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Physiology-guided management of serial coronary artery disease a review

Physiology-guided management of serial coronary artery disease a review
Physiology-guided management of serial coronary artery disease a review

Importance: Ischemia-guided revascularization is the cornerstone of contemporary management of coronary artery disease and has evolved from noninvasive functional evaluation to real-time assessment with invasive physiological indices during diagnostic catheterization. However, serial/diffuse disease is common, and revascularization decisions often need to be made about individual lesions within the same vessel. It is unclear whether current physiological techniques, such as fractional flow reserve, can be reliably used to discern the individual contribution of lesions within a serially diseased vessel with erroneous measurements, potentially leading to suboptimal revascularization decisions. This review addresses the application of physiological techniques to serial coronary disease, highlighting challenges and potential solutions.

Observations: Physiological indices, such as fractional flow reserve, are well validated and correlated with clinical outcomes; however, the challenging physiology of serial stenoses makes it difficult to apply conventional techniques to identify the physiological significance of individual lesions. The 2 methods are most accurate in assessing serial disease are the manual pullback, with treatment of the greatest pressure gradient, or adopting the use of a large disease-free side branch to isolate the significance of the proximal lesion in the context of serial disease involving the left main coronary artery. In addition, resting indices, such as instantaneous wave-free ratio, have theoretical benefits that may make them more reliable in serial disease, with further data awaited.

Conclusions and Relevance: Serial coronary artery disease is common, and physiological assessment is prone to errors. The future, whether it be in improving the interpretation of fractional flow reserve, using resting indices such as instantaneous wave-free ratio, or examining novel flow-based resistance indices, will hopefully improve our management of this common yet unresolved clinical conundrum. In the meantime, revascularisation decisions in this challenging scenario should focus on clinical presentation and physiologic evaluation using a pressure-wire pullback maneuver and left main disease-free side branch where appropriate.

Coronary Artery Disease/physiopathology, Coronary Stenosis/physiopathology, Humans, Myocardial Revascularization
2380-6583
432-438
Modi, Bhavik N.
aa843137-8fd0-467b-b7d9-2b14863b2abb
De Silva, Kalpa
61097142-a3b4-4264-86ba-1f2311261675
Rajani, Ronak
d5ebf00d-fbdb-47a2-8f17-89b47fb78daf
Curzen, Nick
70f3ea49-51b1-418f-8e56-8210aef1abf4
Perera, Divaka
fa856014-f608-48a4-87e1-db05c0b5c942
Modi, Bhavik N.
aa843137-8fd0-467b-b7d9-2b14863b2abb
De Silva, Kalpa
61097142-a3b4-4264-86ba-1f2311261675
Rajani, Ronak
d5ebf00d-fbdb-47a2-8f17-89b47fb78daf
Curzen, Nick
70f3ea49-51b1-418f-8e56-8210aef1abf4
Perera, Divaka
fa856014-f608-48a4-87e1-db05c0b5c942

Modi, Bhavik N., De Silva, Kalpa, Rajani, Ronak, Curzen, Nick and Perera, Divaka (2018) Physiology-guided management of serial coronary artery disease a review. JAMA Cardiology, 3 (5), 432-438. (doi:10.1001/jamacardio.2018.0236).

Record type: Review

Abstract

Importance: Ischemia-guided revascularization is the cornerstone of contemporary management of coronary artery disease and has evolved from noninvasive functional evaluation to real-time assessment with invasive physiological indices during diagnostic catheterization. However, serial/diffuse disease is common, and revascularization decisions often need to be made about individual lesions within the same vessel. It is unclear whether current physiological techniques, such as fractional flow reserve, can be reliably used to discern the individual contribution of lesions within a serially diseased vessel with erroneous measurements, potentially leading to suboptimal revascularization decisions. This review addresses the application of physiological techniques to serial coronary disease, highlighting challenges and potential solutions.

Observations: Physiological indices, such as fractional flow reserve, are well validated and correlated with clinical outcomes; however, the challenging physiology of serial stenoses makes it difficult to apply conventional techniques to identify the physiological significance of individual lesions. The 2 methods are most accurate in assessing serial disease are the manual pullback, with treatment of the greatest pressure gradient, or adopting the use of a large disease-free side branch to isolate the significance of the proximal lesion in the context of serial disease involving the left main coronary artery. In addition, resting indices, such as instantaneous wave-free ratio, have theoretical benefits that may make them more reliable in serial disease, with further data awaited.

Conclusions and Relevance: Serial coronary artery disease is common, and physiological assessment is prone to errors. The future, whether it be in improving the interpretation of fractional flow reserve, using resting indices such as instantaneous wave-free ratio, or examining novel flow-based resistance indices, will hopefully improve our management of this common yet unresolved clinical conundrum. In the meantime, revascularisation decisions in this challenging scenario should focus on clinical presentation and physiologic evaluation using a pressure-wire pullback maneuver and left main disease-free side branch where appropriate.

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More information

e-pub ahead of print date: 1 May 2018
Published date: 1 May 2018
Keywords: Coronary Artery Disease/physiopathology, Coronary Stenosis/physiopathology, Humans, Myocardial Revascularization

Identifiers

Local EPrints ID: 422767
URI: http://eprints.soton.ac.uk/id/eprint/422767
ISSN: 2380-6583
PURE UUID: a5fdb1a3-bdcd-4fd0-a74b-9f5fc197eb9b
ORCID for Nick Curzen: ORCID iD orcid.org/0000-0001-9651-7829

Catalogue record

Date deposited: 03 Aug 2018 16:30
Last modified: 18 Feb 2021 17:04

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Contributors

Author: Bhavik N. Modi
Author: Kalpa De Silva
Author: Ronak Rajani
Author: Nick Curzen ORCID iD
Author: Divaka Perera

University divisions

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