![Page 1: Hyperemia Hyperemic Stimuli - European Society of Cardiologyassets.escardio.org/assets/presentations/OTHER2013... · 2013-06-03 · io-.be ETP, Sofia Antipolis, April 2013 Hyperemia](https://reader030.vdocuments.net/reader030/viewer/2022011816/5e6b1dbd452f913f002b34b5/html5/thumbnails/1.jpg)
Bernard De Bruyne, MD, PhD
Cardiovascular Center Aalst
OLV-Clinic Aalst, Belgium
ww
w.c
ard
io-a
als
t.b
e
Hyperemia
ETP, Sofia Antipolis, April 2013
Hyperemic Stimuli
Why ?
How ?
FAQ !
![Page 2: Hyperemia Hyperemic Stimuli - European Society of Cardiologyassets.escardio.org/assets/presentations/OTHER2013... · 2013-06-03 · io-.be ETP, Sofia Antipolis, April 2013 Hyperemia](https://reader030.vdocuments.net/reader030/viewer/2022011816/5e6b1dbd452f913f002b34b5/html5/thumbnails/2.jpg)
Why?
1. General concept of stress test (as opposed to “rest test”)
2. Standardized measurements (as opposed to “moving target”)
3. All clinical outcome data are based on hyperemic data
ww
w.c
ard
io-a
als
t.b
e
ETP, Sofia Antipolis, April 2013
Hyperemia
![Page 3: Hyperemia Hyperemic Stimuli - European Society of Cardiologyassets.escardio.org/assets/presentations/OTHER2013... · 2013-06-03 · io-.be ETP, Sofia Antipolis, April 2013 Hyperemia](https://reader030.vdocuments.net/reader030/viewer/2022011816/5e6b1dbd452f913f002b34b5/html5/thumbnails/3.jpg)
Aortic Stenosis: Severe ???
ww
w.c
ard
io-a
als
t.b
e
ETP, Sofia Antipolis, April 2013
Hyperemia
![Page 4: Hyperemia Hyperemic Stimuli - European Society of Cardiologyassets.escardio.org/assets/presentations/OTHER2013... · 2013-06-03 · io-.be ETP, Sofia Antipolis, April 2013 Hyperemia](https://reader030.vdocuments.net/reader030/viewer/2022011816/5e6b1dbd452f913f002b34b5/html5/thumbnails/4.jpg)
Aortic Stenosis: Severe ???
ww
w.c
ard
io-a
als
t.b
e
ETP, Sofia Antipolis, April 2013
Hyperemia
![Page 5: Hyperemia Hyperemic Stimuli - European Society of Cardiologyassets.escardio.org/assets/presentations/OTHER2013... · 2013-06-03 · io-.be ETP, Sofia Antipolis, April 2013 Hyperemia](https://reader030.vdocuments.net/reader030/viewer/2022011816/5e6b1dbd452f913f002b34b5/html5/thumbnails/5.jpg)
Cardiac output 3.8 L.min-1
Aortic Gradient 26 mm Hg
Aortic Valve Area 0.77 cm²
Cardiac output 8.6 L.min-1
Aortic Gradient 58 mm Hg
Aortic Valve Area 1.1 cm²
Aortic Stenosis: Severe ???
ww
w.c
ard
io-a
als
t.b
e
ETP, Sofia Antipolis, April 2013
Hyperemia
![Page 6: Hyperemia Hyperemic Stimuli - European Society of Cardiologyassets.escardio.org/assets/presentations/OTHER2013... · 2013-06-03 · io-.be ETP, Sofia Antipolis, April 2013 Hyperemia](https://reader030.vdocuments.net/reader030/viewer/2022011816/5e6b1dbd452f913f002b34b5/html5/thumbnails/6.jpg)
Oral Glucose Tolerance Test (OGTT)
0
20
40
60
80
100
120
140
160
180
200
Fasting 2 hours 4 Hours
75 g of sugar to be drunk within 5 minutes
0
20
40
60
80
100
120
140
160
180
200
Fasting 2 hours 4 Hours
ww
w.c
ard
io-a
als
t.b
e
ETP, Sofia Antipolis, April 2013
Hyperemia
Normal DiabetesMg/dL
Mg/dL
![Page 7: Hyperemia Hyperemic Stimuli - European Society of Cardiologyassets.escardio.org/assets/presentations/OTHER2013... · 2013-06-03 · io-.be ETP, Sofia Antipolis, April 2013 Hyperemia](https://reader030.vdocuments.net/reader030/viewer/2022011816/5e6b1dbd452f913f002b34b5/html5/thumbnails/7.jpg)
Hyperemia puts the stenosis in a windtunnel
ww
w.c
ard
io-a
als
t.b
e
ETP, Sofia Antipolis, April 2013
Hyperemia
![Page 8: Hyperemia Hyperemic Stimuli - European Society of Cardiologyassets.escardio.org/assets/presentations/OTHER2013... · 2013-06-03 · io-.be ETP, Sofia Antipolis, April 2013 Hyperemia](https://reader030.vdocuments.net/reader030/viewer/2022011816/5e6b1dbd452f913f002b34b5/html5/thumbnails/8.jpg)
Why?
