Prognostic value of coronary blood flow velocity and myocardial perfusion in intermediate coronary narrowings and multivessel disease.
OBJECTIVE
This study aimed to investigate the roles of intracoronary derived coronary flow velocity reserve (CFVR) and myocardial perfusion scintigraphy (single photon emission computed tomography, or SPECT) for management of an intermediate lesion in patients with multivessel coronary artery disease.


BACKGROUND
Evaluation of the functional significance of intermediate coronary narrowings (40% to 70% diameter stenosis) is important for clinical decision making and risk stratification.


METHODS
In a prospective, multicenter study, SPECT was performed in 191 patients with stable angina and multivessel disease and scheduled for angioplasty (percutaneous transluminal coronary angioplasty, or PTCA) of a severe coronary narrowing. Coronary flow velocity reserve was determined selectively distal to an intermediate lesion in another artery using a Doppler guidewire. Percutaneous transluminal coronary angioplasty of the intermediate lesion was deferred when SPECT was negative or CFVR greater-than-or-equal 2.0. Patients were followed for one year to document major cardiac events (death, infarction, revascularization), related to the intermediate lesion.


RESULTS
Reversible perfusion defects were documented in the area of the intermediate lesion in 30 (16%) patients; CFVR was positive in 46 (24%) patients. Percutaneous transluminal coronary angioplasty of the intermediate lesion was deferred in 182 patients. During follow-up, 19 events occurred (3 myocardial infarctions, 16 revascularizations). Coronary flow velocity reserve was a more accurate predictor of cardiac events than was SPECT; relative risk: CFVR 3.9 (1.7 to 9.1), p < 0.05; SPECT 0.5 (0.1 to 3.2), p = NS. Multivariate analysis revealed CFVR as the only significant predictor for cardiac events.


CONCLUSIONS
Deferral of PTCA of intermediate lesions in multivessel disease is safe when CFVR greater-than-or-equal 2.0 (event rate 6%). This selective evaluation of coronary lesion severity during cardiac catheterization allows a more accurate risk stratification than does SPECT, which is important for clinical decision making in this patient cohort.
Chamuleau
Steven A J
SA
Departments of Cardiology, Academic Medical Center-University of Amsterdam, The Netherlands. s.a.chamuleau@amc.uva.nl
Tio
Rene A
RA
de Cock
Carel C
CC
de Muinck
Ebo D
ED
Pijls
Nico H J
NH
van Eck-Smit
Berthe L F
BL
Koch
Karel T
KT
Meuwissen
Martijn
M
Dijkgraaf
Marcel G W
MG
de Jong
Angelina
A
Verberne
Hein J
HJ
van Liebergen
Rob A M
RA
Laarman
Gert Jan
GJ
Tijssen
Jan G P
JG
Piek
Jan J
JJ
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015906:Angioplasty, Balloon, Coronary; D001783:Blood Flow Velocity / Q000502:physiology; D006328:Cardiac Catheterization; D003324:Coronary Artery Disease / Q000000981:diagnostic imaging* / Q000503:physiopathology* / Q000628:therapy; D003326:Coronary Circulation / Q000502:physiology*; D023921:Coronary Stenosis / Q000000981:diagnostic imaging* / Q000503:physiopathology* / Q000628:therapy; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D011446:Prospective Studies; D012720:Severity of Illness Index; D015899:Tomography, Emission-Computed, Single-Photon; D016896:Treatment Outcome