Diagnostic Accuracy of Combined Intracoronary Pressure and Flow Velocity Information During Baseline Conditions

Hoef, Tim P. van de; Nolte, Froukje; Damman, Peter; Delewi, Ronak; Bax, Matthijs; Chamuleau, Steven A.J.; Voskuil, Michiel; Siebes, Maria; Tijssen, Jan G.P.; Spaan, Jos A. E.; Piek, Jan J.; Meuwissen, Martijn

doi:10.1161/circinterventions.111.965707

Cited by 92 publications

(37 citation statements)

References 39 publications

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“…1 The debate on adenosine may well be an important factor hampering adoption of physiologically guided revascularization, and therefore the value of a vasodilator-free approach deserves consideration in the light of its possible clinical implications. However, we welcome the criticism employed by the correspondents, as we agree that a rise in adoption must not go hand-in-hand with a fall in accuracy.…”

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Response to Michiels et al and Sen et al Regarding Article, “Diagnostic Accuracy of Combined Intracoronary Pressure and Flow Velocity Information During Baseline Conditions: Adenosine-Free Assessment of Functional Coronary Lesion Severity”

Hoef

Nolte

Siebes

et al. 2012

Circ: Cardiovascular Interventions

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We would like to thank the correspondents for their interest in our work.1 The debate on adenosine may well be an important factor hampering adoption of physiologically guided revascularization, and therefore the value of a vasodilator-free approach deserves consideration in the light of its possible clinical implications. However, we welcome the criticism employed by the correspondents, as we agree that a rise in adoption must not go hand-in-hand with a fall in accuracy. As such, although our results are favorable, baseline stenosis resistance index (BSR) is still in need of rigorous validation before the concept is of practical value in daily clinical practice.Although we have primarily evaluated the diagnostic accuracy of BSR for ischemia on an independent noninvasive reference standard, the conclusion of Michiels and colleagues that FFR determined in our study was suboptimal is important for the interpretation of our results. However, several aspects contrasting their conclusion need consideration. First, the rate of inaccurate FFR in our study is in accordance with other investigations reporting on this subject within a similarly heterogeneous patient population and noninvasive stress testing as a reference standard.2 Second, the use of low-dose (40 µg maximum) intracoronary adenosine has unequivocally been shown to equal intravenous (IV) (140 µg·kg -1 ·min -1 ) infusion in terms of FFR values.3 Third, all validation studies, evaluating the relation between FFR and myocardial ischemia on noninvasive stress testing, were performed using either low-dose intracoronary or IV adenosine. Both approaches yield equal optimal cut-off values averaging 0.74; a clear indication of their equality. Finally, the search for true maximal hyperemia has indicated that IV adenosine does not induce maximal hyperemia. 4 Hence, one may safely conclude that a direct relationship between FFR and myocardial ischemia is unequivocally determined for both low-dose intracoronary and IV adenosine, whereas neither achieves true maximal hyperemia. Therefore, FFR determined in our study can be considered accurate from a diagnostic point of view and a comparison between FFR and BSR valid.Indeed, the pressure gradient across a stenosis is flow-dependent. Importantly, the relation between this gradient and flow is unique for a given coronary stenosis geometry. This results in a unique and predictable course of this relationship from basal to hyperemic conditions. 5 Combining both pressure and flow information, BSR is a specific characteristic of the stenosis determined during basal conditions, with a high diagnostic accuracy for myocardial ischemia.1 Sen and colleagues interestingly raise the extent of flow velocity as an explanation for the difference in discriminative value between BSR and hyperemic stenosis resistance index. We believe that this difference arises from 2 factors that are indeed related to the extent of flow velocity. First, the presence of a measurement error, which unequivocally accompanies any measurement method, induces a...