1. General concept of stress test (as opposed to “rest test”)
2. Standardized measurements (as opposed to “moving target”)
3. All clinical outcome data are based on hyperemic data (FFR)
ww
w.c
ard
io-a
als
t.b
e
ETP, Sofia Antipolis, April 2013
Hyperemia
![Page 9: Hyperemia Hyperemic Stimuli - European Society of Cardiologyassets.escardio.org/assets/presentations/OTHER2013... · 2013-06-03 · io-.be ETP, Sofia Antipolis, April 2013 Hyperemia](https://reader030.vdocuments.net/reader030/viewer/2022011816/5e6b1dbd452f913f002b34b5/html5/thumbnails/9.jpg)
The Control of Resting Myocardial Blood Flow
Adapted from D.J.G.M. Duncker
Endo- and paracrine
factors
Noradrenaline
Adrenaline
Acethylcholine
Adenosine
PO2
Histamine
Bradykinine
Systolic compression
Diastolic compression
Arterial Pressure
Coronary pressure
RAP, LVDP and Pf=0
PCO2, H+, K+
Angiotensine II
Physical
factors
α1 α2
β1 β 2
H1
A2
M
H2
AT1
ETB
ETETA
ETB5-HT
TXA2NOPGI2
EDHF
Mα2
NO PGI2 EDHF
NO PGI2 EDHFB2
P2H1
P2
EndotheliumTXA2
5-HT
M
P2
Neuro-humoral
factors
Metabolic
factors
ww
w.c
ard
io-a
als
t.b
e
ETP, Sofia Antipolis, April 2013
Hyperemia
The balance between supply and demand depends on
mechanisms which are
multiple, interacting, cumulative, nonlinear
![Page 10: Hyperemia Hyperemic Stimuli - European Society of Cardiologyassets.escardio.org/assets/presentations/OTHER2013... · 2013-06-03 · io-.be ETP, Sofia Antipolis, April 2013 Hyperemia](https://reader030.vdocuments.net/reader030/viewer/2022011816/5e6b1dbd452f913f002b34b5/html5/thumbnails/10.jpg)
The Control of Resting Myocardial Blood Flow
Endo- and paracrine
factors
Noradrenaline
Adrenaline
Acethylcholine
Adenosine
PO2
Histamine
Bradykinine
Systolic compression
Diastolic compression
Arterial Pressure
Coronary pressure
RAP, LVDP and Pf=0
PCO2, H+, K+
Angiotensine II
Physical
factors
α1 α2
β1 β 2
H1
A2
M
H2
AT1
ETB
ETETA
ETB5-HT
TXA2NOPGI2
EDHF
Mα2
NO PGI2 EDHF
NO PGI2 EDHFB2
P2H1
P2
EndotheliumTXA2
5-HT
M
P2
Neuro-humoral
factors
Metabolic
factors
ww
w.c
ard
io-a
als
t.b
e
ETP, Sofia Antipolis, April 2013
Hyperemia
The “resting state” in biology is
wishful thinking of biologists
![Page 11: Hyperemia Hyperemic Stimuli - European Society of Cardiologyassets.escardio.org/assets/presentations/OTHER2013... · 2013-06-03 · io-.be ETP, Sofia Antipolis, April 2013 Hyperemia](https://reader030.vdocuments.net/reader030/viewer/2022011816/5e6b1dbd452f913f002b34b5/html5/thumbnails/11.jpg)
Why?
1. General concept of stress test (as opposed to “rest test”)
2. Standardized measurements (as opposed to “moving target”)
3. All clinical outcome data are based on hyperemic data (FFR)
ww
w.c
ard
io-a
als
t.b
e
ETP, Sofia Antipolis, April 2013
Hyperemia
![Page 12: Hyperemia Hyperemic Stimuli - European Society of Cardiologyassets.escardio.org/assets/presentations/OTHER2013... · 2013-06-03 · io-.be ETP, Sofia Antipolis, April 2013 Hyperemia](https://reader030.vdocuments.net/reader030/viewer/2022011816/5e6b1dbd452f913f002b34b5/html5/thumbnails/12.jpg)
How?
