The impact of fractional flow reserve measurement on clinical outcomes after transradial coronary stenting.

AIMS: Fractional flow reserve (FFR) ≥0.96 after stenting correlates well with an optimal stent expansion, but outcomes based on FFR after drug eluting stents (DES) have not been studied. This study sought to investigate the proportion of patients in whom an FFR ≥0.96 can be achieved after transradial stenting using primarily DES and to determine outcomes based on a post-stent FFR ≥0.96 vs. an FFR<0.96. METHODS AND RESULTS: A total of 66 patients with single-vessel disease and FFR<0.75 underwent transradial stenting. After stenting, FFR was <0.96 in 34 patients and there was a hyperaemic trans-stent gradient across the edges of stent in five patients; after high-pressure balloon inflation, FFR increased to ≥0.96 in three patients and an FFR ≥0.96 was achieved in 35 patients (53%, group 1), but FFR remained <0.96 in 31 patients (47%, group 2). There was no correlation between FFR and minimum lumen diameter in group 1 or group 2 (r=0.03; p=0.72 and r=0.02; p=0.22, respectively). The 24-month event-free survival estimate defined as freedom from death, MI, and target vessel revascularisation (PCI or CABG) was significantly greater in group 1 than in group 2 (94% versus 72%, respectively; p=0.02). CONCLUSIONS: After transradial stenting with predominately DES, an FFR ≥0.96 was achieved in only 53% of patients and event rates among patients with a post-stent FFR ≥0.96 were significantly lower than those with an FFR<0.96.

Congenital ostial left main coronary artery stenosis associated with a bicuspid aortic valve in a young woman.

We describe a 41-year-old woman with no cardiac risk factors, typical exertional angina and an abnormal noninvasive stress test. Coronary angiography demonstrated an ambiguous left main coronary artery (LMCA) stenosis. Intravascular ultrasound (IVUS) demonstrated no atheroma, but the minimum lumen diameter and area of the ostial LMCA were significantly reduced. Transesophageal echocardiography showed normal left ventricular function with a bicuspid aortic valve. Two-vessel coronary artery bypass grafting was subsequently performed. To our knowledge, this is the first IVUS-documented case of a congenital left main coronary artery stenosis associated with a bicuspid aortic valve.

Thirty-month outcome after fractional flow reserve-guided versus conventional multivessel percutaneous coronary intervention.

We investigated the value of fractional flow reserve (FFR)-guided percutaneous coronary intervention (FFR-PCI) versus conventional PCI in patients with multivessel disease (MVD). Conventional PCI is performed by visual estimation of the stenosis. Deferral of PCI because of a FFR >or=0.75 is associated with low event rates. However, the value of FFR-PCI in patients with MVD is unknown. We prospectively enrolled 137 patients (312 vessels) with MVD to compare FFR-PCI and conventional PCI. In the FFR-PCI group, FFR of all vessels was performed, and PCI of stenoses with a FFR <0.75 was performed. In the conventional PCI group, patients underwent multivessel PCI by visual estimation of the stenoses. Procedural characteristics, event rates, and cost were compared between the 2 groups. In the FFR-PCI group, after FFR analysis in 57 patients (128 vessels), PCI was performed in 48 patients (53 vessels). In the conventional PCI group, 80 patients (184 vessels) underwent PCI. The average number of vessels per patient that underwent PCI and the cost of procedure were significantly greater in the conventional PCI group than in the FFR-PCI group (2.27 +/- 0.50 vs 1.12 +/- 0.30 vessels and 3,167 dollars +/- 1,194 dollars vs 2,572 dollars +/- 934 dollars, respectively; p <0.001). The 30-month Kaplan-Meier event-free survival estimate was significantly higher in the FFR-PCI group than in the conventional PCI group (89% vs 59%, p <0.01). In conclusion, the results of the present study have demonstrated that in patients with MVD, compared with conventional PCI, FFR-PCI significantly reduces the number of vessels undergoing PCI, the event rate, and the cost of the procedure.

Increased prevalence of coronary artery aneurysms among cocaine users.

