Eligibility and Cost-Utility Analysis of Dapagliflozin in Patients with Heart Failure Across the Whole Spectrum of Ejection Fraction in South Korea.

BACKGROUND: The DAPA-HF and DELIVER trials demonstrated the clinical benefits of dapagliflozin in heart failure (HF) patients across the entire ejection fraction (EF) spectrum. However, further investigation is needed for the real-world application of dapagliflozin in HF patients. This study examines the proportion of real-world HF patients eligible for dapagliflozin and evaluates the cost-effectiveness of adding dapagliflozin to current HF therapy. METHODS: Data from the nationwide prospective registry, the Korean Acute Heart Failure (KorAHF) registry, were used to determine dapagliflozin eligibility based on the enrollment criteria of the DAPA-HF/DELIVER trials. A cost-utility analysis was conducted using a Markov model to assess the cost-effectiveness of dapagliflozin by comparing it to the standard of care. RESULTS: Out of 5178 KorAHF patients, 48.7% met the enrollment criteria of the DAPA-HF/DELIVER trials, while 89.5% met the label criteria (US Food and Drug Administration, European Medicines Agency, and Korean Ministry of Food and Drug Safety). Eligibility was highest among HF patients with preserved EF (55.3% vs. HF with mildly reduced EF and HF with reduced EF 46.4%). Dapagliflozin proved to be cost-effective, with an incremental cost-effectiveness ratio (ICER) of 4557 US dollar (US$) per quality-adjusted life year, which falls below the US$18,182 willingness-to-pay threshold. The cost-effectiveness benefit was more pronounced in patients with a left ventricular EF (LVEF) ≤ 40% (ICER US$3279 for LVEF ≤ 40% vs. US$8383 for LVEF > 40%). CONCLUSIONS: Discrepancies in dapagliflozin eligibility were observed between real-world data and clinical trial results. The addition of dapagliflozin to HF therapy proved to be highly cost-effective across the entire EF spectrum.

Real-World Eligibility and Cost-Effectiveness Analysis of Empagliflozin for Heart Failure in Korea.

BACKGROUND: The US Food and Drug Administration (FDA) and European Medicines Agency (EMA) approved empagliflozin for reducing cardiovascular mortality and heart failure (HF) hospitalization in patients with both HF with reduced ejection fraction (HFrEF) and HF with preserved ejection fraction (HFpEF). However, limited data are available on the generalizability of empagliflozin to clinical practice. Therefore, we evaluated real-world eligibility and potential cost-effectiveness based on a nationwide prospective HF registry. METHODS: A total of 3,108 HFrEF and 2,070 HFpEF patients from the Korean Acute Heart Failure (KorAHF) registry were analyzed. Eligibility was estimated by inclusion and exclusion criteria of EMPagliflozin outcomE tRial in Patients With chrOnic heaRt Failure With Reduced Ejection Fraction (EMPEROR-Reduced) and EMPagliflozin outcomE tRial in Patients With chrOnic heaRt Failure With Preserved Ejection Fraction (EMPEROR-Preserved) trials and by FDA & EMA label criteria. The cost-utility analysis was done using a Markov model to project the lifetime medical cost and quality-adjusted life year (QALY). RESULTS: Among the KorAHF patients, 91.4% met FDA & EMA label criteria, while 44.7% met the clinical trial criteria. The incremental cost-effectiveness ratio of empagliflozin was calculated at US$6,764 per QALY in the overall population, which is far below a threshold of US$18,182 per QALY. The cost-effectiveness benefit was more evident in patients with HFrEF (US$5,012 per QALY) than HFpEF (US$8,971 per QALY). CONCLUSION: There is a large discrepancy in real-world eligibility for empagliflozin between FDA & EMA labels and clinical trial criteria. Empagliflozin is cost-effective in HF patients regardless of ejection fraction in South Korea health care setting. The efficacy and safety of empagliflozin in real-world HF patients should be further investigated for a broader range of clinical applications. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01389843.

