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. 2023 Sep 19;3(6):865-877.
doi: 10.1016/j.jacasi.2023.07.009. eCollection 2023 Dec.

Prognostic Implications of Individual and Combinations of Resting and Hyperemic Coronary Pressure and Flow Parameters

Seokhun Yang  1 , Doyeon Hwang  1 , Joo Myung Lee  2 , Seung Hun Lee  3 , Coen K M Boerhout  4 , Janneke Woudstra  4 , Caitlin E M Vink  4 , Guus A de Waard  5 , Ji Hyun Jung  6 , Hernan Mejia Renteria  7 , Masahiro Hoshino  8 , Mauro Echavarria Pinto  9 , Martijn Meuwissen  10 , Hitoshi Matsuo  11 , Maribel Madera Cambero  12 , Ashkan Eftekhari  13 , Mohamed A Effat  14 , Tadashi Murai  8 , Koen Marques  5 , Yolande Appelman  5 , Joon Hyung Doh  15 , Evald H Christiansen  13 , Rupak Banerjee  16 , Hyun Kuk Kim  17 , Chang Wook Nam  18 , Giampaolo Niccoli  19 , Masafumi Nakayama  11   20 , Nobuhiro Tanaka  21 , Eun Seok Shin  22 , Marcel A M Beijk  4 , Steven A J Chamuleau  4   5 , Niels van Royen  23 , Paul Knaapen  5 , Tsunekazu Kakuta  8 , Javier Escaned  7 , Jan J Piek  4 , Tim P van de Hoef  4   5   24 , Bon-Kwon Koo  1
Affiliations

Prognostic Implications of Individual and Combinations of Resting and Hyperemic Coronary Pressure and Flow Parameters

Seokhun Yang et al. JACC Asia. .

Abstract

Background: Coronary pressure- and flow-derived parameters have prognostic value.

Objectives: This study aims to investigate the individual and combined prognostic relevance of pressure and flow parameters reflecting resting and hyperemic conditions.

Methods: A total of 1,971 vessels deferred from revascularization after invasive pressure and flow assessment were included from the international multicenter registry. Abnormal resting pressure and flow were defined as distal coronary pressure/aortic pressure ≤0.92 and high resting flow (1/resting mean transit time >2.4 or resting average peak flow >22.7 cm/s), and abnormal hyperemic pressure and flow as fractional flow reserve ≤0.80 and low hyperemic flow (1/hyperemic mean transit time <2.2 or hyperemic average peak flow <25.0 cm/s), respectively. The clinical endpoint was target vessel failure (TVF), myocardial infarction (MI), or cardiac death at 5 years.

Results: The mean % diameter stenosis was 46.8% ± 16.5%. Abnormal pressure and flow were independent predictors of TVF and cardiac death/MI (all P < 0.05). The risk of 5-year TVF or MI/cardiac death increased proportionally with neither, either, and both abnormal resting pressure and flow, and abnormal hyperemic pressure and flow (all P for trend < 0.001). Abnormal resting pressure and flow were associated with a higher rate of TVF or MI/cardiac death in vessels with normal fractional flow reserve; this association was similar for abnormal hyperemic pressure and flow in vessels with normal resting distal coronary pressure/aortic pressure (all P < 0.05).

Conclusions: Abnormal resting and hyperemic pressure and flow were independent prognostic predictors. The abnormal flow had an additive prognostic value for pressure in both resting and hyperemic conditions with complementary prognostic between resting and hyperemic parameters.

Keywords: coronary blood flow; coronary flow reserve; fractional flow reserve; ischemia.

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Conflict of interest statement

Dr J.M. Lee has received research grants from Abbott and Philips. Dr Renteria has received speaker fees from Philips, Abbott, and Medis. Dr Pinto has received speaker fees from Abbott and Philips. Dr van Royen has received speaker fees and institutional research grants from Abbott and Philips. Dr Piek has received support as consultant for Philips/Volcano and has received institutional research grants from Philips. Dr van de Hoof has received speaker fees and institutional research grants from Abbott. Dr Koo has received institutional research grants from Abbott Vascular and Philips Volcano. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Figures

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Graphical abstract
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Graphical abstract
Figure 1
Figure 1
Prognostic Value of Abnormal Resting and Hyperemic Pressure and Flow Cumulative events of target vessel failure (TVF) according to high resting flow, low hyperemic flow, low resting distal coronary pressure/aortic pressure (Pd/Pa), and low fractional flow reserve (FFR) are presented. NA = not available; ref = reference.
Figure 2
Figure 2
Incremental Outcome Trend According to Abnormal Pressure and Flow Parameters The trends of the estimated 5-year rate of TVF according to (A) low resting Pd/Pa and high resting flow and (B) low FFR and low hyperemic flow are shown. The estimated 5-year rate of hard outcomes according to (C) low resting Pd/Pa and high resting flow and (D) low FFR and low hyperemic flow are presented. MI = myocardial infarction; other abbreviations as in Figure 1.
Figure 3
Figure 3
Prognostic Value of Abnormal Resting Parameters in Normal FFR In 1,640 vessels with normal FFR, the risks of (A) TVF or (B) hard outcomes according to high resting flow and low resting Pd/Pa are presented. Abbreviations as in Figures 1 and 2.
Figure 4
Figure 4
Prognostic Value of Abnormal Hyperemic Parameters in Normal Resting Pd/Pa In 1,556 vessels with normal resting Pd/Pa, the risks of (A) TVF or (B) hard outcomes according to low hyperemic flow and low FFR are presented. Abbreviations as in Figures 1 and 2.
Figure 5
Figure 5
Importance and Additive Value Among Pressure and Flow Parameters (A) The information gain of individual abnormal pressure and flow parameters in the prediction of TVF is presented. (B) The cumulative event of 5-year TVF or MI/cardiac death is presented according to the number of high resting flow, low hyperemic flow, low resting Pd/Pa, and low FFR. Abbreviations as in Figures 1 and 2.
Central Illustration
Central Illustration
Comprehensive Prognostic Implications of Resting and Hyperemic Pressure and Flow Abnormal resting and hyperemic pressure and flow parameters had independent prognostic values for the prediction of target vessel failure (TVF) or myocardial infarction (MI)/cardiac death. There was an increasing outcome trend according to abnormal pressure and flow parameters in each resting and hyperemic condition. In vessels with normal fractional flow reserve (FFR), resting parameters (ie, high resting flow and low resting distal coronary pressure/aortic pressure [Pd/Pa]) were associated with a higher risk of MI/cardiac death, and in vessels with normal resting Pd/Pa, hyperemic parameters (low hyperemic flow and low FFR) were related to a higher risk of MI/cardiac death.
Central Illustration
Central Illustration
Comprehensive Prognostic Implications of Resting and Hyperemic Pressure and Flow Abnormal resting and hyperemic pressure and flow parameters had independent prognostic values for the prediction of target vessel failure (TVF) or myocardial infarction (MI)/cardiac death. There was an increasing outcome trend according to abnormal pressure and flow parameters in each resting and hyperemic condition. In vessels with normal fractional flow reserve (FFR), resting parameters (ie, high resting flow and low resting distal coronary pressure/aortic pressure [Pd/Pa]) were associated with a higher risk of MI/cardiac death, and in vessels with normal resting Pd/Pa, hyperemic parameters (low hyperemic flow and low FFR) were related to a higher risk of MI/cardiac death.
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