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Response to Michiels et al and Sen et al Regarding Article, “Diagnostic Accuracy of Combined Intracoronary Pressure and Flow Velocity Information During Baseline Conditions: Adenosine-Free Assessment of Functional Coronary Lesion Severity”

Hoef

Nolte

Siebes

et al. 2012

Circ: Cardiovascular Interventions

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“…1 We congratulate the authors with this meticulous and well-written investigational report; however, we have a number of comments.…”

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Letter by Michiels et al Regarding Article, “Diagnostic Accuracy of Combined Intracoronary Pressure and Flow Velocity Information During Baseline Conditions: Adenosine-Free Assessment of Functional Coronary Lesion Severity”

Hoef

Nolte

Siebes

et al. 2012

Circ: Cardiovascular Interventions

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“…17 The stenosis resistance index during baseline conditions (ie, baseline stenosis resistance index [BSR]) has more recently been introduced, a notion based on the limited influence of hyperemia on HSR. 39 This index is defined as the ratio of the pressure gradient across the stenosis to the distal flow velocity during baseline conditions (Figure 2) and has been shown to provide a diagnostic accuracy for inducible myocardial ischemia on noninvasive stress testing equivalent to that of FFR Figure 4. Algorithm proposed by the RINASCI study for the measurement of FFR using sequential utilization of contrast medium (which can be utilized more quickly), intracoronary and intravenous adenosine (which is the gold standard but more time-consuming) to obtained maximal coronary vasodilation.…”

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Coronary Functional Tests in the Catheterization Laboratory　– Pathophysiological and Clinical Relevance –

Niccoli

Scalone

Crea

2015

Circ J

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Coronary angiography has long been the only diagnostic tool for the invasive assessment of coronary artery disease. Yet it does not allow establishing the functional severity of epicardial stenoses or vasomotor disorders of the epicardial arteries or coronary microcirculation. Functional tests in the catheterization laboratory have recently emerged as an important adjunct to coronary angiography for providing a comprehensive evaluation of the coronary circulation. In this review, we will describe and interpret the key functional tests used in current clinical practise in different clinical settings. (Circ J 2015; 79: 676 -684)

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Diagnostic Accuracy of Combined Intracoronary Pressure and Flow Velocity Information During Baseline Conditions

Cited by 92 publications

References 39 publications

Response to Michiels et al and Sen et al Regarding Article, “Diagnostic Accuracy of Combined Intracoronary Pressure and Flow Velocity Information During Baseline Conditions: Adenosine-Free Assessment of Functional Coronary Lesion Severity”

Response to Michiels et al and Sen et al Regarding Article, “Diagnostic Accuracy of Combined Intracoronary Pressure and Flow Velocity Information During Baseline Conditions: Adenosine-Free Assessment of Functional Coronary Lesion Severity”

Letter by Michiels et al Regarding Article, “Diagnostic Accuracy of Combined Intracoronary Pressure and Flow Velocity Information During Baseline Conditions: Adenosine-Free Assessment of Functional Coronary Lesion Severity”

Coronary Functional Tests in the Catheterization Laboratory　– Pathophysiological and Clinical Relevance –

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Diagnostic Accuracy of Combined Intracoronary Pressure and Flow Velocity Information During Baseline Conditions

Cited by 92 publications

References 39 publications

Response to Michiels et al and Sen et al Regarding Article, “Diagnostic Accuracy of Combined Intracoronary Pressure and Flow Velocity Information During Baseline Conditions: Adenosine-Free Assessment of Functional Coronary Lesion Severity”

Response to Michiels et al and Sen et al Regarding Article, “Diagnostic Accuracy of Combined Intracoronary Pressure and Flow Velocity Information During Baseline Conditions: Adenosine-Free Assessment of Functional Coronary Lesion Severity”

Letter by Michiels et al Regarding Article, “Diagnostic Accuracy of Combined Intracoronary Pressure and Flow Velocity Information During Baseline Conditions: Adenosine-Free Assessment of Functional Coronary Lesion Severity”

Coronary Functional Tests in the Catheterization Laboratory – Pathophysiological and Clinical Relevance –

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Coronary Functional Tests in the Catheterization Laboratory　– Pathophysiological and Clinical Relevance –