Artificial intelligence assessment for early detection and prediction of renal impairment using electrocardiography.

PURPOSE: Although renal failure is a major healthcare burden globally and the cornerstone for preventing its irreversible progression is an early diagnosis, an adequate and noninvasive tool to screen renal impairment (RI) reliably and economically does not exist. We developed an interpretable deep learning model (DLM) using electrocardiography (ECG) and validated its performance. METHODS: This retrospective cohort study included two hospitals. We included 115,361 patients who had at least one ECG taken with an estimated glomerular filtration rate measurement within 30 min of the index ECG. A DLM was developed using 96,549 ECGs of 55,222 patients. The internal validation included 22,949 ECGs of 22,949 patients. Furthermore, we conducted an external validation with 37,190 ECGs of 37,190 patients from another hospital. The endpoint was to detect a moderate to severe RI (estimated glomerular filtration rate < 45 ml/min/1.73m2). RESULTS: The area under the receiver operating characteristic curve (AUC) of a DLM using a 12-lead ECG for detecting RI during the internal and external validation was 0.858 (95% confidence interval 0.851-0.866) and 0.906 (0.900-0.912), respectively. In the initial evaluation of 25,536 individuals without RI patients whose DLM was defined as having a higher risk had a significantly higher chance of developing RI than those in the low-risk group (17.2% vs. 2.4%, p < 0.001). The sensitivity map indicated that the DLM focused on the QRS complex and T-wave for detecting RI. CONCLUSION: The DLM demonstrated high performance for RI detection and prediction using 12-, 6-, single-lead ECGs.

Artificial intelligence assessment for early detection of heart failure with preserved ejection fraction based on electrocardiographic features.

Aims: Although heart failure with preserved ejection fraction (HFpEF) is a rapidly emerging global health problem, an adequate tool to screen it reliably and economically does not exist. We developed an interpretable deep learning model (DLM) using electrocardiography (ECG) and validated its performance. Methods and results: This retrospective cohort study included two hospitals. 34 103 patients who underwent echocardiography and ECG within 1 week and indicated normal left ventricular systolic function were included in this study. A DLM based on an ensemble neural network was developed using 32 671 ECGs of 20 169 patients. The internal validation included 1979 ECGs of 1979 patients. Furthermore, we conducted an external validation with 11 955 ECGs of 11 955 patients from another hospital. The endpoint was to detect HFpEF. During the internal and external validation, the area under the receiver operating characteristic curves of a DLM using 12-lead ECG for detecting HFpEF were 0.866 (95% confidence interval 0.850-0.883) and 0.869 (0.860-0.877), respectively. In the 1412 individuals without HFpEF at initial echocardiography, patients whose DLM was defined as having a higher risk had a significantly higher chance of developing HFpEF than those in the low-risk group (33.6% vs. 8.4%, P < 0.001). Sensitivity map showed that the DLM focused on the QRS complex and T-wave. Conclusion: The DLM demonstrated high performance for HFpEF detection using not only a 12-lead ECG but also 6- single-lead ECG. These results suggest that HFpEF can be screened using conventional ECG devices and diverse life-type ECG machines employing the DLM, thereby preventing disease progression.

Body fluid status assessment by bio-impedance analysis in patients presenting to the emergency department with dyspnea.

