vs. 5%, P = 0.005). Most MACE consisted of CRs, with no differences between groups in MI and cardiac death rate at follow‐up. Both MT and FFR measurements in an artery supplying a territory with previous MI were independent predictive factors of MACE at follow‐up, respectively (hazard ratio 5.2, 95% CI 1.4–18.9, P = 0.01; hazard ratio 4.1, 95% CI 1.1–15.3, P = 0.03). The presence of angina at follow‐up was more frequent in the MT group compared with the CR group (41% vs. 9%, P = 0.002). Conclusions : In patients with moderate coronary lesions and borderline FFR measurements deferral of revascularization was associated with a higher rate of MACE (CR) and a higher prevalence of angina at follow‐up, especially in those with previous MI in the territory evaluated by FFR. Further prospective randomized studies should confirm whether or not an FFR cut‐off point of 0.80 instead of 0.75 would be more appropriate for deferring CR in these cases. © 2008 Wiley‐Liss, Inc.     

血流储备分数的临床应用进展

冠状动脉造影一直被认为是诊断冠状动脉狭窄的金标准,它为我们提供了冠状动脉的解剖信息,但是它易受主观因素影响,且不能提供狭窄的血流动力学信息。最好能在造影的同时增加一项简单、快捷的检查,该检查能给临床医生提供狭窄的血流动力学信息,以评价冠脉狭窄引起的功能改变。如今该检查已经被运用在常规临床工作中,即血流储备分数(fractional flow reserve,FFR)。本文将就FFR的基本原理、特点及其临床应用进行综述。     

心肌血流储备分数在冠心病诊断及介入治疗中的应用研究进展

冠状动脉造影（CAG）是目前诊断冠心病最常用和最重要的手段,是进一步行经皮冠状动脉介入治疗（PCI）或冠脉搭桥术（CABG）的金标准。但是随着对冠脉血流动力学及病理学研究的不断深入,单纯冠脉造影提供的形态学已不能满足临床对狭窄病变解剖特征和生理功能评价的需要。     

Value of fractional flow reserve in making decisions about bypass surgery for equivocal left main coronary artery disease

OBJECTIVE—To investigate the value of coronary pressure derived fractional flow reserve (FFR) measurements in supporting decisions about medical or surgical treatment in patients with angiographically equivocal left main coronary artery stenosis.
DESIGN—A two centre prospective single cohort follow up study.
INTERVENTIONS—FFR of the left main coronary artery was determined in 54 consecutive patients with angiographically equivocal left main coronary artery disease. If FFR was 0.75, medical treatment was chosen; if FFR was < 0.75, surgical treatment was chosen.
MAIN OUTCOME MEASURES—Freedom from death, myocardial infarction, or any coronary revascularisation procedure.
RESULTS—In 24 patients (44%), FFR was 0.75 and medical treatment was chosen (medical group). In the remaining 30 patients (56%), FFR was < 0.75 and bypass surgery was performed (surgical group). Mean (SD) follow up was 29 (15) months (range 12-65 months). Survival among patients at three years of follow up was 100% in the medical group and 97% in the surgical group. Event-free survival was 76% in the medical group and 83% in the surgical group.
CONCLUSIONS—FFR supports decision making in equivocal left main coronary artery disease. If FFR is below 0.75, the decision for bypass surgery is supported. If FFR is above 0.75, a conservative approach is justified.


Keywords: coronary artery disease; left main coronary artery; fractional flow reserve; coronary artery bypass     

心肌血流储备分数评价糖尿病患者冠状动脉临界病变的可靠性

目的通过测定冠状动脉中等程度狭窄的糖尿病和非糖尿病患者的心肌血流储备分数(fractional flow reserve,FFR)来评估糖尿病对FFR检测的影响。方法本研究入组68例冠状动脉造影明确诊断为冠状动脉粥样硬化性心脏病(冠心病),且经量化冠状动脉造影(quantitative coronary angiography,QCA)诊断为中等程度狭窄的患者,分为糖尿病组和非糖尿病组;再根据病变处管腔狭窄程度进一步细分为50%~60%亚组和60%~70%亚组;根据糖化血红蛋白(glycated hemoglobin,GHb)水平分为GHb≥7.0亚组和GHb<7.0亚组。以三磷腺苷(ATP)为冠状动脉扩张剂。比较每两组间FFR的测量值(两次取平均值)及冠状动脉扩张前后的FFR差值。结果冠状动脉狭窄程度相似的糖尿病组和非糖尿病组的FFR比较,差异无统计学意义[50%~60%亚组:(0.84±0.06)vs.(0.86±0.08),P=0.45;60%~70%亚组:[(0.76±0.09)vs.(0.81±0.07),P=0.061]。糖尿病GHb≥7.0亚组的FFR高于糖尿病GHb<7.0亚组,差异有统计学意义[(0.77±0.06)vs.(0.72±0.11),P<0.05]。结论糖尿病对测定中等程度狭窄的冠状动脉的FFR没有明显影响,糖尿病且GHb≥7.0患者的FFR较GHb<7.0患者高。     

无创血流储备分数测定对冠心病患者心肌缺血功能评估的临床进展

在中度病变的稳定型冠状动脉疾病(CAD)患者中,判断病变是否造成了冠状动脉远端血流动力学的显著改变(即心肌缺血),在制定临床决策中起着至关重要的作用。而在这些临界病变中,血流储备分数(FFR)测定是识别心肌缺血存在与否的金标准。近年来,随着计算机流体动力学(CFD)的发展,基于冠状动脉CT血管造影的无创性FFR(FFRCT)得以发展。本综述旨在通过阐述FFRCT的概念及应用原理,总结目前针对FFRCT技术的几项临床研究,说明其良好的诊断性能、临床实践进展、优点、局限性以及临床应用前景。     

心肌血流储备分数的临床应用

随着冠状动脉介入治疗（PCI）在临床上的广泛应用,冠脉造影（CAG）越来越多地用来诊断病变和指导治疗。然而,人们在对冠状动脉血流动力学及病理生理学不断深入研究的同时,逐渐认识到CAG在评价冠脉狭窄病变解剖特征和生理功能上还存在一些不足,     

Sequential moderate coronary artery fistula and moderate coronary artery stenosis causing ischemia demonstrated by fractional flow reserve and relieved following percutaneous coronary intervention

Coronary artery fistulae are rare anomalous connections arising from the coronary circulation. We report a case of anterior wall myocardial ischemia caused by the combination of sequential coronary‐to‐pulmonary artery fistula and moderate (50–60%) stenosis of the left anterior descending coronary artery. Ischemia was demonstrated by myocardial stress perfusion imaging as well as fractional flow reserve. Percutaneous coronary intervention of the lesion resulted in resolution of ischemia. © 2013 Wiley Periodicals, Inc.     

基于冠状动脉CT的血流储备分数诊断冠心病的价值和临床研究进展

冠状动脉CT血管成像(CCTA)可以评估冠状动脉的解剖学狭窄,但不能准确判断冠状动脉狭窄尤其临界病变是否可引起相应的心肌缺血。血流储备分数(FFR)是评估冠状动脉狭窄是否引起功能性缺血的金标准,但属于有创性检查,且费用昂贵,临床上尚未普及应用。基于冠状动脉CT的血流储备分数(FFRCT)实现了无创条件功能学和解剖学的结合,对冠心病的诊断具有重要的意义,本文就FFRCT诊断冠心病的价值和临床研究进展作一综述。