ww
w.c
ard
io-a
als
t.b
e
ETP, Sofia Antipolis, April 2013
Hyperemia
The KISS principle
“Keep it Simple and Standardized”
![Page 13: Hyperemia Hyperemic Stimuli - European Society of Cardiologyassets.escardio.org/assets/presentations/OTHER2013... · 2013-06-03 · io-.be ETP, Sofia Antipolis, April 2013 Hyperemia](https://reader030.vdocuments.net/reader030/viewer/2022011816/5e6b1dbd452f913f002b34b5/html5/thumbnails/13.jpg)
Maximal Vasodilation
Vasospasm Autoregulation
Epicardial= Conductance Arteries > 550 µ
Microvasculature= Resistance
Arteries < 550 µ
ww
w.c
ard
io-a
als
t.b
e
ETP, Sofia Antipolis, April 2013
Hyperemia
![Page 14: Hyperemia Hyperemic Stimuli - European Society of Cardiologyassets.escardio.org/assets/presentations/OTHER2013... · 2013-06-03 · io-.be ETP, Sofia Antipolis, April 2013 Hyperemia](https://reader030.vdocuments.net/reader030/viewer/2022011816/5e6b1dbd452f913f002b34b5/html5/thumbnails/14.jpg)
ww
w.c
ard
io-a
als
t.b
e
ETP, Sofia Antipolis, April 2013
Hyperemia
Maximal Vasodilation
1. Nitrates Epicardial arteries
2. Adenosine Microvasculature
IV: 140 µg/kg/min
IC: 100 – 200 µg in bolus
![Page 15: Hyperemia Hyperemic Stimuli - European Society of Cardiologyassets.escardio.org/assets/presentations/OTHER2013... · 2013-06-03 · io-.be ETP, Sofia Antipolis, April 2013 Hyperemia](https://reader030.vdocuments.net/reader030/viewer/2022011816/5e6b1dbd452f913f002b34b5/html5/thumbnails/15.jpg)
ww
w.c
ard
io-a
als
t.b
e
ETP, Sofia Antipolis, April 2013
Hyperemia
Maximal Vasodilation
1. Nitrates Epicardial arteries
2. Adenosine Microvasculature
3. Papaverine inhibition of phosphodiesterase cyclic adenosine MP ↑
4. Regadenoson precursor of adenosine
5. Apadenoson precursor of adenosine
6. Binodenoson precursor of adenosine
7. Nitroprusside NO pathways direct non-selective vasodilator
8. Nicorandil ↑ guanylate cyclase to increase formation of cyclic GMP
9. Dopamine ß1-agonist ↑ O2 consumption adenosine ↑
10. Exercise Adren stimulation ↑ O2 consumption Adenosine ↑
11. Coronary occlusion Ischemia release of adenosine
![Page 16: Hyperemia Hyperemic Stimuli - European Society of Cardiologyassets.escardio.org/assets/presentations/OTHER2013... · 2013-06-03 · io-.be ETP, Sofia Antipolis, April 2013 Hyperemia](https://reader030.vdocuments.net/reader030/viewer/2022011816/5e6b1dbd452f913f002b34b5/html5/thumbnails/16.jpg)
Target organs
- Coronary arteriolar smooth muscle cells
- Renal arteries (organ level)
- Peripheral and central nervous system
- Myocardium
- Cardiac Conduction system
- Respiratory tract
Adenosine: Mechanisms of ActionReceptors (A1, A2A, A2B, A3)
A2A
A1
A1 A2A
A3
A1
A1
ww
w.c
ard
io-a
als
t.b
e
ETP, Sofia Antipolis, April 2013
Hyperemia
Half Life = 4 to 10 s
ADO 40 µg bolus in Renal Artery ADO 40 µg bolus in LAD
![Page 17: Hyperemia Hyperemic Stimuli - European Society of Cardiologyassets.escardio.org/assets/presentations/OTHER2013... · 2013-06-03 · io-.be ETP, Sofia Antipolis, April 2013 Hyperemia](https://reader030.vdocuments.net/reader030/viewer/2022011816/5e6b1dbd452f913f002b34b5/html5/thumbnails/17.jpg)
ww
w.c
ard
io-a
als
t.b
e
ETP, Sofia Antipolis, April 2013
Hyperemia
Maximal Vasodilation
1. Nitrates Epicardial arteries
2. Adenosine Microvasculature
IV: 140 µg/kg/min
IC: 100 – 200 µg in bolus
![Page 18: Hyperemia Hyperemic Stimuli - European Society of Cardiologyassets.escardio.org/assets/presentations/OTHER2013... · 2013-06-03 · io-.be ETP, Sofia Antipolis, April 2013 Hyperemia](https://reader030.vdocuments.net/reader030/viewer/2022011816/5e6b1dbd452f913f002b34b5/html5/thumbnails/18.jpg)
ww
w.c
ard
io-a
als
t.b
e
ETP, Sofia Antipolis, April 2013
Hyperemia
Specificities of IV Adenosine (140 µg/kg/min)
1. Preferred route when a pressure pull back is needed
2. Induces a brief increase in systemic pressure followed
by a decrease in systemic pressure by 10-20%
3. Is almost uniformly accompanied by a burning
sensation
4. Fluctuation of the Pd/Pa ratio are observed in some
cases
5. A-V blocks are relatively frequent, always transient
![Page 19: Hyperemia Hyperemic Stimuli - European Society of Cardiologyassets.escardio.org/assets/presentations/OTHER2013... · 2013-06-03 · io-.be ETP, Sofia Antipolis, April 2013 Hyperemia](https://reader030.vdocuments.net/reader030/viewer/2022011816/5e6b1dbd452f913f002b34b5/html5/thumbnails/19.jpg)
AdenosineSTOP
ww
w.c
ard
io-a
als
t.b
e
ETP, Sofia Antipolis, April 2013
Hyperemia
![Page 20: Hyperemia Hyperemic Stimuli - European Society of Cardiologyassets.escardio.org/assets/presentations/OTHER2013... · 2013-06-03 · io-.be ETP, Sofia Antipolis, April 2013 Hyperemia](https://reader030.vdocuments.net/reader030/viewer/2022011816/5e6b1dbd452f913f002b34b5/html5/thumbnails/20.jpg)
ww
w.c
ard
io-a
als
t.b
e
ETP, Sofia Antipolis, April 2013
Hyperemia
Specificities of IC Adenosine (100-200 µg)