BACKGROUND/AIMS: Fluid retention occurs in patients with heart failure, accounting for dyspnea. We investigated the diagnostic implication of body fluid status, assessed by bio-impedance analysis (BIA), in acute heart failure (AHF) among patients who presented with dyspnea. METHODS: A total of 100 patients who presented with dyspnea and suspected with AHF were analyzed in this study. We enrolled 50 AHF and 50 non-AHF patients discriminated through echocardiographic analysis and Framingham criteria and were matched by age and sex. Body composition was analyzed using a multifrequency BIA. RESULTS: AHF patients demonstrated higher extracellular water (ECW)/total body water (TBW) compared with non-AHF patients (0.412 ± 0.017 vs. 0.388 ± 0.023, p < 0.001). A significant difference of ECW/TBW between AHF patients and nonAHF patients was noted when the upper extremities, trunk, and lower extremities were analyzed (all p < 0.001, respectively). ECW/TBW was not different between patients with reduced ejection fraction (EF) and preserved EF along body compartments. The best cut-off value to predict AHF was > 0.412 at lower extremities with sensitivity and specificity of 0.780 and 0.960. The ECW/TBW of the lower extremities (ECW/TBWL) was correlated with log B-type natriuretic peptide (BNP) levels (r = 0.603, p < 0.001) and also improved the net reclassification improvement and integrated discriminated improvement when added to log BNP level. Multivariate analysis revealed that ECW/TBWL > 0.412 had an independent association with AHF patients (p = 0.011). CONCLUSION: The ECW/TBWL was higher in patients with dyspnea caused by AHF than their counterparts and demonstrated an independent diagnostic implication. It may be a promising marker to diagnose AHF at bedside.

Cardio-ankle vascular index reflects coronary atherosclerosis in patients with abnormal glucose metabolism: assessment with 256 slice multi-detector computed tomography.

OBJECTIVE: The association between arterial stiffness, as measured by the cardio-ankle vascular index (CAVI), and coronary atherosclerosis, using coronary artery computed tomography (CT), was investigated in the asymptomatic general population, with special interest in subjects with abnormal glucose metabolism. PATIENTS AND METHODS: A total of 158 normoglycemic subjects and 373 subjects with abnormal glucose metabolism were evaluated. CAVI was assessed in relation with coronary artery calcium score (CACS) and degree of stenosis detected by CT. RESULTS: The association of CAVI with other clinical parameters was evaluated in patients with abnormal glucose metabolism. CAVI was higher, and CACS and the degree of coronary artery stenosis were both greater compared to the normal group. CAVI showed a significant correlation with CACS and the degree of stenosis (r=0.167, p=0.001; r=0.182, p<0.001, respectively). The cut-off level of CAVI from receiver operating characteristic (ROC) curve was ≥ 8.0 for predicting ≥ 50% coronary artery stenosis (area under the curve 0.713, sensitivity 69%, and specificity 61%). CAVI ≥ 8.0 was independently associated with significant coronary artery stenosis, even after adjusting for age, sex, and presence of hypertension and hypercholesterolemia (odds ratio 3.143, 95% confidence interval 1.004-9.842, p=0.049). CONCLUSION: CAVI is an independent parameter which reflects coronary atherosclerosis in patients with abnormal glucose metabolism. CAVI can be a useful tool not only to assess arterial stiffness, but also to evaluate the risk for subclinical coronary atherosclerosis in asymptomatic patients.

Epicardial fat reflects arterial stiffness: assessment using 256-slice multidetector coronary computed tomography and cardio-ankle vascular index.

AIM: The cardio-ankle vascular index (CAVI) reflects overall arterial stiffness from the aorta to the ankle, independent of blood pressure. We aimed to investigate the association of fat burden assessed by visceral adipose tissue (VAT), subcutaneous adipose tissue (SAT) and epicardial adipose tissue (EAT) with CAVI in an asymptomatic population. METHODS: A total of 260 asymptomatic Korean individuals who had CAVI, abdominal computed tomography (CT) and coronary CT were evaluated retrospectively. The VAT, SAT, EAT and SAT to VAT ratio (SVR) were measured and assessed for correlation with CAVI. RESULTS: Different fat compartments showed different correlations with arterial stiffness as assessed by CAVI. The amount of fat measured by VAT (r= 0.129, p= 0.037), EAT (r=0.193, p= 0.002) and SVR (r=-0.168, p= 0.007) showed a significant correlation with CAVI, whereas the amount of total abdominal fat and SAT did not (p= 0.261 and p= 0.434 respectively). From step-wise multivariate regression analysis including age, pulse pressure, fasting blood sugar level, VAT, SVR and EAT, EAT (p= 0.036) and age (p<0.001) showed significant associations with CAVI. When quartiles of CAVI were assessed, EAT showed serial increment, whereas SVR showed a stepwise decrease from the first quartile to fourth quartile of CAVI (p=0.041). CONCLUSION: VAT, EAT and SVR, which reflect metabolic risk, have shown significant correlations with arterial stiffness measured by CAVI. EAT showed an independent association with arterial stiffness after adjusting for covariables by multivariable correlation analysis. Among the different parameters reflecting fat burden, EAT showed the strongest correlation with CAVI.

