Accuracy of the angiography-based quantitative flow ratio in intermediate left main coronary artery lesions and comparison with visual estimation.

BACKGROUND: Revascularization of left main coronary artery (LMCA) stenosis is mostly based on angiography. Indices based on angiography might increase accuracy of the decision, although they have been scarcely used in LMCA. The objective of this study is to study the diagnostic agreement of QFR (quantitative flow ratio) with wire-based fractional flow reserve (FFR) in LMCA lesions and to compare with visual severity assessment. METHODS: In a series of patients with invasive FFR assessment of intermediate LMCA stenoses we retrospectively compared the measured value of QFR with that of FFR and the estimate of significance from angiography. RESULTS: 107 QFR studies were included. The QFR intra-observer and inter-observer agreement was 87% and 82% respectively. The mean QFR-FFR difference was 0.047 ± 0.05 with a concordance of 90.7%, sensitivity 88.1%, specificity 92.3%, positive predictive value 88.1% and negative predictive value 92.3%. All these values were superior to those observed with the visual estimation which showed an intra- and inter-observer agreement of 73% and 72% respectively, besides 78% with the FFR value. The low diagnostic performance of the visual estimation and the acceptable performance of the QFR index measurement were observed in all subgroups analysed. CONCLUSIONS: QFR allows an acceptable estimate of the FFR obtained with intracoronary pressure guidewire in intermediate LMCA lesions, and clearly superior to the assessment based on angiography alone. The decision to revascularize patients with moderate LMCA lesions should not be based solely on the degree of angiographic stenosis.

Impact of diabetes in patients waiting for invasive cardiac procedures during COVID-19 pandemic.

BACKGROUND: During COVID-19 pandemic, elective invasive cardiac procedures (ICP) have been frequently cancelled or postponed. Consequences may be more evident in patients with diabetes. OBJECTIVES: The objective was to identify the peculiarities of patients with DM among those in whom ICP were cancelled or postponed due to the COVID-19 pandemic, as well as to identify subgroups in which the influence of DM has higher impact on the clinical outcome. METHODS: We included 2,158 patients in whom an elective ICP was cancelled or postponed during COVID-19 pandemic in 37 hospitals in Spain. Among them, 700 (32.4%) were diabetics. Patients with and without diabetes were compared. RESULTS: Patients with diabetes were older and had a higher prevalence of other cardiovascular risk factors, previous cardiovascular history and co-morbidities. Diabetics had a higher mortality (3.0% vs. 1.0%; p = 0.001) and cardiovascular mortality (1.9% vs. 0.4%; p = 0.001). Differences were especially important in patients with valvular heart disease (mortality 6.9% vs 1.7% [p < 0.001] and cardiovascular mortality 4.9% vs 0.9% [p = 0.002] in patients with and without diabetes, respectively). In the multivariable analysis, diabetes remained as an independent risk factor both for overall and cardiovascular mortality. No significant interaction was found with other clinical variables. CONCLUSION: Among patients in whom an elective invasive cardiac procedure is cancelled or postponed during COVID-19 pandemic, mortality and cardiovascular mortality is higher in patients with diabetes, irrespectively on other clinical conditions. These procedures should not be cancelled in patients with diabetes.

Consequences of canceling elective invasive cardiac procedures during Covid-19 outbreak.