1. Can be used in the vast majority of lesions
2. Short half live
3. Rare AV blocks, always transient
4. Extremely reproducible: do it twice or more!
![Page 21: Hyperemia Hyperemic Stimuli - European Society of Cardiologyassets.escardio.org/assets/presentations/OTHER2013... · 2013-06-03 · io-.be ETP, Sofia Antipolis, April 2013 Hyperemia](https://reader030.vdocuments.net/reader030/viewer/2022011816/5e6b1dbd452f913f002b34b5/html5/thumbnails/21.jpg)
ww
w.c
ard
io-a
als
t.b
e
ETP, Sofia Antipolis, April 2013
Hyperemia
![Page 22: Hyperemia Hyperemic Stimuli - European Society of Cardiologyassets.escardio.org/assets/presentations/OTHER2013... · 2013-06-03 · io-.be ETP, Sofia Antipolis, April 2013 Hyperemia](https://reader030.vdocuments.net/reader030/viewer/2022011816/5e6b1dbd452f913f002b34b5/html5/thumbnails/22.jpg)
ww
w.c
ard
io-a
als
t.b
e
ETP, Sofia Antipolis, April 2013
Hyperemia
Specificities of IC Adenosine (140 µg/kg/min)
1. Can be used in the vast majority of lesions
2. Short half live
3. Rare AV blocks, always transient
4. Extremely reproducible: do it twice (or more!)
![Page 23: Hyperemia Hyperemic Stimuli - European Society of Cardiologyassets.escardio.org/assets/presentations/OTHER2013... · 2013-06-03 · io-.be ETP, Sofia Antipolis, April 2013 Hyperemia](https://reader030.vdocuments.net/reader030/viewer/2022011816/5e6b1dbd452f913f002b34b5/html5/thumbnails/23.jpg)
ADO IC 1 ADO IC 2 ADO IC 3
FFR = 0.53 FFR = 0.53 FFR = 0.54
ww
w.c
ard
io-a
als
t.b
e
ETP, Sofia Antipolis, April 2013
Hyperemia
![Page 24: Hyperemia Hyperemic Stimuli - European Society of Cardiologyassets.escardio.org/assets/presentations/OTHER2013... · 2013-06-03 · io-.be ETP, Sofia Antipolis, April 2013 Hyperemia](https://reader030.vdocuments.net/reader030/viewer/2022011816/5e6b1dbd452f913f002b34b5/html5/thumbnails/24.jpg)