Load independence of two-dimensional speckle-tracking-derived left ventricular twist and apex-to-base rotation delay in nonischemic dilated cardiomyopathy: implications for left ventricular dyssynchrony assessment.

BACKGROUND: Left ventricular (LV) twist mechanics are a promising, sensitive tool for assessing pathophysiologic changes in patients with systolic heart failure. Although LV twist is known to be load dependent in healthy volunteers, this has not been examined in patients with "long-standing" dilated cardiomyopathy (DCM). The aim of this study was to determine whether LV twist remains load dependent in the setting of long-standing, nonischemic DCM. METHODS: Thirty-four patients with DCM with baseline LV ejection fractions (LVEFs) < 40% and 13 subjects with preserved LVEFs (≥50%) were enrolled. After baseline measurements, pneumatic compression of the lower extremities (Pcom) was used to increase LV afterload. Subsequently, sublingual nitroglycerin (SL-NG) was administered to modify preload. Conventional echocardiographic parameters, LV end-systolic wall stress, net LV twist angle, and apex-to-base-rotation delay (ABRD) were assessed under each condition. RESULTS: In patients with DCM, although LV end-systolic wall stress significantly increased under Pcom (196.9 ± 64.9 g/m(2) at baseline vs 231.8 ± 78.9 g/m(2) under Pcom, P < .017) and decreased after SL-NG application (231.8 ± 78.9 g/m(2) under Pcom vs 197.4 ± 67.4 g/m(2) after SL-NG, P < .017), net LV twist angle and ABRD showed no significant changes depending on LV loading condition (for LV twist, 7.63 ± 4.47° at baseline vs 7.03 ± 4.13° under Pcom vs 7.35 ± 4.36° after SL-NG, P = 0.65; for ABRD, 16.56 ± 13.81% at baseline vs 17.19 ± 14.81% under Pcom vs 15.95 ± 13.27% after SL-NG, P = .53). Careful examination of individual patient data revealed that LV twist was load independent when patients had LV twist < 12°. ABRD was also found to be load independent, but only in patients with LVEFs < 34%. In contrast, LV twist and ABRD were load dependent in patients with preserved LVEFs. CONCLUSIONS: LV twist and its component, ABRD, had relatively load insensitive properties in patients with long-standing DCM and can be used in future clinical trials as load-independent indexes of LV dyssynchrony.

Clinical predictors of high posttreatment platelet reactivity to clopidogrel in Koreans.

