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Review
. 2022 Feb 18;17(15):1271-1280.
doi: 10.4244/EIJ-D-21-00402.

Principles and pitfalls in coronary vasomotor function testing

Rutger G T Feenstra  1 , Andreas Seitz  2 , Coen K M Boerhout  1 , Laura H Bukkems  3 , Valérie E Stegehuis  1 , Patty J I Teeuwisse  3 , Robbert J de Winter  1 , Udo Sechtem  2 , Jan J Piek  1 , Tim P van de Hoef  1 , Peter Ong  2 , Marcel A M Beijk  1
Affiliations
Review

Principles and pitfalls in coronary vasomotor function testing

Rutger G T Feenstra et al. EuroIntervention. .

Abstract

Background: Coronary vasomotor dysfunction can be diagnosed in a large proportion of patients with angina in the presence of non-obstructive coronary artery disease (ANOCA) using comprehensive protocols for coronary vasomotor function testing (CFT). Although consensus on diagnostic criteria for endotypes of coronary vasomotor dysfunction has been published, consensus on a standardised study testing protocol is lacking.

Aims: In this review we provide an overview of the variations in CFT used and discuss the practical principles and pitfalls of CFT.

Methods: For the purposes of this review, we assessed study protocols that evaluate coronary vasomotor response as reported in the literature. We compared these protocols regarding a number of procedural aspects and chose six examples to highlight the differences and uniqueness.

Results: Currently, numerous protocols co-exist and vary in vascular domains tested, the manner in which to test these domains (e.g., preprocedural discontinuation of medication, provocative agent, solution, infusion time, and target artery) and techniques used for measurements (e.g., Doppler vs thermodilution technique).

Conclusions: This lack of consensus on a uniform functional testing protocol hampers both a broader clinical acceptance of the concepts of coronary vasomotor dysfunction, and the widespread adoption of such testing protocols in current clinical practice. Furthermore, the endotype of coronary vasomotor dysfunction might differ among the few specialised centres that perform CFT as a result of the use of different protocols.

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Conflict of interest statement

M. Beijk receives an unrestricted grant from Johnson & Johnson. U. Sechtem, P. Ong and A. Seitz receive payments to their institution from Berthold-Leibinger-Foundation. U. Sechtem declares payment or honoraria for lectures, presentations, speakers’ bureaus, manuscript writing or educational events and support for attending meetings and/or travel by Servier and Abbott. P. Ong has received honoraria for lectures at Pfizer, Bayer Healthcare and Philips/Volcano. He has received travel support from Pfizer and is on the Advisory Board of Boehringer Ingelheim. The other authors have no conflicts of interest to declare.

Figures

Figure 1
Figure 1. Vascular testing domains.
Invasive evaluation of ANOCA includes the assessment of vasodilatory and vasoconstrictive disorders of the epicardial arteries and the microcirculation. LVH: left ventricular hypertrophy; VSMC: vascular smooth muscle cells
Figure 2
Figure 2. Current diagnostic criteria.
Summary of definitions used in current CFT and of considerations when performing CFT. ACh: acetylcholine; ANOCA: angina and non-obstructive coronary arteries; CFR: coronary flow reserve; CFT: coronary vasomotor function testing; FFR: factional flow reserve; HMR: hyperaemic microcirculatory resistance; iFR: instantaneous wave-free ratio; IMR: index of microcirculatory resistance; LCA: left coronary artery; NOCAD: non-obstructive coronary artery disease; NTG: nitroglycerine; oCAD: obstructive coronary artery disease; RCA: right coronary artery
Central illustration
Central illustration. Overview of different coronary vasomotor function testing protocols.
ACh: acetylcholine; APV: average peak velocity; CFR: coronary flow reserve; ECG: electrocardiogram; ER: ergonovine; FFR: factional flow reserve; IC: intracoronary; IMR: index of microcirculatory resistance; IV: intravenous; LAD: left anterior descending artery; LCA: left coronary artery; LM: left main; NTG: nitroglycerine; RCA: right coronary artery; RV: right ventricular
See this image and copyright information in PMC

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