Tips and Tricks
1. IV: either central or large venous access
2. IC: keep the injection as short as possible
3. Be consistent, teach the nursing staff, the techs, ...
4. Pay attention to the quality of the recording of the tracings:
“record every tracing as if you have to present this case at the
opening session of the AHA”
ww
w.c
ard
io-a
als
t.b
e
ETP, Sofia Antipolis, April 2013
Hyperemia
![Page 25: Hyperemia Hyperemic Stimuli - European Society of Cardiologyassets.escardio.org/assets/presentations/OTHER2013... · 2013-06-03 · io-.be ETP, Sofia Antipolis, April 2013 Hyperemia](https://reader030.vdocuments.net/reader030/viewer/2022011816/5e6b1dbd452f913f002b34b5/html5/thumbnails/25.jpg)
ww
w.c
ard
io-a
als
t.b
e
ETP, Sofia Antipolis, April 2013
Hyperemia
Tips and Tricks
![Page 26: Hyperemia Hyperemic Stimuli - European Society of Cardiologyassets.escardio.org/assets/presentations/OTHER2013... · 2013-06-03 · io-.be ETP, Sofia Antipolis, April 2013 Hyperemia](https://reader030.vdocuments.net/reader030/viewer/2022011816/5e6b1dbd452f913f002b34b5/html5/thumbnails/26.jpg)
ww
w.c
ard
io-a
als
t.b
e
ETP, Sofia Antipolis, April 2013
Hyperemia
Tips and Tricks
![Page 27: Hyperemia Hyperemic Stimuli - European Society of Cardiologyassets.escardio.org/assets/presentations/OTHER2013... · 2013-06-03 · io-.be ETP, Sofia Antipolis, April 2013 Hyperemia](https://reader030.vdocuments.net/reader030/viewer/2022011816/5e6b1dbd452f913f002b34b5/html5/thumbnails/27.jpg)
ww
w.c
ard
io-a
als
t.b
e
ETP, Sofia Antipolis, April 2013
Hyperemia
Tips and Tricks
0.79 0.78
![Page 28: Hyperemia Hyperemic Stimuli - European Society of Cardiologyassets.escardio.org/assets/presentations/OTHER2013... · 2013-06-03 · io-.be ETP, Sofia Antipolis, April 2013 Hyperemia](https://reader030.vdocuments.net/reader030/viewer/2022011816/5e6b1dbd452f913f002b34b5/html5/thumbnails/28.jpg)
ww
w.c
ard
io-a
als
t.b
e
ETP, Sofia Antipolis, April 2013
Hyperemia
![Page 29: Hyperemia Hyperemic Stimuli - European Society of Cardiologyassets.escardio.org/assets/presentations/OTHER2013... · 2013-06-03 · io-.be ETP, Sofia Antipolis, April 2013 Hyperemia](https://reader030.vdocuments.net/reader030/viewer/2022011816/5e6b1dbd452f913f002b34b5/html5/thumbnails/29.jpg)
ww
w.c
ard
io-a
als
t.b
e
ETP, Sofia Antipolis, April 2013
Hyperemia
![Page 30: Hyperemia Hyperemic Stimuli - European Society of Cardiologyassets.escardio.org/assets/presentations/OTHER2013... · 2013-06-03 · io-.be ETP, Sofia Antipolis, April 2013 Hyperemia](https://reader030.vdocuments.net/reader030/viewer/2022011816/5e6b1dbd452f913f002b34b5/html5/thumbnails/30.jpg)
ww
w.c
ard
io-a
als
t.b
e
ETP, Sofia Antipolis, April 2013
Hyperemia
![Page 31: Hyperemia Hyperemic Stimuli - European Society of Cardiologyassets.escardio.org/assets/presentations/OTHER2013... · 2013-06-03 · io-.be ETP, Sofia Antipolis, April 2013 Hyperemia](https://reader030.vdocuments.net/reader030/viewer/2022011816/5e6b1dbd452f913f002b34b5/html5/thumbnails/31.jpg)
ww
w.c
ard
io-a
als
t.b
e
ETP, Sofia Antipolis, April 2013
Hyperemia
![Page 32: Hyperemia Hyperemic Stimuli - European Society of Cardiologyassets.escardio.org/assets/presentations/OTHER2013... · 2013-06-03 · io-.be ETP, Sofia Antipolis, April 2013 Hyperemia](https://reader030.vdocuments.net/reader030/viewer/2022011816/5e6b1dbd452f913f002b34b5/html5/thumbnails/32.jpg)
ww
w.c
ard
io-a
als
t.b
e
ETP, Sofia Antipolis, April 2013
Hyperemia
![Page 33: Hyperemia Hyperemic Stimuli - European Society of Cardiologyassets.escardio.org/assets/presentations/OTHER2013... · 2013-06-03 · io-.be ETP, Sofia Antipolis, April 2013 Hyperemia](https://reader030.vdocuments.net/reader030/viewer/2022011816/5e6b1dbd452f913f002b34b5/html5/thumbnails/33.jpg)
ww
w.c
ard
io-a
als
t.b
e
ETP, Sofia Antipolis, April 2013
Hyperemia
Conclusive Remarks
1. Hyperemia is mandatory to “interrogate”
a lesions properly
2. Can be obtained very easily, safely, cheaply, ...
3. Provided it is standardized in each laboratory
![Page 34: Hyperemia Hyperemic Stimuli - European Society of Cardiologyassets.escardio.org/assets/presentations/OTHER2013... · 2013-06-03 · io-.be ETP, Sofia Antipolis, April 2013 Hyperemia](https://reader030.vdocuments.net/reader030/viewer/2022011816/5e6b1dbd452f913f002b34b5/html5/thumbnails/34.jpg)
ww
w.c
ard
io-a
als
t.b
e
ETP, Sofia Antipolis, April 2013
Hyperemia
FAQ
When Pd/Pa at rest > 0.90, do we have to induce hyperemia ?
When Pd/Pa at rest < 0.80, do we have to induce hyperemia ?
Useful to increase the dose of IV ado > 140 µg/kg/min ?
Useful to increase the dose of IC ado > 200 µg (bolus) ?
Is the burning sensation related to ischemia ?
Are some patients resistant to Adenosine ?