BACKGROUND: During COVID-19 pandemic in Spain, elective procedures were canceled or postponed, mainly due to health care systems overwhelming. OBJECTIVE: The objective of this study was to evaluate the consequences of interrupting invasive procedures in patients with chronic cardiac diseases due to the COVID-19 outbreak in Spain. METHODS: The study population is comprised of 2,158 patients that were pending on elective cardiac invasive procedures in 37 hospitals in Spain on the 14th of March 2020, when a state of alarm and subsequent lockdown was declared in Spain due to the COVID-19 pandemic. These patients were followed-up until April 31th. RESULTS: Out of the 2,158 patients, 36 (1.7%) died. Mortality was significantly higher in patients pending on structural procedures (4.5% vs. 0.8%, respectively; p < .001), in those >80 year-old (5.1% vs. 0.7%, p < .001), and in presence of diabetes (2.7% vs. 0.9%, p = .001), hypertension (2.0% vs. 0.6%, p = .014), hypercholesterolemia (2.0% vs. 0.9%, p = .026) [Correction added on December 23, 2020, after first online publication: as per Dr. Moreno's request changes in p-values were made after original publication in Abstract.], chronic renal failure (6.0% vs. 1.2%, p < .001), NYHA > II (3.8% vs. 1.2%, p = .001), and CCS > II (4.2% vs. 1.4%, p = .013), whereas was it was significantly lower in smokers (0.5% vs. 1.9%, p = .013). Multivariable analysis identified age > 80, diabetes, renal failure and CCS > II as independent predictors for mortality. CONCLUSION: Mortality at 45 days during COVID-19 outbreak in patients with chronic cardiovascular diseases included in a waiting list due to cancellation of invasive elective procedures was 1.7%. Some clinical characteristics may be of help in patient selection for being promptly treated when similar situations happen in the future.

Prevalence and Postdischarge Incidence of Malignancies in Patients With Acute Coronary Syndrome.

INTRODUCTION AND OBJECTIVES: Malignancies are the second cause of death in developed countries after cardiovascular disease and both share common risk factors. METHODS: This prospective study assessed the prevalence and postdischarge incidence of malignancies in all consecutive patients admitted for an acute coronary syndrome. RESULTS: A total of 1819 patients were included. On admission, the prevalence of malignancies was 3.4%, and 41.9% of the patients were considered disease-free; of the 1731 discharged patients, the incidence was 3.1% (53 cases) and the most common locations were the colon, lung, bladder, and pancreas. Patients with prevalent malignancies were older and had more comorbidities and complications. There were no differences in the revascularization rate, but implantation of drug-eluting stents was less frequent in patients with prevalent malignancies. During follow-up, the median time to diagnosis of incident malignancies was 25 months. On multivariate analysis, independent risk factors were age and current or former smoking. All-cause mortality was much higher in patients with incident (64.2%) or prevalent (40.0%) malignancies. Multivariate analysis showed that prevalent and incident malignancies increased the risk of all-cause mortality by 4-fold. CONCLUSIONS: Among patients admitted for an acute coronary syndrome, 3.8% had a history of malignancy, with less than 50% considered cured. The incidence of new malignancies was 3.4% and both types of malignancies substantially impaired the long-term prognosis.

Factors Associated With Errors in Visual Estimation of the Functional Significance of Coronary Lesions.

UNLABELLED: INTRODUCTION AND  OBJECTIVES: Visual angiographic assessment continues to be used when decisions are made on whether to revascularize ambiguous coronary lesions. Multiple factors, other than the degree of stenosis, have been associated with the functional significance of a coronary lesion. The aim of this study was to investigate the ability of interventionists to visually predict the functional significance of a coronary lesion and the clinical and angiographic characteristics associated with errors in prediction. METHODS: We conducted a concordance study of the functional significance of coronary lesions predicted by experienced interventionists and fractional flow reserve values measured by intracoronary pressure wire in 665 intermediate lesions (40%-70% diameter stenosis) in 587 patients. We determined which factors were independently associated with errors in prediction. RESULTS: There was disagreement between the predicted fractional flow reserve value of ≤ 0.80 and the observed value in 30.1% of the lesions (overestimation: 11.3%; underestimation, 18.8%). Stent location in an artery other than the anterior descending artery or in a bifurcation was associated with overestimation. Male sex, severe calcification, and a greater myocardial territory distal to the lesion were significantly associated with the functional significance of the underestimated lesion. CONCLUSIONS: Even when taking into account angiographic and clinical characteristics, there is a high rate of disagreement between visual estimation and direct measurement of intermediate coronary stenosis in relation to its functional significance. Specific angiographic and clinical characteristics are associated with an increased tendency to overestimate or underestimate the significance of lesions.

Changes in Acute Coronary Syndrome Treatment and Prognosis After Implementation of the Infarction Code in a Hospital With a Cardiac Catheterization Unit.