INTRODUCTION: High posttreatment platelet reactivity to clopidogrel (HPPR) is associated with major adverse cardiac events. However, the clinical predictors of HPPR in Asians have not been studied previously. AIMS: We sought to determine clinical predictors of HPPR in Koreans. RESULTS: We measured platelet reactivity with the VerifyNow P2Y12 assay in 1431 consecutive patients undergoing coronary angiography. We used the cut-off value of greater than 275 P2Y12 Reaction Unit (PRU) to define patients with HPPR. The clinical characteristics were compared between patients with HPPR (36.3%) and those without HPPR (63.7%). The mean age (65.4 ± 9.1 vs. 62.2 ± 9.7 years) was higher, hypertension (68.5% vs. 62.0%), diabetes mellitus (35.4% vs. 28.5%), chronic kidney disease (36.3% vs. 22.5%), renal replacement treatment (1.2% vs. 0.2%), and congestive heart failure (1.3% vs. 0.3%) were more common among patients with HPPR, while male gender (72.6% vs. 54.8%) and smoking (19.9% vs. 13.1%) were more common among non-HPPR patients. Mean glomerular filtration rate (63.5 ± 18.6 vs. 69.7 ± 16.1 mL/min/1.73 m(3) ) was lower and C-reactive protein (hs-CRP) (6.6 ± 20.5 mg/L vs. 4.2 ± 12.1 mg/L) level was higher among those with HPPR. Independent predictors of HPPR were female gender (OR 1.90, P≤ 0.001), chronic kidney disease (OR 1.51, 0 = 0.004), diabetes mellitus (OR 1.35, P= 0.024), hs-CRP ≥ 2.0 mg/L (OR 1.31, P= 0.005), and age increase in decades (OR 1.21, P= 0.002), while smoking was negative risk factor (OR 0.63, P= 0.015). The number of risk factors was linearly associated with the risk of HPPR, with most patients having one or two predictors. CONCLUSION: In Korean population, independent clinical predictors of HPPR included diabetes mellitus, increased age, female gender, chronic kidney disease, and hs-CRP ≥ 2.0 mg/L, while cigarette smoking was associated with better responsiveness. Mean platelet reactivity and HPPR prevalence steadily increased with the number of clinical predictors.

Enhanced clopidogrel responsiveness in smokers: smokers' paradox is dependent on cytochrome P450 CYP1A2 status.

OBJECTIVE: Observational studies have reported enhanced response to clopidogrel in smokers (the smokers' paradox). We examined whether genetic variations in the cytochrome and drug transporter system are associated with the effect of smoking on clopidogrel response. METHODS AND RESULTS: Clopidogrel on-treatment platelet reactivity (OPR) was measured in 1431 consecutive patients who underwent coronary angiography. Gene samples were available and genotyping was successful in 1123 patients. Nine candidate single-nucleotide polymorphisms in 5 cytochrome genes and 1 drug transporter gene were assessed. The mean OPR of the entire population was 241.9 ± 79.3 (P2Y(12) reaction units). Two hundred forty-nine (17%) smokers had lower OPR compared with 1182 (83%) nonsmokers (227.6 ± 76.0 versus 244.9 ± 79.7, P=0.001). Among the 9 single-nucleotide polymorphisms, only CYP1A2 showed a genotype-dependent change in the effect of smoking on OPR. After adjustment for possible confounding factors, cigarette smoking was associated with a lower OPR by -19 P2Y(12) reaction units (P=0.009) and lower risk for high OPR (odds ratio [OR], 0.48; 95% CI, 0.31 to 0.74) in the AA and CA genotypes but not in the CC genotype. CONCLUSIONS: Enhanced clopidogrel response in smokers, known as the smokers' paradox, is not universal but was observed only in cytochrome P450 CYP1A2 (-163C>A) A-allele carriers, suggesting a genotype-dependent effect of smoking on clopidogrel responsiveness.

Persistent regional diastolic dysfunction after myocardial ischemia and the effect of statin treatment: assessment with two-dimensional radial strain rate.

