Myocardial FFR (Fractional Flow Reserve) in patients with angiographically intermediate coronary artery stenosis - an initial institutional experience

Jagadish H. Ramaiah, Raghu T. Ramegowda, Srinivas B. Chikkaswamy, Manjunath C. Nanjappa


Background: The clinical significance of coronary artery stenosis of intermediate severity can be difficult to determine. The management of intermediate coronary lesions, defined by a diameter stenosis of ≥40% to ≤70%, continues to be a therapeutic dilemma for cardiologists. The 2-dimensional representation of the arterial lesion provided by angiography is limited in distinguishing intermediate lesions that require stenting from those that simply need appropriate medical therapy. In the era of drug-eluting stents, some might propose that stenting all intermediate coronary lesions is an appropriate solution. However, the possibility of procedural complications such as coronary dissection, no reflow phenomenon, in-stent restenosis, and stent thrombosis requires accurate stratification of patients with intermediate coronary lesions to appropriate therapy. Myocardial fractional flow reserve (FFR) is an index of the functional severity of coronary stenosis that is calculated from pressure measurements made during coronary angiography. The objective of the study is to evaluate the usefulness of FFR in patients with angiographically intermediate coronary artery stenosis.

Methods: 20 patients with intermediate coronary stenosis and chest pain of uncertain origin. The Exercise Electrocardiography (TMT), Myocardial Perfusion Imaging study (MPI), Quantitative Coronary Angiography (QCA) were compared with the results of FFR measurements.

Results: 20 patients were undergone FFR measurement during the study period. With the mean age of 57.25±11.2 and male patients were 16 (80%), female patients 4 (20%), in all 13 patients with an FFR of <0.75, reversible myocardial ischemia was demonstrated unequivocally on at least one noninvasive test. In contrast, 5 of 7 patients with an FFR of >0.75 tested negative for reversible myocardial ischemia on TMT and MPI study. No revascularization procedures were performed in 7 (35%) patients, and no adverse cardiovascular events were noted in all these patients during 6 months of follow-up.

Conclusions: In patients with coronary stenosis of intermediate severity, FFR appears to be a useful index of the functional severity of the stenosis and the need for coronary revascularization.



Myocardial Fractional Flow Reserve, Intermediate stenosis, Exercise Electrocardiography Myocardial Perfusion Imaging, Quantitative Coronary Angiography

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Stone GW, Ellis SG, Cox DA, et al. One-year clinical results with the slow-release, polymer-based, aclitaxel-eluting TAXUS stent: the TAXUS-IV trial. Circulation 2004;109:1942-7.

Moses JW, Leon MB, Popma JJ, et al. Sirolimus-eluting stents versus standard stents in patients with stenosis in a native coronary artery. N Engl J Med 2003;349:1315-23.

Topol EJ, Ellis SG, Cosgrove DM, et al. Analysis of coronary angioplasty practice in the United States with an insurance-claims data base. Circulation 1993;87:1489-97.

Kern MJ, Donohue TJ, Aguirre FV, et al. Clinical outcome of deferring angioplasty in patients with normal translesional pressure-flow velocity measurements. J Am Coll Cardiol 1995;25:178-87.

Kirkeeide RL, Gould KL, Parsel L. Assessment of coronary stenoses by myocardial perfusion imaging during pharmacologic coronary vasodilation. VII. Validation of coronary flow reserve as a single integrated functional measure of stenosis severity reflecting all its geometric dimensions. J Am Coll Cardiol 1986;7:103-13.

Gould KL, Kirkeeide RL, Buchi M. Coronary flow reserve as a physiologic measure of stenosis severity. J Am Coll Cardiol 1990;15:459-74.

Pijls NHJ, van Son JAM, Kirkeeide RL, De Bruyne B, Gould KL. Experimental basis of determining maximum coronary, myocardial, and collateral blood flow by pressure measurements for assessing functional stenosis severity before and after percutaneous transluminal coronary angioplasty. Circulation 1993;87:1354-67.

De Bruyne B, Baudhuin T, Melin JA, et al. Coronary flow reserve calculated from pressure measurements in humans: validation with positron emission tomography. Circulation 1994;89:1013-22.

De Bruyne B, Paulus WJ, Pijls NHJ. Rationale and application of coronary transstenotic pressure gradient measurements. Cathet Cardiovasc Diagn 1994;33:250-61.