INTRODUCTION AND OBJECTIVES: Emergency care systems have been created to improve treatment and revascularization in myocardial infarction but they may also improve the management of all patients with acute coronary syndrome. METHODS: A comparative study of all patients admitted with acute coronary syndrome before and after implementation of an infarction protocol. RESULTS: The study included 1210 patients. While the mean age was the same in both periods, the patient group admitted after implementation of the protocol had a lower prevalence of diabetes mellitus and hypertension but more active smokers and higher GRACE scores. The percentage of ST-segment elevation acute coronary syndrome (29.8%-39.5%) and coronary revascularizations (82.1%-90.1%) significantly increased among patients admitted with acute coronary syndrome, and primary angioplasty became routine (51.9%-94.9%); there was also a reduction in time to catheterization and an increase in early revascularization. The mean hospital stay was significantly shorter after implementation of the infarction protocol. In-hospital mortality was unchanged, except in high-risk patients (38.8%-22.4%). After discharge, no differences were observed between the 2 periods in cardiovascular mortality, all-cause mortality, reinfarction, or major cardiovascular complications. CONCLUSIONS: After implementation of the infarction protocol, the percentage of patients admitted with ST-segment elevation acute coronary syndrome and the mean GRACE score increased among patients admitted with acute coronary syndrome. Hospital stay was reduced, and primary angioplasty use increased. In-hospital mortality was reduced in high-risk patients, and prognosis after discharge was the same in both periods.

Comparison of Long-Term Mortality for Cardiac Diseases in Patients With Versus Without Diabetes Mellitus.

Diabetes mellitus confers the highest mortality risk in primary and secondary cardiovascular prevention, but long-term prognosis differences between different forms of cardiovascular disease have not been assessed. We hypothesized that acute heart failure (HF) could have poorer outcomes than acute coronary heart disease (CHD) in patients with diabetes. We performed a prospective study of all consecutive patients admitted in a single year. Patients were categorized according to main cardiologic diagnosis: acute HF, acute CHD, rhythm disorders, or noncardiac disease. A total of 1,293 patients were included, 31.8% had diabetes and had higher mean age, more risk factors, previous cardiovascular disease, and co-morbidities. Hospital mortality (5.6% vs 1.7%; p <0.01) was higher in patients with diabetes. During follow-up (median 58.0 months; interquartile range 31.0 to 60.0), diabetic patients had higher cardiovascular mortality (27.2% vs 9.6%; p <0.01) and all-cause mortality (35.8% vs 14.5%; p <0.01); cardiovascular disease accounted for 75% of deaths. According to discharge diagnosis, patients with diabetes only had higher mortality rates in the subgroup of acute CHD. Acute HF was the diagnosis with higher cardiovascular (36.9%) and all-cause mortality (44.1%), followed by acute CHD (16.8% and 24.4%) and rhythm disorders (5.8% and 8.8%). Multivariate analysis identified an independent association with higher long-term mortality of acute HF and acute CHD in patients with and without diabetes. In conclusion, 1/3 of cardiology-admitted patients have diabetes and have poorer long-term prognosis, especially when discharged with the diagnosis of acute HF or acute CHD.

Comparison of effectiveness of high-dose intracoronary adenosine versus intravenous administration on the assessment of fractional flow reserve in patients with coronary heart disease.

Intravenous adenosine is considered the drug of choice to obtain maximum hyperemia in the measurement of the fractional flow reserve (FFR). However, comparative studies performed between intravenous and intracoronary administration have not used high doses of intracoronary adenosine. The present study compared the efficacy and safety of high doses of intracoronary adenosine to intravenous administration when calculating the FFR. Intracoronary bolus doses of 60, 180, 300, and 600 µg adenosine were compared to an intravenous administration of 140 µg/kg/min, 200 µg/kg/min, and 140 µg/kg/min plus an intracoronary bolus of 120 µg. All the cases were performed using the radial approach. FFR was assessed in 102 patients with 108 intermediate lesions by an intracoronary pressure wire. The intracoronary dose of 60 µg was associated with a significantly greater FFR compared to the intravenous infusion (0.02 ± 0.03, p = 0.001). The intracoronary doses of 300 (-0.01 ± 0.00; p = 0.006) and 600 µg (-0.02 ± 0.00; p <0.0005) were significantly associated with a smaller FFR compared to the intravenous infusion. An intracoronary dose of 600 µg revealed a significantly greater percentage of lesions with an FFR <0.80 compared to intravenous infusion at 140 µg/kg/min (37.6 vs 31.5%; p <0.05) and 200 µg/kg/min (37.6 vs 32.4%; p <0.05) and compared to intracoronary doses of 60 (26.9%) and 180 µg (31.5%). In conclusion, an intracoronary bolus dose >300 µg can be equal to or more effective than an intravenous infusion of adenosine in achieving maximum hyperemia when calculating the FFR. Its use could simplify these procedures without having an effect on safety.

