Novel Contrast-Derived Indices of Coronary Microvascular Function: Potential Clinical and Cost Benefits

Abstract

Background: Intravenous adenosine induces stable myocardial hyperemia for coronary microvascular function testing. Iodinated radiographic contrast media induce transient, submaximal hyperemia. We assessed the feasibility, diagnostic value, and potential cost-effectiveness of contrast-derived indices of microvascular function.

Methods: Coronary flow reserve, index of microvascular resistance, and microvascular resistance reserve were assessed using a diagnostic guidewire. Intracoronary bolus thermodilution injections were performed at rest, immediately after an 8-mL bolus of iohexol, repeated after a second 8-mL bolus, and during intravenous adenosine infusion. Receiver operating characteristic analyses assessed the discriminatory ability of the contrast-derived indices (contrast-derived coronary flow reserve, contrast-derived index of microcirculatory resistance, contrast-derived microvascular resistance reserve) to detect abnormal adenosine-derived indices (coronary flow reserve <2.0, index of microvascular resistance ≥25, and microvascular resistance reserve <2.1).

Results: Among 106 coronary arteries from 93 patients (median age 63 years; 62% women; 13% with diabetes), 88% of assessments were undertaken in the left anterior descending artery. Median fractional flow reserve was 0.88 (interquartile range, 0.85-0.92). Contrast-derived coronary flow reserve <2.0 (area under the curve 0.81; sensitivity 67%, specificity 80%, positive predictive value 40%, negative predictive value 92%), contrast-derived index of microcirculatory resistance >47 (area under the curve 0.82; 80%, 79%, 60%, 91%), and contrast-derived microvascular resistance reserve <1.9 (area under the curve 0.82; 67%, 89%, 35%, 97%) were best for predicting their adenosine-derived counterpart indices. There was good correlation on repeatability testing from the second contrast bolus. A hybrid approach reduced adenosine use by 40%, saving $30 800 (USA) or £8000 (UK) per 1000 vessels assessed.

Conclusions: Contrast-derived indices have high specificity and negative predictive value, enabling rapid exclusion of microvascular dysfunction. This method is feasible, clinically useful and cost-saving compared with routine adenosine testing.

Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT04674449.

Keywords: angina pectoris; chest pain; coronary vessels; humans; hyperemia; myocardial ischemia; thermodilution.