Pijls NHJ, Bech GJW, el Gamal MIH, et al. Quantification of recruitable coronary collateral blood flow in conscious humans and its potential to predict future ischemic events. J Am Coll Cardiol 1995;25:1522-8.

Pijls NHJ, Van Gelder B, Van der Voort P, et al. Fractional flow reserve: a useful index to evaluate the influence of an epicardial coronary stenosis on myocardial blood flow. Circulation 1995;92:3183-93.

De Bruyne B, Bartunek J, Sys SU, Heyndrickx GR. Relation between myocardial fractional flow reserve calculated from coronary pressure measurements and exercise-induced myocardial ischemia. Circulation 1995;92:39-46.

Emanuelsson H, Dohnal M, Lamm C, Tenerz L. Initial experiences with a miniaturized pressure transducer during coronary angioplasty. Cathet Cardiovasc Diagn 1991;24:137-43.

Lamm C, Dohnal M, Serruys PW, Emanuelsson H. High-fidelity translesional pressure gradients during percutaneous transluminal coronary angioplasty: correlation with quantitative coronary angiography. Am Heart J 1993;126:66-75.

Serruys PW, Di Mario C, Meneveau N, et al. Intracoronary pressure and flow velocity with sensor-tip guidewires: a new methodologic approach for assessment of coronary hemodynamics before and after coronary interventions. Am J Cardiol 1993;71:41D-53D.

Dilsizian V, Rocco TP, Freedman NMT, Leon MB, Bonow RO. Enhanced detection of ischemic but viable myocardium by the reinjection of thallium after stress-redistribution imaging. N Engl J Med 1990;323:141.

Salustri A, Fioretti PM, Pozzoli MMA, McNeill AJ, Roelandt JR. Dobutamine stress echocardiography: its role in the diagnosis of coronary artery disease. Eur Heart J 1992;13:70-7.

Sawada SG, Segar DS, Ryan T, et al. Echocardiographic detection of coronary artery disease during dobutamine infusion. Circulation 1991;83:1605-14.

McNeill AJ, Fioretti PM, el-Said SM, Salustri A, Forster T, Roelandt JR. Enhanced sensitivity for detection of coronary artery disease by addition of atropine to dobutamine stress echocardiography. Am J Cardiol 1992;70:41-6.

Bourdillon PDV, Broderick TM, Sawada SG, et al. Regional wall motion index for infarct and noninfarct regions after reperfusion in acute myocardial infarction: comparison with global wall motion index. J Am Soc Echocardiogr 1989;2:398-407.

Marwick T, Willemart B, D’Hondt A-M, et al. Selection of the optimal nonexercise stress for the evaluation of ischemic regional myocardial dysfunction and malperfusion: comparison of dobutamine and adenosine using echocardiography and 99mTc-MIBI single photon emission computed tomography. Circulation 1993;87:345-54.

Tonino PA, Fearon WF, De Bruyne B, Oldroyd KG, Leesar MA, Ver Lee PN, et al. Angiographic versus functional severity of coronary artery stenoses in the FAME study fractional flow reserve versus angiography in multivessel evaluation. J Am Coll Cardiol 2010;55;2816-21.

Klocke FJ. Cognition in the era of technology: “seeing the shades of gray”. J Am Coll Cardiol 1990;16:763-9.

Ryan TJ, Faxon DP, Gunnar RM, et al. Guidelines for percutaneous transluminal coronary angioplasty: a report of the American College of Cardiology/ American Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Subcommittee on Percutaneous Transluminal Coronary Angioplasty). Circulation 1988;78:486-502.

ACC/AHA guidelines and indications for coronary artery bypass graft surgery: a report of the American College of Cardiology/American Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Subcommittee on Coronary Artery Bypass Graft Surgery). Circulation 1991;83:1125-73.

Nahser PJ Jr, Brown RE, Oskarsson H, Winniford MD, Rossen JD. Maximal coronary flow reserve and metabolic coronary vasodilation in patients with diabetes mellitus. Circulation 1995;91:635-40.

Nabel EG, Ganz P, Gordon JB, Alexander RW, Selwyn AP. Dilation of normal and constriction of atherosclerotic coronary arteries caused by the cold pressor test. Circulation 1988;77:43-52.