BACKGROUND: Persistence of regional diastolic dysfunction after ischemic insult remains debatable. With speckle tracking echocardiography (STE), we sought to (1) prove the persistence of regional diastolic dysfunction, (2) assess the feasibility of applying persistent regional diastolic dysfunction to differentiating ischemic and nonischemic chest pain, and finally (3) examine statin effects on postischemic regional diastolic dysfunction. METHODS: Nineteen patients with variant angina (VA) and 12 normal subjects were enrolled. Comprehensive echocardiographic examinations were performed before and 1 day after coronary angiography (CAG) with ergonovine provocation. Radial systolic (rSRsys) and diastolic (rSRdia) strain rates were obtained and averaged using standard segmentation models corresponding to the three major coronary territories assigned. RESULTS: No significant changes in rSRsys and rSRdia values were observed for controls and in rSRsys for VA. However, rSRdia for VA demonstrated a weak, but significant, decrease from -2.25 +/- 0.71/sec to -2.04 +/- 0.71/sec (P = 0.003) 1 day after CAG. However, because of the wide overlap between rSRdia values in normal and ischemic segments for VA patients, predictability of remote ischemia based solely on the rSRdia was limited. Subgroup analysis according to statin prescription showed that statin administration contributed to the elimination of rSRdia reduction (-2.28 +/- 0.84/sec on pre-CAG vs. -2.29 +/- 0.77/sec on post-CAG, P = 0.72 for patients without statin premedication; -2.23 +/- 0.64/sec for pre-CAG vs. -1.88 +/- 0.65/sec for post-CAG, P = 0.002 for those without). Expectedly, rSRsys values showed no significant changes in all situations. CONCLUSIONS: The presence and sustained nature of regional diastolic dysfunction can be demonstrated with STE. Statin minimized the persistence of regional diastolic dysfunction after an acute ischemia. Although the clinical usefulness of rSRdia by STE appears to be limited, its clinical utility requires further consideration, given the brevity of the ischemia provoked during CAG with ergonovine and the protracted regional diastolic dysfunction.

Extracolonic findings in an asymptomatic screening population undergoing intravenous contrast-enhanced computed tomography colonography.

BACKGROUND AND AIM: The purpose of this study was to evaluate extracolonic findings that could be encountered with computed tomography colonography (CTC) using intravenous (IV) contrast material in an asymptomatic screening population. METHODS: Intravenous contrast medium-enhanced CTC was performed in 2230 asymptomatic adults (mean age, 57.5 years). Axial images were prospectively examined for extracolonic lesions. These findings were classified into three categories: potentially important findings, likely unimportant findings, and clinically unimportant findings. Potentially important extracolonic findings were defined as those which required immediate further diagnostic studies and treatment. Clinical and radiologic follow up, missed lesions and clinical outcomes were assessed using medical records (mean duration of follow up, 1.6 years). RESULTS: A total of 115 new potentially important findings in 5.2% of subjects (115/2230) were found. Subsequent medical or surgical intervention was performed in 2.0% (45/2230). New extracolonic cancer was detected in 0.5% (12/2230), and the majority of them (83.3%) were not metastasized. Computed tomography colonography missed eight potentially important extracolonic findings in eight subjects (0.4%, 8/2230): 0.8-cm early-stage prostatic cancer, six adrenal mass and one intraductal papillary mucinous tumor. There were no severe life-threatening complications related to contrast medium. CONCLUSION: Intravenous contrast-enhanced CTC could safely detect asymptomatic early-stage extracolonic malignant diseases without an unreasonable number of additional work-ups, thus reducing their morbidity or mortality.

Assessment of left ventricular rotation and torsion with two-dimensional speckle tracking echocardiography.

