Instantaneous wave-free ratio and fractional flow reserve for the assessment of nonculprit lesions during the index procedure in patients with ST-segment elevation myocardial infarction: The WAVE study

Musto, Carmine; Felice, Francesco De; Rigattieri, Stefano; Chin, Diana; Marra, Andrea; Nazzaro, Marco Stefano; Cifarelli, Alberta; Violini, Roberto

doi:10.1016/j.ahj.2017.07.017

Cited by 40 publications

(19 citation statements)

References 17 publications

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“…Invasive pressure-derived fractional flow reserve (FFR) has been established as gold standard for functional lesion assessment in chronic coronary syndromes (CCS) [ 7 – 9 ] and proves supportive results for non-culprit lesion interrogation in ACS patients [ 10 , 11 ]. Resting indices such as instantaneous wave-free ratio (iFR) have also shown reasonable correlations with FFR-assessment and advantages in clinical outcome [ 12 – 14 ]. In patients with ACS, there is some concern that microvascular dysfunction in a highly prothrombotic and inflammatory setting could prevent reliable functional assessment of non-culprit coronary lesions [ 15 ].…”

Section: Introductionmentioning

confidence: 99%

“…In patients with ACS, there is some concern that microvascular dysfunction in a highly prothrombotic and inflammatory setting could prevent reliable functional assessment of non-culprit coronary lesions [ 15 ]. However, several studies have proven the feasibility and safety of FFR measurements for non-culprit coronary arteries during ACS considering follow-up measurements as a reference [ 14 , 16 , 17 ]. Similarly, serial measurements of the index of microcirculatory resistance (IMR) demonstrated no significant difference between immediate and follow-up assessment [ 17 ].…”

Section: Introductionmentioning

confidence: 99%

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Feasibility and diagnostic reliability of quantitative flow ratio in the assessment of non-culprit lesions in acute coronary syndrome

Erbay

Penzel

Abdelwahed

et al. 2021

Int J Cardiovasc Imaging

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Several studies have demonstrated the feasibility and safety of hemodynamic assessment of non-culprit coronary arteries in setting of acute coronary syndromes (ACS) using fractional flow reserve (FFR) measurements. Quantitative flow ratio (QFR), recently introduced as angiography-based fast FFR computation, has been validated with good agreement and diagnostic performance with FFR in chronic coronary syndromes. The aim of this study was to assess the feasibility and diagnostic reliability of QFR assessment during primary PCI. A total of 321 patients with ACS and multivessel disease, who underwent primary PCI and were planned for staged PCI of at least one non-culprit lesion were enrolled in the analysis. Within this patient cohort, serial post-hoc QFR analyses of 513 non-culprit vessels were performed. The median time interval between primary and staged PCI was 49 [42–58] days. QFR in non-culprit coronary arteries did not change between acute and staged measurements (0.86 vs 0.87, p = 0.114), with strong correlation (r = 0.94, p ≤ 0.001) and good agreement (mean difference -0.008, 95%CI -0.013–0.003) between measurements. Importantly, QFR as assessed at index procedure had sensitivity of 95.02%, specificity of 93.59% and diagnostic accuracy of 94.15% in prediction of QFR ≤ 0.80 at the time of staged PCI. The present study for the first time confirmed the feasibility and diagnostic accuracy of non-culprit coronary artery QFR during index procedure for ACS. These results support QFR as valuable tool in patients with ACS to detect further hemodynamic relevant lesions with excellent diagnostic performance and therefore to guide further revascularisation therapy.

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Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Feasibility and diagnostic reliability of quantitative flow ratio in the assessment of non-culprit lesions in acute coronary syndrome

Erbay

Penzel

Abdelwahed

et al. 2021

Int J Cardiovasc Imaging

View full text Add to dashboard Cite

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“…The time interval between myocardial infarction and normalisation of baseline coronary blood flow and maximal hyperaemic blood flow remains uncertain and may differ between patients. The impact of these temporary blood flow changes on iFR may resolve before the impact on FFR and the impact on iFR may need more than 2 weeks to resolve [4][5][6][7][8].…”

