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. 2018 Aug 28;72(9):970-983.
doi: 10.1016/j.jacc.2018.06.033.

Impact of Percutaneous Revascularization on Exercise Hemodynamics in Patients With Stable Coronary Disease

Christopher M Cook  1 , Yousif Ahmad  1 , James P Howard  1 , Matthew J Shun-Shin  1 , Amarjit Sethi  1 , Gerald J Clesham  2 , Kare H Tang  3 , Sukhjinder S Nijjer  1 , Paul A Kelly  3 , John R Davies  2 , Iqbal S Malik  1 , Raffi Kaprielian  1 , Ghada Mikhail  1 , Ricardo Petraco  1 , Firas Al-Janabi  2 , Grigoris V Karamasis  2 , Shah Mohdnazri  2 , Reto Gamma  3 , Rasha Al-Lamee  1 , Thomas R Keeble  2 , Jamil Mayet  1 , Sayan Sen  1 , Darrel P Francis  1 , Justin E Davies  4
Affiliations

Impact of Percutaneous Revascularization on Exercise Hemodynamics in Patients With Stable Coronary Disease

Christopher M Cook et al. J Am Coll Cardiol. .

Abstract

Background: Recently, the therapeutic benefits of percutaneous coronary intervention (PCI) have been challenged in patients with stable coronary artery disease (SCD).

Objectives: The authors examined the impact of PCI on exercise responses in the coronary circulation, the microcirculation, and systemic hemodynamics in patients with SCD.

Methods: A total of 21 patients (mean age 60.3 ± 8.4 years) with SCD and single-vessel coronary stenosis underwent cardiac catheterization. Pre-PCI, patients exercised on a supine ergometer until rate-limiting angina or exhaustion. Simultaneous trans-stenotic coronary pressure-flow measurements were made throughout exercise. Post-PCI, this process was repeated. Physiological parameters, rate-limiting symptoms, and exercise performance were compared between pre-PCI and post-PCI exercise cycles.

Results: PCI reduced ischemia as documented by fractional flow reserve value (pre-PCI 0.59 ± 0.18 to post-PCI 0.91 ± 0.07), instantaneous wave-free ratio value (pre-PCI 0.61 ± 0.27 to post-PCI 0.96 ± 0.05) and coronary flow reserve value (pre-PCI 1.7 ± 0.7 to post-PCI 3.1 ± 1.0; p < 0.001 for all). PCI increased peak-exercise average peak coronary flow velocity (p < 0.0001), coronary perfusion pressure (distal coronary pressure; p < 0.0001), systolic blood pressure (p = 0.01), accelerating wave energy (p < 0.001), and myocardial workload (rate-pressure product; p < 0.01). These changes observed immediately following PCI resulted from the abolition of stenosis resistance (p < 0.0001). PCI was also associated with an immediate improvement in exercise time (+67 s; 95% confidence interval: 31 to 102 s; p < 0.0001) and a reduction in rate-limiting angina symptoms (81% reduction in rate-limiting angina symptoms post-PCI; p < 0.001).

Conclusions: In patients with SCD and severe single-vessel stenosis, objective physiological responses to exercise immediately normalize following PCI. This is seen in the coronary circulation, the microcirculation, and systemic hemodynamics.

Keywords: coronary physiology; exercise; percutaneous coronary intervention; stable coronary disease.

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Figures

None
Graphical abstract
Figure 1
Figure 1
Coronary Angiograms of the 21 Included Patients The target lesion is marked with a red asterisk.
Figure 2
Figure 2
Limiting Symptoms on Exercise Before and After PCI (A) Reasons for the termination of exercise before (blue dots) and after (orange dots) PCI. (B) Exercise-induced rise in arterial blood lactate before and after PCI. The horizontal gray line indicates the mean value. The box indicates the standard deviation, and the whiskers indicate the range of values. PCI = percutaneous coronary intervention.
Figure 3
Figure 3
Exercise Time Before and After PCI (A) Mean exercise time of the study population, before (blue bar) and after (orange bar) PCI. The error bars indicate the standard error. (B) Individual patient data. PCI = percutaneous coronary intervention.
Figure 4
Figure 4
Systemic Hemodynamic Responses to Exercise Heart rate, systolic blood pressure, and rate-pressure product responses to exercise at baseline (Base), 1 min of exercise (1 min), 50% of the pre-PCI time (t50Expre), peak-exercise time pre-PCI (PeakExpre), and peak-exercise time post-PCI (PeakExpost), before (blue) and after (orange) PCI. The error bars indicate the standard error. *Significant difference between time-matched exercise stages pre- versus post-PCI; p < 0.05. †Significant difference between peak-exercise pre- versus post-PCI; p < 0.05. PCI = percutaneous coronary intervention.
Figure 5
Figure 5
Aortic Pressure Waveform Responses to Exercise Pulse pressure, tension time index, diastolic time index, and diastolic time fraction responses to exercise, before (blue) and after (orange) percutaneous coronary intervention.
Figure 6
Figure 6
Coronary and Microcirculatory Hemodynamic Responses to Exercise Coronary flow velocity, stenosis resistance, pressure gradient, pressure ratio (Pd/Pa), distal coronary pressure (Pd), and diastolic microvascular resistance (DMR) responses to exercise, before (blue) and after (orange) PCI. *Significant difference between time-matched exercise stages pre- versus post-PCI; p < 0.05. †Significant difference between peak-exercise pre- versus post-PCI; p < 0.05. PCI = percutaneous coronary intervention.
Figure 7
Figure 7
Accelerating Wave Energy Before and After PCI Backward expansion wave (BEW) (checkerboard) and forward compression wave (FCW) (non-checkerboard) energy at rest and peak-exercise, before (orange) and after (blue) PCI. *Significant difference between FCW wave energy pre- versus post-PCI; p < 0.05. †Significant difference between BEW wave energy pre- versus post-PCI; p < 0.05. PCI = percutaneous coronary intervention.
Central Illustration
Central Illustration
Invasive Exercise Hemodynamics Before and After PCI CFR = coronary flow reserve; FFR = fractional flow reserve; iFR = instantaneous wave-free ratio; METs = metabolic equivalents; PCI = percutaneous coronary intervention.
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