Abstract
IntroductionIn patients with acute myocardial infarction (AMI) and multivessel coronary disease, revascularization of non-culprit lesions guided by proof of ischemia usually requires staged ischemia testing. Quantitative flow ratio (QFR) has been shown to be effective in assessing the hemodynamic relevance of lesions in stable coronary disease. However, its suitability in AMI patients is unknown. In this study, we tested the diagnostic value of QFR based on acute angiograms (aQFR) during AMI to assess the hemodynamic relevance of non-culprit lesions.MethodsWe retrospectively assessed the diagnostic efficiency of aQFR in 280 vessels from 220 patients, comparing it with staged ischemia testing using elective coronary angiography with FFR (n = 47), stress cardiac MRI (n = 200) or SPECT (n = 33).ResultsaQFR showed a very good diagnostic efficiency (AUC = 0.887, 95% CI 0.832–0.943, p < 0.001) in predicting ischemia of non-culprit lesions, significantly superior to coronary lesion’s geometry as assessed by quantitative coronary angiography. The optimal cut-off for aQFR to predict ischemia was 0.80 (sensitivity = 83.7%, specificity = 86.1%). Maintaining a predefined level of 95% sensitivity and specificity, we created a decision model based on aQFR: lesions with aQFR ≤ 0.75 should be treated, lesions with aQFR ≥ 0.92 do not yield any hemodynamic relevance, and lesions in the “grey zone” (aQFR 0.75–0.92) benefit from further ischemia testings. This model would allow to reduce staged ischemia tests by 46.8% without a relevant loss in diagnostic efficiency.ConclusionOur data demonstrate that aQFR allows an effective assessment of hemodynamic relevance of non-culprit lesions in AMI and may guide interventions of non-culprit coronary lesions.Graphic abstract
Highlights
In patients with acute myocardial infarction (AMI) and multivessel coronary disease, revascularization of nonculprit lesions guided by proof of ischemia usually requires staged ischemia testing
Ischemia testings included in the study protocol were (1) fractional flow reserve (FFR) measured in a staged coronary angiography, (2) stress cardiac magnetic resonance imaging (MRI) or (3) single-photon emission computed tomography (SPECT); these tests had to be performed within 6 months of the date of the acute MI
Hemodynamic relevance of lesions was assessed with FFR in 47 cases (16.8%), with cMRI in 200 cases (71.4%) and with SPECT in 33 cases (11.8%)
Summary
In patients with acute myocardial infarction (AMI) and multivessel coronary disease, revascularization of nonculprit lesions guided by proof of ischemia usually requires staged ischemia testing. In intermediate non-culprit coronary stenoses, the assessment of functional relevance is not possible with the sole use of coronary angiography and may require future ischemia testing including fractional flow reserve (FFR) or non-invasive testing such as stress cardiac magnetic resonance imaging (MRI) or single-photon emission computed tomography (SPECT). This implies further invasive or non-invasive testing, which may be associated to prolonged/another hospitalization, increased costs and/
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