Prognostic Value of the Index of Microcirculatory Resistance Measured After Primary Percutaneous Coronary Intervention

Fearon, William F.; Low, Adrian; Yong, A.; McGeoch, Ross; Berry, Colin; Shah, Maulik; Ho, Michael; Kim, Hyun Sook; Loh, Joshua P.; Oldroyd, Keith G.

doi:10.1161/circulationaha.112.000298

Cited by 358 publications

(288 citation statements)

References 30 publications

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“…First, this is a single‐center observational cohort study. Nevertheless, our cohort of 261 compares well in size with the original study reporting the long‐term prognostic value of IMR in 253 patients 12. Second, the 6.5% rate of in‐hospital major cardiac complications in our study is lower than reported in registry data.…”

Section: Discussionsupporting

confidence: 62%

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Index of Microcirculatory Resistance at the Time of Primary Percutaneous Coronary Intervention Predicts Early Cardiac Complications: Insights From the OxAMI (Oxford Study in Acute Myocardial Infarction) Cohort

Fahrni

Wolfrum

Maria

et al. 2017

JAHA

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BackgroundEarly risk stratification after primary percutaneous coronary intervention (PPCI) for ST‐segment–elevation myocardial infarction is currently challenging. Identification of a low‐risk group may improve triage of patients to alternative clinical pathways and support early hospital discharge. Our aim was to assess whether the index of microcirculatory resistance (IMR) at the time of PPCI can identify patients at low risk of early major cardiac complications and to compare its performance against guideline‐recommended risk scores.Methods and Results IMR was measured using a pressure–temperature sensor wire. Cardiac complications were defined as the composite of cardiac death, cardiogenic shock, pulmonary edema, malignant arrhythmias, cardiac rupture, and presence of left ventricular thrombus either before hospital discharge or within 30‐day follow‐up. In total, 261 patients undergoing PPCI who were eligible for coronary physiology assessment were prospectively enrolled. Twenty‐two major cardiac complications were reported. Receiver operating characteristic curve analysis confirmed the utility of IMR in predicting complications and showed significantly better performance than coronary flow reserve, the Primary Angioplasty in Myocardial Infarction II (PAMI‐II), and Zwolle score (P≤0.006). Low microvascular resistance (IMR ≤40) was measured in 159 patients (61%) of the study population and identified all patients who were free of major cardiac complications (sensitivity: 100%; 95% CI, 80.5–100%).Conclusions IMR immediately at the end of PPCI for ST‐segment–elevation myocardial infarction reliably predicts early major cardiac complications and performed significantly better than recommended risk scores. These novel data have implications for early risk stratification after PPCI.

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Section: Discussionsupporting

confidence: 62%

“…According the established cutoff values,12, 17, 18, 20 IMR >40 was measured in 102 of 261 patients (39.1%) and was able to identify all 17 patients (sensitivity: 100%) with early major cardiac complications following an acute myocardial infarction, with a specificity of 65.2% (Figure 2). The individual complications are shown in Table 2.…”

Section: Resultsmentioning

confidence: 99%

Index of Microcirculatory Resistance at the Time of Primary Percutaneous Coronary Intervention Predicts Early Cardiac Complications: Insights From the OxAMI (Oxford Study in Acute Myocardial Infarction) Cohort

Fahrni

Wolfrum

Maria

et al. 2017

JAHA

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“…Fearon et al first reported that an IMR>40 measured after angiographically successful primary PCI was an independent predictor of adverse clinical outcome 12. We previously found that an IMR value of >27 was most closely associated with microvascular obstruction and myocardial hemorrhage, whereas an IMR >40 was most closely associated with all‐cause death or heart failure 13.…”

Section: Discussionmentioning

confidence: 96%

“…The thermodilution curve (time [seconds] on x‐axis, temperature on y‐axis) was recorded in real time (RADIAnalyzer, Abbott Vascular, Santa Clara, CA) and available for analysis (Radiview 2.2, St Jude Medical, St. Paul, MN). IMR was calculated as the product of simultaneously measured distal coronary pressure (mm Hg) and mean hyperemic transit time (seconds), as previously described 12, 13…”

Section: Methodsmentioning

confidence: 99%

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Coronary Thermodilution Waveforms After Acute Reperfused ST‐Segment–Elevation Myocardial Infarction: Relation to Microvascular Obstruction and Prognosis