Effect of lesion length on functional significance of intermediate long coronary lesions.

OBJECTIVE: To assess the relationship between lesion length and other angiographic parameters on the functional significance of long coronary lesions with moderate stenosis. BACKGROUND: Coronary revascularization is usually based on angiographic percent stenosis. Coronary stenosis length is not usually considered in daily clinical practice for revascularization decision-making. The relevance of lesion length might be greater in longer lesions with intermediate stenosis. METHODS: All coronary lesions >20 mm and of 40-70% percent stenosis assessed by intracoronary pressure wire between 2007 and 2009 were included. Interventionists performing digital quantification of lesion stenosis were blinded to the result of fractional flow reserve (FFR). Correlations between angiographic data and FFR were analyzed. RESULTS: One hundred and six lesions from 103 patients were included. Reference diameter: 2.9 ± 0.56 mm; maximal stenosis: 49.0 ± 8.7%; minimal luminal diameter (MinimalLD): 1.48 ± 0.4 mm; mean luminal diameter (MeanLD): 2.3 ± 0.5 mm; mean lesion length: 28.7 ± 10.6 mm. Lesions with FFR <0.75 accounted for 33% (n = 35). Weak correlations were obtained between FFR and MinimalLD (r = 0.36; P < 0.0005), MeanLD (r = 0.24; P = 0.014), maximal stenosis (r = 0.31; P = 0.001), and mean stenosis (r = 0.018; P = 0.85); strong correlations were observed between FFR and lesion length (r = 0.63; P < 0.0005), lesion length/MinimalLD (r = 0.67; P < 0.0005), and lesion length/MeanLD (0.72; P < 0.0005). The predictive values of lesion length, lesion length/MinimalLD, and lesion length/MeanLD for FFR <0.75 were 0.86, 0.91, and 0.92, respectively. CONCLUSIONS: In long lesions (>20 mm) with moderate angiographic stenosis, lesion length might be the strongest determinant of functional repercussion. Lesion length should be considered when judging the benefit of revascularization or perform functional functional measures that overcome the limitations of simple stenosis quantification.

Correlation between intracoronary ultrasound and fractional flow reserve in long coronary lesions. A three-dimensional intracoronary ultrasound study.

INTRODUCTION AND OBJECTIVES: Intracoronary ultrasound estimation of the functional significance of intermediate angiographic lesions has mainly been based on measuring the minimal lumen area. These estimates take no account of lesion length and pay insufficient attention to long coronary lesions. METHODS: We included 61 lesions with visual angiographic stenosis of 40% to 70% that required treatment with a ≥20mm stent, studied with ultrasound and fractional flow reserve. Three-dimensional analysis of the ultrasound study was conducted offline and blinded to fractional reserve values. Angiographic and ultrasound parameters were correlated with fractional reserve. RESULTS: From the angiography we obtained data on mean reference diameter (2.87 [0.57] mm), length (29.8 [10.01] mm), and severity of stenosis (50.3% [8.7]%). Mean fractional flow reserve was 0.78 (0.09). We found a weak linear correlation (R) between fractional reserve and the ultrasound parameters that did not include lesion length: fractional reserve-minimal luminal area (R=0.4; P=.003). The correlation was stronger when lesion length was included: fractional reserve-volume of plaque (R=-0.65; P<.0005); fractional reserve-length/mean luminal area (R=0.73; P<.0005). The strongest correlation came from the product of mean stenosis by area multiplied by lesion length (R=-0.78; P<.0005). CONCLUSIONS: In long coronary lesions, the correlation between ultrasound-measured minimal lumen area and functional significance is weak. In these cases, estimates of functional significance should incorporate lesion length or be derived from direct fractional flow reserve measurement.