BACKGROUND: Speckle tracking echocardiography (STE) has a unique feature of angle independence and, thus, may provide a powerful means of assessing left ventricular (LV) torsion (LVtor). The aims of this study were to assess: (1) the feasibility of 2-dimensional STE in the measurement of LVtor; and (2) the relationship of LVtor with age and conventional echocardiographic parameters. METHODS: We consecutively recruited 160 healthy volunteers. After obtaining conventional echocardiographic parameters, apical and basal short-axis rotations were assessed with STE. LVtor was defined as the net difference between rotation angles in the two short-axis planes normalized for LV longitudinal length. RESULTS: Reliable LVtor measurement was possible only in 56 volunteers (35%). This low feasibility was largely a result of the failure to obtain reliable basal rotation values. In 56 volunteers who were finally enrolled in this study, a significant correlation was found between LV ejection fraction and LVtor (r = 0.56, P < .001) and this correlation was attributed to apical (r = 0.47, P < .001) but not basal (P = .14) rotation. There was no significant change in LVtor with aging. However, initial counterclockwise motion (r = -0.51, P = .001) and its interval (r = -0.44, P = .001) in the basal rotation gradually decreased with aging, and correlated with early transmitral inflow velocity (r = 0.44 and 0.49, respectively) and its deceleration time (r = -0.43 and -0.48, respectively) (all P < .001). In contrast, such correlations were not found for initial clockwise motion and its interval in the apical rotation. CONCLUSIONS: Currently, STE has limited feasibility in the measurement of LVtor. There was no significant age-related change in LVtor. In LV rotations, basal rotation was affected by the age-related changes in the LV early diastolic filling, whereas apical rotation was mainly related to LV systolic performance.

Assessment of coronary vasodilatation in response to nitroglycerin with transthoracic Doppler echocardiography.

BACKGROUND: Previous studies demonstrated impaired coronary vasodilatory response (VR) to nitroglycerin (NG) in patients with coronary atherosclerosis. We hypothesized that the effect of the NG on the coronary blood flow (CBF) is negligible compared with its effect on the epicardial coronary artery dilatation and, therefore, that CBF velocity reduction after NG can reflect the magnitude of epicardial coronary artery dilatation. METHODS: Quantitative coronary angiography was performed at the left anterior descending coronary artery (LAD) before and after intracoronary NG (200 mug) infusion in 18 patients with normal-looking coronary angiogram. VR assessed by quantitative coronary angiography (VRangio) was defined as: (LAD diameter after NG)(2)/(LAD diameter before NG)(2). Mean values measured at the ostium and at the junction of mid and distal LAD were used in the analysis. Diastolic CBF velocity was evaluated by using a 7-MHz transducer at the distal LAD before and 3 minutes after sublingual NG. VR assessed by echocardiography (VRecho) was defined as: (mean diastolic CBF velocity before sublingual NG)/(mean diastolic CBF velocity after sublingual NG). In 11 patients, plaque burden was assessed by intravascular ultrasound and results were compared with VRangio and VRecho. RESULTS: VRecho was found to correlate well with VRangio (r = 0.71, P = .001), and VRangio and VRecho showed significant negative correlations with plaque burden (r = -0.66, P = .03; r = -0.77, P = .005, respectively). CONCLUSIONS: VR to NG can be evaluated noninvasively with transthoracic Doppler echocardiography.

Physiologic assessment of jailed side branch lesions using fractional flow reserve.

OBJECTIVES: This study was performed to evaluate the feasibility of the physiologic assessment of jailed side branches using fractional flow reserve (FFR) and to compare the measured FFR with the stenosis severity assessed by quantitative coronary angiography (QCA). BACKGROUND: It is not well-known which side branches should be treated after stent implantation at main branches and how to assess the functional significance of these lesions. METHODS: Ninety-seven jailed side branch lesions (vessel size > 2.0 mm, percent stenosis > 50% by visual estimation) after stent implantation at main branches were consecutively enrolled. The FFR was measured using a pressure wire at 5 mm distal and proximal to the ostial lesion of the jailed side branch. RESULTS: The FFR measurement was successful in 94 lesions. Mean FFRs were 0.94 +/- 0.04 and 0.85 +/- 0.11 at the main branches and jailed side branches, respectively. There was a negative correlation between the percent stenosis and FFR (r = -0.41, p < 0.001). However, no lesion with < 75% stenosis had FFR < 0.75. Among 73 lesions with > or = 75% stenosis, only 20 lesions were functionally significant. CONCLUSIONS: The FFR measurement in jailed side branch lesions is both safe and feasible. Quantitative coronary angiography is unreliable in the assessment of the functional severity of jailed side branch lesions, and measurement of FFR suggests that most of these lesions do not have functional significance.