Coronary Physiology-Based Approaches for Plaque Vulnerability:Implications for Risk Prediction and Treatment Strategies

In the catheterization laboratory, the measurement of physiological indexes can help identify functionally significant lesions and has become one of the standard methods to guide treatment decision-making. Plaque vulnerability refers to a coronary plaque susceptible to rupture, enabling risk prediction before coronary events, and it can be detected by defining a certain type of plaque morphology on coronary imaging modalities. Although coronary physiology and plaque vulnerability have been considered different attributes of coronary artery disease, the underlying pathophysiological basis and clinical data indicate a strong correlation between coronary hemodynamic properties and vulnerable plaque. In prediction of coronary events, emerging data have suggested independent and additional implications of a physiology-based approach to a plaque-based approach. This review covers the fundamental interplay between coronary physiology and plaque morphology during disease progression with clinical data supporting this relationship and examines the clinical relevance of physiological indexes in prediction of clinical outcomes and therapeutic decision-making along with plaque vulnerability.

Differential Prognostic Implications of Pre- and Post-Stent Fractional Flow Reserve in Patients Undergoing Percutaneous Coronary Intervention

Background and Objectives@#The influence of pre-intervention coronary physiologic status on outcomes post percutaneous coronary intervention (PCI) is not well known. We sought to investigate the prognostic implications of pre-PCI fractional flow reserve (FFR) combined with post-PCI FFR. @*Methods@#A total of 1,479 PCI patients with pre-and post-PCI FFR data were analyzed. The patients were classified according to the median values of pre-PCI FFR (0.71) and post-PCI FFR (0.88). The primary outcome was target vessel failure (TVF) at 2 years. @*Results@#The risk of TVF was higher in the low pre-PCI FFR group than in the high pre-PCI FFR group (hazard ratio, 1.82; 95% confidence interval, 1.15–2.87; p=0.011). In 4 group comparisons, the cumulative incidences of TVF at 2 years were 3.8%, 4.1%, 4.8%, and 10.2% in the high pre-/high post-, low pre-/high post-, high pre-/low post-, and low pre-/low post-PCI FFR groups, respectively. The risk of TVF was the highest in the low pre-/low post-PCI FFR group among the groups (p values for comparisons 0.05). When the prognostic value of the post-PCI FFR was evaluated according to the pre-PCI FFR, the risk of TVF significantly decreased with an increase in postPCI FFR in the low pre-PCI FFR group, but not in the high pre-PCI FFR group. @*Conclusions@#Pre-PCI FFR was associated with clinical outcomes after PCI, and the prognostic value of post-PCI FFR differed according to the pre-PCI FFR.

Physiologic Assessment after Coronary Stent Implantation

The presence of myocardial ischemia is a prerequisite for the benefit of coronary revascularization. In the cardiac catheterization laboratory, fractional flow reserve and non-hyperemic pressure ratios are used to define the ischemia-causing coronary stenosis, and several randomized studies showed the benefit of physiology-guided coronary revascularization. However, physiology-guided revascularization does not necessarily guarantee the relief of ischemia. Recent studies reported that residual ischemia might exist in up to 15–20% of cases after angiographically successful percutaneous coronary intervention (PCI). Therefore, post-PCI physiologic assessment is necessary for judging the appropriateness of PCI, detecting the lesions that may benefit from additional PCI, and risk stratification after PCI. This review will focus on the current evidence for post-PCI physiologic assessment, how to interpret these findings, and the future perspectives of physiologic assessment after PCI.

Physiologic Assessment after Coronary Stent Implantation

The presence of myocardial ischemia is a prerequisite for the benefit of coronary revascularization. In the cardiac catheterization laboratory, fractional flow reserve and non-hyperemic pressure ratios are used to define the ischemia-causing coronary stenosis, and several randomized studies showed the benefit of physiology-guided coronary revascularization. However, physiology-guided revascularization does not necessarily guarantee the relief of ischemia. Recent studies reported that residual ischemia might exist in up to 15–20% of cases after angiographically successful percutaneous coronary intervention (PCI). Therefore, post-PCI physiologic assessment is necessary for judging the appropriateness of PCI, detecting the lesions that may benefit from additional PCI, and risk stratification after PCI. This review will focus on the current evidence for post-PCI physiologic assessment, how to interpret these findings, and the future perspectives of physiologic assessment after PCI.

Prognostic value of routine blood tests along with clinical risk factors in predicting ischemic stroke in non‑valvular atrial fibrillation:a prospective cohort study

Background@#In patients with atrial fibrillation (AF), most biomarkers are still of limited use due to cost-effectiveness and complexity in clinical practice.Hypotheses Biomarkers from routine blood tests improve the current risk stratification in AF patients. @*Methods@#This prospective study enrolled 600 patients diagnosed with non-valvular AF, of whom 537 were analyzed. Platelet count; platelet distribution width (PDW); red cell distribution width (RDW); and creatinine, D-dimer, and troponin I levels were measured at enrollment. @*Results@#During the mean follow-up period (2.2 ± 0.6 years), 1.9% patients developed ischemic stroke. According to the optimal cutoff of each biomarker, the risk of ischemic stroke was higher in patients with RDW ≥ 13.5%, creatinine ≥ 1.11 mg/dL, or PDW ≥ 13.2% (significant biomarkers; P value: < 0.01, 0.04, or 0.07, respectively). These 3 significant biomarkers had higher information gain than clinical risk factors in predicting ischemic stroke. The cumulative incidence of ischemic stroke was 1.2%, 1.1%, 8.4%, and 40.0% in patients with 0, 1, 2, and 3 significant biomarkers, respectively (P-for-trend < 0.001). Patients with  ≥ 2 significant biomarkers had a significantly higher risk of ischemic stroke than those with  < 2 significant biomarkers (adjusted hazard ratio 11.5, 95% confidence interval 3.3–40.2, P < 0.001). The predictability for ischemic stroke was significantly improved when  ≥ 2 significant biomarkers were added to the CHA2DS2–VASc score (area under the curve 0.790 vs. 0.620, P = 0.043). @*Conclusion@#Routine blood tests can provide better risk stratification of AF along with clinical risk factors.