Results of fractional flow reserve measurement to evaluate nonculprit coronary artery stenoses in patients with acute coronary syndrome.

INTRODUCTION AND OBJECTIVES: Multivessel disease is usually present in almost half of patients with acute coronary syndromes. Angiography is insufficiently accurate to decide on coronary revascularization in moderate nonculprit lesions. There is some debate about the usefulness of fractional flow reserve assessed by intracoronary pressure wire in acute coronary syndromes. We studied the results of using fractional flow reserve values to decide whether to perform coronary revascularization of nonculprit angiographically moderate lesions in patients with acute coronary syndrome and multivessel disease. METHODS: The fractional flow reserve was used to decide whether to revascularize angiographically moderate nonculprit lesions in a cohort of consecutive patients with acute coronary syndromes recruited in 2 centers. RESULTS: One hundred and seven patients were included. Based on fractional flow reserve values, 81 patients (75.7%) were not revascularized. All lesions studied were revascularized in 26 patients (24.3%). Patient characteristics of the nontreated group and treated group were, respectively, diseased vessels, 1.3 (0.7) vs 1.4 (0.6) (P<.4); fractional flow reserve-studied lesions, 1.2 (0.5) vs 1.1 (0.4) (P=.3); stenosis, 46.1 (8.3)% vs 47.9 (10.3)% (P=.4); fractional flow reserve, 0.86 (0.1) vs 0.70 (0.1) (P<.005). After 1 year of follow-up, no significant differences in major cardiovascular events were observed between groups. There no deaths or nonfatal myocardial infarctions attributable to fractional flow reserve -deferred lesions. Coronary revascularization of the studied lesions was performed in 3 nontreated group patients (3.7%) due to disease progression. CONCLUSIONS: Fractional flow reserve assessed by intracoronary pressure wire is useful in deciding whether to revascularize angiographically moderate nonculprit lesions in patients with acute coronary syndrome and multivessel disease.

Usefulness of the fractional flow reserve derived by intracoronary pressure wire for evaluating angiographically intermediate lesions in acute coronary syndrome.

INTRODUCTION AND OBJECTIVES: In contrast to findings in stable ischemic heart disease, in acute coronary syndrome (ACS), measurement of the fractional flow reserve (FFR) using an intracoronary pressure wire has not been shown to be useful for evaluating angiographically equivocal coronary lesions. The aim of this study was to analyze outcomes at 1 year in ACS patients with lesions that were classed as intermediate on coronary angiography and which were not nonrevascularized because of the FFR value determined by intracoronary pressure wire. METHODS: The observational study involved a cohort of patients admitted for ACS who had intermediate lesions on coronary angiography that were not revascularized because the FFR was >0.75. Functional studies were not carried out if there was angiographic evidence of instability. All-cause mortality, non-fatal myocardial infarction, revascularization of the target lesion and readmission for cardiac causes in the first year of the study were recorded. RESULTS: The study included 106 patients with 127 lesions that were not revascularized because the FFR was >0.75. Their mean age was 69.9+/-10 years, 92 (86.8%) had non-ST-elevation ACS, the mean angiographic stenosis was 40.5+/-7.8%, and the mean FFR was 0.88+/-0.06. There were no complications during the procedure. The follow-up rate at 1 year was 95.1%. Events observed at 1 year were: 2 deaths (total mortality 1.9%), 0 fatal acute myocardial infarctions, 1 (0.9%) target lesion revascularization and 5 (4.7%) readmissions for cardiac causes. CONCLUSIONS: Once lesions with clear angiographic signs of instability are excluded, intracoronary pressure wire measurement could be useful in ACS patients for avoiding unnecessary revascularization of angiographically intermediate coronary lesions.