Clinical use of coronary artery pressure flow measurements
- Morton J Kern, MD, MSCAI, FAHA, FACC
Morton J Kern, MD, MSCAI, FAHA, FACC
- Professor of Medicine
- University of California, Irvine
Myocardial revascularization with either percutaneous coronary intervention or coronary artery bypass graft surgery is indicated when there is documentation of significant obstruction to coronary blood flow associated with myocardial ischemia in patients for whom medical therapy is expected to lead to suboptimal outcomes. In most cases, coronary artery stenoses with greater than 80 percent diameter reduction as seen on coronary angiography are associated with myocardial ischemia, the extent of which may or may not have been assessed with prior noninvasive testing.
In some patients, the coronary angiogram demonstrates one or more lesions that are not severely stenosed or appear hemodynamically "benign." For lesions associated with narrowing in the range of 40 to 80 percent diameter reduction [1,2], also called intermediate severity stenoses, obtaining coronary artery physiologic data, usually coronary artery pressure and flow, can facilitate clinical decision making regarding need for revascularization, particularly in individuals without noninvasive stress test documentation of myocardial ischemia (figure 1).
Sensor tipped angioplasty guidewires have been developed and are used to measure pressure and flow across a coronary stenosis in the catheterization lab [3-8]. The use of coronary pressure guidewires is generally safe and typically adds a few minutes to the total procedure time for the assessment of each lesion.
Fractional flow reserve (FFR) measures the pressures proximal to (aortic pressure) and distal to (guidewire pressure) stenotic lesions at maximal flow and creates a pressure ratio, representing the proportion of flow across that stenosis (waveform 1). For accurate FFR measurements, pressures obtained during hyperemia are required. Maximal blood flow (hyperemia) is most commonly induced by intravenous (140 mcg/kg/min) or intracoronary adenosine (right coronary artery 50 to 100 mcg, left coronary artery 100 to 200 mcg bolus ). The ratio of distal coronary pressure to aortic pressure (as recorded from the guide catheter) during maximal hyperemia is called the FFR. A normal value is 1, while values <0.80 are associated with provocable ischemia with an accuracy >90 percent . The occurrence of false negative and false positive FFR values is rare.
FFR measurements in intermediate severity lesions have some inherent limitations. Both false positive and negative FFR values are uncommon but exist. The most common reasons to have a false negative FFR (ie, a high FFR) is guide catheter pressure damping (preventing flow into the vessel), failure to induce hyperemia (wrong concentration, poor intravenous infusion), or acute coronary syndrome with an impaired myocardial bed acutely that then improves over time. The initially high FFR, while not truly false, may be lower after the bed and the myocardial flow improve.
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- TECHNICAL ASPECTS
- IFR COMPARED WITH FFR
- COMPARISON WITH OTHER DIAGNOSTIC TECHNIQUES
- INTERMEDIATE SEVERITY STENOSIS
- Patients needing CABG
- DIFFUSE DISEASE AND LONG LESIONS
- STENTED SIDE BRANCHES
- MULTIVESSEL DISEASE
- LEFT MAIN AND OSTIAL LESIONS
- POST-PROCEDURE FFR AND PROGNOSIS
- RECOMMENDATIONS OF OTHERS
- SUMMARY AND RECOMMENDATIONS