BACKGROUND: Cocaine abuse has been implicated in multiple cardiovascular complications. Coronary artery aneurysms (CAAs) and ectasia occur in 0.2% to 5.3% of patients referred for angiography and are associated with atherosclerosis, Kawasaki's disease, and several rare disorders. After observing CAAs in multiple young cocaine users, we investigated the prevalence of CAAs among cocaine users undergoing coronary angiography. METHODS AND RESULTS: Clinical and angiographic characteristics of 112 consecutive patients with a history of cocaine use and coronary angiography were compared with a control group of similar age and risk factors from an existing angiographic database over the same time period. Coronary angiograms were independently read by 3 reviewers blinded to cocaine use. Cocaine users were young (mean age, 44 years), predominantly male (80%), and cigarette smokers (95%). Control patients had higher rates of diabetes (33%) and more severe coronary artery disease (P=0.01). Previous myocardial infarction was common in both groups (45% of cocaine users, 38% of control patients). Despite the frequent history of myocardial infarction among cocaine users, 48% had nonobstructive coronary artery disease. Among cocaine users, 34 of 112 (30.4%) had CAAs compared with 6 of 79 (7.6%) in the control group (P<0.001). Cocaine use was a strong predictor of CAA by univariate and multivariate analyses. CONCLUSIONS: This is the first description of an association between cocaine use and CAA. The prevalence of CAA among cocaine users was higher than expected (30.4%), given such a young cohort. Cocaine use may predispose to the formation of CAA, which may in turn be a contributing factor to myocardial infarction.

Changes in coronary endothelial function predict progression of allograft vasculopathy after heart transplantation.

OBJECTIVE: Coronary endothelial dysfunction may be an early marker for cardiac allograft vasculopathy (CAV) in orthotopic heart transplant recipients. We used serial studies to evaluate changes in coronary endothelial function in patients with and without clinically evident CAV. BACKGROUND: In serial studies with intravascular ultrasound (IVUS) and Doppler flow wire measurements, we previously demonstrated that annual decrements in coronary endothelial function are associated with progressive intimal thickening. METHODS: We studied 45 patients annually, beginning at transplantation until pre-specified end-points (angiographic CAV or cardiac death) were reached. At each study, we measured coronary endothelial function using intracoronary infusions of adenosine, acetylcholine, and nitroglycerin. We simultaneously recorded IVUS images and Doppler velocities. RESULTS: Of the 45 patients studied, 9 reached end-points during the study (6 had CAV and 3 died). The mean annual change in area response to acetylcholine was -4.5% +/- 3.0% in patients who reached end-points and -0.9% +/- 1.5% in those who did not (p = 0.04). The mean annual decrement in flow response to acetylcholine was greater in patients who reached end-points (-31% +/- 11% vs -5% +/- 5%, p = 0.08). Responses to adenosine and nitroglycerin did not differ. CONCLUSIONS: When serial responses were evaluated, patients with end-points had more rapid decreases in endothelial function. The rate of disease progression may be more important than the absolute degree of intimal thickening in early CAV. These data implicate endothelial dysfunction in the development of clinically significant vasculopathy and suggest that serial studies of endothelial function may provide important prognostic information about the development of CAV after heart transplantation.

The impact of adjunctive adenosine infusion during exercise myocardial perfusion imaging: Results of the Both Exercise and Adenosine Stress Test (BEAST) trial.

BACKGROUND: Failure to achieve an adequate heart rate limits the sensitivity of exercise myocardial perfusion imaging (MPI) for the detection of coronary artery disease. In addition, it is often not possible to discontinue medications that may blunt the heart rate response to exercise, because of conditions such as hypertension or angina. However, if pharmacologic stress testing is performed, the ability to assess functional capacity is lost. Accordingly, we developed a protocol that incorporates adenosine stress with symptom-limited exercise. METHODS AND RESULTS: As part of a multicenter study, 35 patients were enrolled prospectively and underwent both exercise MPI and exercise MPI with a 4-minute adenosine infusion on a separate day. Technetium 99m sestamibi was injected at or near peak exercise (exercise only) and at 2 minutes into the adenosine infusion (combined exercise and adenosine). The perfusion images were interpreted in a blinded fashion. The combined adenosine and exercise protocol was well tolerated. The summed stress scores and summed difference scores were greater in the exercise-plus-adenosine group than in the exercise-only group (10.0 vs 8.5, P =.02, and 4.9 vs 3.3, P =.002, respectively). Exercise time was slightly but significantly less with the exercise-plus-adenosine protocol (8 minutes 46 seconds vs 8 minutes 11 seconds, P =.027). CONCLUSION: A protocol combining 4 minutes of adenosine infusion with symptom-limited exercise was safe and well tolerated. Furthermore, this protocol resulted in a greater amount of myocardial ischemia detected on MPI while allowing for the assessment of functional capacity. A combined exercise and adenosine protocol may be a useful test for patients undergoing MPI who are unlikely to achieve an adequate chronotropic response.