Can Papaverine be used instead of Adenosine ?
Is hyperemia expensive ?
What to do with radial procedures ?
Interference with some medications ?
Is adenosine contraindicated in patients with lung disease
![Page 35: Hyperemia Hyperemic Stimuli - European Society of Cardiologyassets.escardio.org/assets/presentations/OTHER2013... · 2013-06-03 · io-.be ETP, Sofia Antipolis, April 2013 Hyperemia](https://reader030.vdocuments.net/reader030/viewer/2022011816/5e6b1dbd452f913f002b34b5/html5/thumbnails/35.jpg)
ww
w.c
ard
io-a
als
t.b
e
ETP, Sofia Antipolis, April 2013
Hyperemia
FAQ
When Pd/Pa at rest > 0.90, do we have to induce hyperemia ?
YES
Pd/Pa = 0.96 FFR = 0.62
![Page 36: Hyperemia Hyperemic Stimuli - European Society of Cardiologyassets.escardio.org/assets/presentations/OTHER2013... · 2013-06-03 · io-.be ETP, Sofia Antipolis, April 2013 Hyperemia](https://reader030.vdocuments.net/reader030/viewer/2022011816/5e6b1dbd452f913f002b34b5/html5/thumbnails/36.jpg)
ww
w.c
ard
io-a
als
t.b
e
ETP, Sofia Antipolis, April 2013
Hyperemia
FAQ
When Pd/Pa at rest < 0.80, do we have to induce hyperemia ?
![Page 37: Hyperemia Hyperemic Stimuli - European Society of Cardiologyassets.escardio.org/assets/presentations/OTHER2013... · 2013-06-03 · io-.be ETP, Sofia Antipolis, April 2013 Hyperemia](https://reader030.vdocuments.net/reader030/viewer/2022011816/5e6b1dbd452f913f002b34b5/html5/thumbnails/37.jpg)
ww
w.c
ard
io-a
als
t.b
e
ETP, Sofia Antipolis, April 2013
Hyperemia
When Pd/Pa at rest < 0.80, do we have to induce hyperemia ?
Pd/Pa = 0.56 FFR = 0.42
![Page 38: Hyperemia Hyperemic Stimuli - European Society of Cardiologyassets.escardio.org/assets/presentations/OTHER2013... · 2013-06-03 · io-.be ETP, Sofia Antipolis, April 2013 Hyperemia](https://reader030.vdocuments.net/reader030/viewer/2022011816/5e6b1dbd452f913f002b34b5/html5/thumbnails/38.jpg)
ww
w.c
ard
io-a
als
t.b
e
ETP, Sofia Antipolis, April 2013
Hyperemia
FAQ
Useful to increase the dose of IV ado > 140 µg/kg/min ?
NO
![Page 39: Hyperemia Hyperemic Stimuli - European Society of Cardiologyassets.escardio.org/assets/presentations/OTHER2013... · 2013-06-03 · io-.be ETP, Sofia Antipolis, April 2013 Hyperemia](https://reader030.vdocuments.net/reader030/viewer/2022011816/5e6b1dbd452f913f002b34b5/html5/thumbnails/39.jpg)
ww
w.c
ard
io-a
als
t.b
e
ETP, Sofia Antipolis, April 2013
Hyperemia
Increasing the dose above 140 µg/kg/min decreases systematic BP
and increases the thoracic pain
![Page 40: Hyperemia Hyperemic Stimuli - European Society of Cardiologyassets.escardio.org/assets/presentations/OTHER2013... · 2013-06-03 · io-.be ETP, Sofia Antipolis, April 2013 Hyperemia](https://reader030.vdocuments.net/reader030/viewer/2022011816/5e6b1dbd452f913f002b34b5/html5/thumbnails/40.jpg)
ww
w.c
ard
io-a
als
t.b
e
ETP, Sofia Antipolis, April 2013
Hyperemia
FAQUseful to increase the dose of IC ado > 200 µg (bolus) ?
720 µg decreases Pd/Pa a bit further w/o any decrease in BP, any
increase in HR and no heart blocks ????
De Luca et al JACC Interv 2011
Pd / PaBlood Pressure
N=46
![Page 41: Hyperemia Hyperemic Stimuli - European Society of Cardiologyassets.escardio.org/assets/presentations/OTHER2013... · 2013-06-03 · io-.be ETP, Sofia Antipolis, April 2013 Hyperemia](https://reader030.vdocuments.net/reader030/viewer/2022011816/5e6b1dbd452f913f002b34b5/html5/thumbnails/41.jpg)
ww
w.c
ard
io-a
als
t.b
e
ETP, Sofia Antipolis, April 2013
Hyperemia
FAQ
Is the burning sensation related to ischemia ?