Section: Discussionmentioning

confidence: 99%

“…The observations after ≥ 5 days probably resemble observations in stable conditions more closely, i.e., FFR is more often significant than iFR with similar outcomes of revascularisation guided by iFR and FFR [ 9 , 10 ]. Within < 5 days after STEMI, both iFR and FFR may be affected, but in opposite directions, and the optimal method for nonculprit stenosis evaluation in this setting remains undetermined [ 4 – 8 ]. Also, the optimal time point for making this assessment remains to be established [ 2 ].…”

Section: Discussionmentioning

confidence: 99%

Agreement between nonculprit stenosis follow-up iFR and FFR after STEMI (iSTEMI substudy)

et al. 2020

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Objective: To evaluate agreement between instantaneous wave free ratio (iFR) and fractional flow reserve (FFR) for the functional assessment of nonculprit coronary stenoses at staged follow-up after ST-segment elevation myocardial infarction (STEMI). Results: We measured iFR and FFR at staged follow-up in 112 STEMI patients with 146 nonculprit stenoses. Median interval between STEMI and follow-up was 16 (interquartile range 5-32) days. Agreement between iFR and FFR was 77% < 5 days after STEMI and 86% after ≥ 5 days (p = 0.19). Among cases with disagreement, the proportion of cases with hemodynamically significant iFR and non-significant FFR were different when assessed < 5 days (5 in 8, 63%) versus ≥ 5 days (3 in 15, 20%) after STEMI (p = 0.04). Overall classification agreement between iFR and FFR was comparable to that observed in stable patients. Time interval between STEMI and follow-up evaluation may impact agreement between iFR and FFR.

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“…Whether FFR measurement should therefore be postponed until such time is unclear, particularly given the importance of early intervention in these patients. It is also not known if the process of microvascular recovery differs between the culprit and non-culprit territories, as the FFR value for the non-culprit lesions appeared to remain stable over time29 despite a significantly impaired culprit territory microcirculation in patients with STEMI 28. Consequently, deferral of invasive therapy on the basis FFR values obtained acutely, particularly in the presence of large infarction and impaired baseline coronary microcirculation,28 remains uncertain and should be treated with caution.…”

Section: Discussionmentioning

confidence: 99%

Fractional flow reserve in acute coronary syndrome: a meta-analysis and systematic review

et al. 2019

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BackgroundThe utility of fractional flow reserve (FFR) to guide revascularisation in the management of acute coronary syndrome (ACS) remains unclear.ObjectiveThis study aims to compare the clinical outcomes of patients following FFR-guided revascularisation for either ACS or stable angina (SA) and in particular focuses on the outcome of those with deferred revascularisation after FFR.MethodsA meta-analysis of existing literature was performed. Outcomes including the rate of major adverse cardiovascular events (MACE), recurrent myocardial infarction (MI), mortality and unplanned revascularisation were analysed.ResultsA review of 937 records yielded 9 studies comparing 5457 patients, which were included in the analyses. Patients with ACS had a higher rate of recurrent MI (OR 1.81, p=0.02) and a strong trend towards more MACE and all-cause mortality compared with patients with SA when treated by an FFR-guided revascularisation strategy. Deferral of invasive therapy on the basis of FFR led to a higher rate of MACE (17.6% vs 7.3 %; p=0.004), recurrent MI (5.3% vs 1.5%, p=0.001) and target vessel revascularisation (16.4% vs 5.6 %; p=0.02) in patients with ACS, and a strong trend towards a higher cardiovascular mortality at follow-up when compared with patients with SA.ConclusionThe event rate in patients with ACS is much higher than SA despite following an FFR-guided revascularisation strategy. Deferring revascularisation does not appear to be as safe for ACS as it is for SA using contemporary FFR cut-offs validated in SA. Refinement of the therapeutic strategy for patients with ACS with multivessel disease is needed to redress the balance.

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Instantaneous wave-free ratio and fractional flow reserve for the assessment of nonculprit lesions during the index procedure in patients with ST-segment elevation myocardial infarction: The WAVE study

Cited by 40 publications

References 17 publications

Feasibility and diagnostic reliability of quantitative flow ratio in the assessment of non-culprit lesions in acute coronary syndrome

Feasibility and diagnostic reliability of quantitative flow ratio in the assessment of non-culprit lesions in acute coronary syndrome

Agreement between nonculprit stenosis follow-up iFR and FFR after STEMI (iSTEMI substudy)

Fractional flow reserve in acute coronary syndrome: a meta-analysis and systematic review

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