Yew

Carrick

Corcoran

et al. 2018

JAHA

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BackgroundInvasive measures of microvascular resistance in the culprit coronary artery have potential for risk stratification in acute ST‐segment–elevation myocardial infarction. We aimed to investigate the pathological and prognostic significance of coronary thermodilution waveforms using a diagnostic guidewire.Methods and ResultsCoronary thermodilution was measured at the end of percutaneous coronary intervention, (PCI) and contrast‐enhanced cardiac magnetic resonance imaging (MRI) was intended on day 2 and 6 months later to assess left ventricular (LV) function and pathology. All‐cause death or first heart failure hospitalization was a pre‐specified outcome (median follow‐up duration 1469 days). Thermodilution recordings underwent core laboratory assessment. A total of 278 patients with acute ST‐segment elevation myocardial infarction EMI (72% male, 59±11 years) had coronary thermodilution measurements classified as narrow unimodal (n=143 [51%]), wide unimodal (n=100 [36%]), or bimodal (n=35 [13%]). Microvascular obstruction and myocardial hemorrhage were associated with the thermodilution waveform pattern (P=0.007 and 0.011, respectively), and both pathologies were more prevalent in patients with a bimodal morphology. On multivariate analysis with baseline characteristics, thermodilution waveform status was a multivariable associate of microvascular obstruction (odds ratio [95% confidence interval]=5.29 [1.73, 16.22];, P=0.004) and myocardial hemorrhage (3.45 [1.16, 10.26]; P=0.026), but the relationship was not significant when index of microvascular resistance (IMR) >40 or change in index of microvascular resistance (5 per unit) was included. However, a bimodal thermodilution waveform was independently associated with all‐cause death and hospitalization for heart failure (odds ratio [95% confidence interval]=2.70 [1.10, 6.63]; P=0.031), independent of index of microvascular resistance>40, ST‐segment resolution, and TIMI (Thrombolysis in Myocardial Infarction) Myocardial Perfusion Grade.ConclusionsThe thermodilution waveform in the culprit coronary artery is a biomarker of prognosis and may be useful for risk stratification immediately after reperfusion therapy.

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Cost-Effectiveness of Fractional Flow Reserve–Guided Treatment for Acute Myocardial Infarction and Multivessel Disease

Hong,

Lee,

Lee

et al. 2024

JAMA Netw Open

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ImportanceComplete revascularization by non–infarct-related artery (IRA) percutaneous coronary intervention (PCI) in patients with acute myocardial infarction is standard practice to improve patient prognosis. However, it is unclear whether a fractional flow reserve (FFR)–guided or angiography-guided treatment strategy for non-IRA PCI would be more cost-effective.ObjectiveTo evaluate the cost-effectiveness of FFR-guided compared with angiography-guided PCI in patients with acute myocardial infarction and multivessel disease.Design, Setting, and ParticipantsIn this prespecified cost-effectiveness analysis of the FRAME-AMI randomized clinical trial, patients were randomly allocated to either FFR-guided or angiography-guided PCI for non-IRA lesions between August 19, 2016, and December 24, 2020. Patients were aged 19 years or older, had ST-segment elevation myocardial infarction (STEMI) or non-STEMI and underwent successful primary or urgent PCI, and had at least 1 non-IRA lesion (diameter stenosis &gt;50% in a major epicardial coronary artery or major side branch with a vessel diameter of ≥2.0 mm). Data analysis was performed on August 27, 2023.InterventionFractional flow reserve–guided vs angiography-guided PCI for non-IRA lesions.Main Outcomes and MeasuresThe model simulated death, myocardial infarction, and repeat revascularization. Future medical costs and benefits were discounted by 4.5% per year. The main outcomes were quality-adjusted life-years (QALYs), direct medical costs, incremental cost-effectiveness ratio (ICER), and incremental net monetary benefit (INB) of FFR-guided PCI compared with angiography-guided PCI. State-transition Markov models were applied to the Korean, US, and European health care systems using medical cost (presented in US dollars), utilities data, and transition probabilities from meta-analysis of previous trials.ResultsThe FRAME-AMI trial randomized 562 patients, with a mean (SD) age of 63.3 (11.4) years. Most patients were men (474 [84.3%]). Fractional flow reserve–guided PCI increased QALYs by 0.06 compared with angiography-guided PCI. The total cumulative cost per patient was estimated as $1208 less for FFR-guided compared with angiography-guided PCI. The ICER was −$19 484 and the INB was $3378, indicating that FFR-guided PCI was more cost-effective for patients with acute myocardial infarction and multivessel disease. Probabilistic sensitivity analysis showed consistent results and the likelihood iteration of cost-effectiveness in FFR-guided PCI was 97%. When transition probabilities from the pairwise meta-analysis of the FLOWER-MI and FRAME-AMI trials were used, FFR-guided PCI was more cost-effective than angiography-guided PCI in the Korean, US, and European health care systems, with an INB of $3910, $8557, and $2210, respectively. In probabilistic sensitivity analysis, the likelihood iteration of cost-effectiveness with FFR-guided PCI was 85%, 82%, and 31% for the Korean, US, and European health care systems, respectively.Conclusions and RelevanceThis cost-effectiveness analysis suggests that FFR-guided PCI for non-IRA lesions saved medical costs and increased quality of life better than angiography-guided PCI for patients with acute myocardial infarction and multivessel disease. Fractional flow reserve–guided PCI should be considered in determining the treatment strategy for non-IRA stenoses in these patients.Trial RegistrationClinicalTrials.gov Identifier: NCT02715518

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Prognostic Value of the Index of Microcirculatory Resistance Measured After Primary Percutaneous Coronary Intervention

Cited by 358 publications

References 30 publications

Index of Microcirculatory Resistance at the Time of Primary Percutaneous Coronary Intervention Predicts Early Cardiac Complications: Insights From the OxAMI (Oxford Study in Acute Myocardial Infarction) Cohort

Index of Microcirculatory Resistance at the Time of Primary Percutaneous Coronary Intervention Predicts Early Cardiac Complications: Insights From the OxAMI (Oxford Study in Acute Myocardial Infarction) Cohort

Coronary Thermodilution Waveforms After Acute Reperfused ST‐Segment–Elevation Myocardial Infarction: Relation to Microvascular Obstruction and Prognosis

Cost-Effectiveness of Fractional Flow Reserve–Guided Treatment for Acute Myocardial Infarction and Multivessel Disease

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