NO
Adenosine is an algesic substance which stimulates the
same nerves than those resposnsible for angina ...
which is also due to the local release of adenosine
during ischemia
Sylven C. Cardiovasc Drugs Ther 1993;7:745
![Page 42: Hyperemia Hyperemic Stimuli - European Society of Cardiologyassets.escardio.org/assets/presentations/OTHER2013... · 2013-06-03 · io-.be ETP, Sofia Antipolis, April 2013 Hyperemia](https://reader030.vdocuments.net/reader030/viewer/2022011816/5e6b1dbd452f913f002b34b5/html5/thumbnails/42.jpg)
ww
w.c
ard
io-a
als
t.b
e
ETP, Sofia Antipolis, April 2013
Hyperemia
FAQ
Are some patients resistant to Adenosine ?
NO,
Resistance to exogenous Adenosine does not exist
![Page 43: Hyperemia Hyperemic Stimuli - European Society of Cardiologyassets.escardio.org/assets/presentations/OTHER2013... · 2013-06-03 · io-.be ETP, Sofia Antipolis, April 2013 Hyperemia](https://reader030.vdocuments.net/reader030/viewer/2022011816/5e6b1dbd452f913f002b34b5/html5/thumbnails/43.jpg)
ww
w.c
ard
io-a
als
t.b
e
ETP, Sofia Antipolis, April 2013
Hyperemia
FAQ
Can Papaverine be used instead of Adenosine ?
![Page 44: Hyperemia Hyperemic Stimuli - European Society of Cardiologyassets.escardio.org/assets/presentations/OTHER2013... · 2013-06-03 · io-.be ETP, Sofia Antipolis, April 2013 Hyperemia](https://reader030.vdocuments.net/reader030/viewer/2022011816/5e6b1dbd452f913f002b34b5/html5/thumbnails/44.jpg)
ww
w.c
ard
io-a
als
t.b
e
ETP, Sofia Antipolis, April 2013
Hyperemia
Papaverine IC16 mg IC in LCA 12 mg IC in RCA
![Page 45: Hyperemia Hyperemic Stimuli - European Society of Cardiologyassets.escardio.org/assets/presentations/OTHER2013... · 2013-06-03 · io-.be ETP, Sofia Antipolis, April 2013 Hyperemia](https://reader030.vdocuments.net/reader030/viewer/2022011816/5e6b1dbd452f913f002b34b5/html5/thumbnails/45.jpg)
NO PULLBACK Sensor left in the distal LAD
PULLBACK from distal to proximal LAD
ww
w.c
ard
io-a
als
t.b
e
ETP, Sofia Antipolis, April 2013
Hyperemia
Papaverine IC16 mg IC in LCA 12 mg IC in RCA
![Page 46: Hyperemia Hyperemic Stimuli - European Society of Cardiologyassets.escardio.org/assets/presentations/OTHER2013... · 2013-06-03 · io-.be ETP, Sofia Antipolis, April 2013 Hyperemia](https://reader030.vdocuments.net/reader030/viewer/2022011816/5e6b1dbd452f913f002b34b5/html5/thumbnails/46.jpg)
Van Belleghem Rene (22.10.2001)
ww
w.c
ard
io-a
als
t.b
e
ETP, Sofia Antipolis, April 2013
Hyperemia
Papaverine IC16 mg IC in LCA 12 mg IC in RCA
![Page 47: Hyperemia Hyperemic Stimuli - European Society of Cardiologyassets.escardio.org/assets/presentations/OTHER2013... · 2013-06-03 · io-.be ETP, Sofia Antipolis, April 2013 Hyperemia](https://reader030.vdocuments.net/reader030/viewer/2022011816/5e6b1dbd452f913f002b34b5/html5/thumbnails/47.jpg)
ww
w.c
ard
io-a
als
t.b
e
ETP, Sofia Antipolis, April 2013
Hyperemia
Papaverine IC16 mg IC in LCA 12 mg IC in RCA
![Page 48: Hyperemia Hyperemic Stimuli - European Society of Cardiologyassets.escardio.org/assets/presentations/OTHER2013... · 2013-06-03 · io-.be ETP, Sofia Antipolis, April 2013 Hyperemia](https://reader030.vdocuments.net/reader030/viewer/2022011816/5e6b1dbd452f913f002b34b5/html5/thumbnails/48.jpg)
ww
w.c
ard
io-a
als
t.b
e
ETP, Sofia Antipolis, April 2013
Hyperemia
FAQ
Is hyperemia expensive ?
... NOT REALLY:
0.12 € / bolus of 100 µg IC; 0.24 € / bolus of 200 µg
1.34 € / syringe needed for approx 15 minutes of IV administration
![Page 49: Hyperemia Hyperemic Stimuli - European Society of Cardiologyassets.escardio.org/assets/presentations/OTHER2013... · 2013-06-03 · io-.be ETP, Sofia Antipolis, April 2013 Hyperemia](https://reader030.vdocuments.net/reader030/viewer/2022011816/5e6b1dbd452f913f002b34b5/html5/thumbnails/49.jpg)
ww
w.c
ard
io-a
als
t.b
e
ETP, Sofia Antipolis, April 2013
Hyperemia
FAQ
What to do with radial procedures ?
IC BOLUS
IV adenosine INFUSION
IV Regadenosone BOLUS
![Page 50: Hyperemia Hyperemic Stimuli - European Society of Cardiologyassets.escardio.org/assets/presentations/OTHER2013... · 2013-06-03 · io-.be ETP, Sofia Antipolis, April 2013 Hyperemia](https://reader030.vdocuments.net/reader030/viewer/2022011816/5e6b1dbd452f913f002b34b5/html5/thumbnails/50.jpg)
ww
w.c
ard
io-a
als
t.b
e
ETP, Sofia Antipolis, April 2013
Hyperemia
FAQSome medications interfere with Adenosine
Beta-blockers
Alpha-blockers
Caffeine
Ticagrelor
ACE-inhibitors
![Page 51: Hyperemia Hyperemic Stimuli - European Society of Cardiologyassets.escardio.org/assets/presentations/OTHER2013... · 2013-06-03 · io-.be ETP, Sofia Antipolis, April 2013 Hyperemia](https://reader030.vdocuments.net/reader030/viewer/2022011816/5e6b1dbd452f913f002b34b5/html5/thumbnails/51.jpg)
Effect of Caffeine on FFR
Aqel RA et al Am J Cardiol. 2004
Before Caffeine After Caffeine
0.76 0.75
1
0
0,5
ww
w.c
ard
io-a
als
t.b
e
ETP, Sofia Antipolis, April 2013
Hyperemia
![Page 52: Hyperemia Hyperemic Stimuli - European Society of Cardiologyassets.escardio.org/assets/presentations/OTHER2013... · 2013-06-03 · io-.be ETP, Sofia Antipolis, April 2013 Hyperemia](https://reader030.vdocuments.net/reader030/viewer/2022011816/5e6b1dbd452f913f002b34b5/html5/thumbnails/52.jpg)
Beta-Adrenergic Blockade and Myocardial Flow
-15
-10
-5
0
5
10
15
Carvedilol Metoprolol
Rest
Hypermia
Changes in
Myocardial
Blood Flow
Koepli P et al J Nucl Med 2004
ww
w.c
ard
io-a
als
t.b
e
ETP, Sofia Antipolis, April 2013
Hyperemia
![Page 53: Hyperemia Hyperemic Stimuli - European Society of Cardiologyassets.escardio.org/assets/presentations/OTHER2013... · 2013-06-03 · io-.be ETP, Sofia Antipolis, April 2013 Hyperemia](https://reader030.vdocuments.net/reader030/viewer/2022011816/5e6b1dbd452f913f002b34b5/html5/thumbnails/53.jpg)
PHENTOLAMINE URAPIDIL SALINE
Pre Post Pre Post Pre Post
0,50
0,60
0,70
0,80
0,90
1,00
0,50
0,60
0,70
0,80
0,90
1,00
0,50
0,60
0,70
0,80
0,90
1,00
FFR
p=0.03 p=0.0001 p=NSD E F
0,50
0,75
1,00
1,25
1,50
1,75
2,00
2,25
2,50
2,75
MLD
(mm)
p=NS
0,50
0,75
1,00
1,25
1,50
1,75
2,00
2,25
2,50
2,75
p=NS
0,50
0,75
1,00
1,25
1,50
1,75
2,00
2,25
2,50
2,75
p=NSA B C
E. Barbato et al EHJ 2004
Effect of α-Blockers on Diameter and FFR
ww
w.c
ard
io-a
als
t.b
e
ETP, Sofia Antipolis, April 2013
Hyperemia
![Page 54: Hyperemia Hyperemic Stimuli - European Society of Cardiologyassets.escardio.org/assets/presentations/OTHER2013... · 2013-06-03 · io-.be ETP, Sofia Antipolis, April 2013 Hyperemia](https://reader030.vdocuments.net/reader030/viewer/2022011816/5e6b1dbd452f913f002b34b5/html5/thumbnails/54.jpg)
ww
w.c
ard
io-a
als
t.b
e
ETP, Sofia Antipolis, April 2013
Hyperemia
FAQIs adenosine contraindicated in all patients with lung disease ?
NO1. Adenosine is strictly contra indicated in asthma
2. Adenosine is NOT contra indicated in COPD
![Page 55: Hyperemia Hyperemic Stimuli - European Society of Cardiologyassets.escardio.org/assets/presentations/OTHER2013... · 2013-06-03 · io-.be ETP, Sofia Antipolis, April 2013 Hyperemia](https://reader030.vdocuments.net/reader030/viewer/2022011816/5e6b1dbd452f913f002b34b5/html5/thumbnails/55.jpg)
ww
w.c
ard
io-a
als
t.b
e
ETP, Sofia Antipolis, April 2013
Hyperemia