evaluation of ischemia in the cardiac cath lab - · pdf file6/5/2013 1 evaluation of ischemia...
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6/5/2013
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Evaluation of Ischemia in the Cath Lab
Morton J. Kern, MDProfessor of Medicine
Chief of Cardiology, LBVAAssociate Chief Cardiology, UCI
University California IrvineOrange, California
Disclosure:
Morton J. Kern, MD
Within the past 12 months, the presenter or their
spouse/partner have had a financial
interest/arrangement or affiliation with the organization
listed below.
Company Name Relationship
St. Jude Medical Inc. Speakers’ Bureau
Volcano Therapeutics Speakers’ Bureau
Merrit Medical Inc. Consultant
Opsens Consultant
To treat or not to treat?
Ischemia is the question
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R1
R2
R3
The Disconnect: Anatomy (angio or IVUS) = Ischemia, i.e., not every coronary plaque needs a stent.
- Ischemia guides decision for revascularization.- The angiogram cannot always tell us.
How severe is this stenosis?
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PET 1ml/gram flow, Radionuclide perfusion imaging,
Coronary blood flow velocity
Biomarkers, Troponin
Wall motion abnormalities, thickening
and shortening
Transmyocardial Lactate
Exercise ECG
What is Gold Standard of Ischemia in Man in or out of
the Cath Lab?
Pa
Pd
Entrance effects Separation losses
Friction loss
Flow
P
1
2
3
4,5,6
7
ischemic
Not ischemic
Pressure
Coronary flow
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1. CFR = max flow/basal flow and decreases with increasing stenosis (R1) severity.
2. CFR may also be reduced with abnormal microvasculature
The Failing of both Angiography and CFR to predict lesion
significant is major rationale for FFR
The limitation of CFR:
Because there are 2 components, CFR cannot distinguish between
an epicardial stenosis and an impaired microcirculation.
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Stress Testing and Coronary Vasodilatory Reserve
Author (n) Ischemic Test CVR Sens Spec AccuracyCVRMiller 33 Ad/Dipy MIBI <2.0 82 100 89
Joye 30 Ex thall <2.0 94 95 94
Deychak 17 Ex thall <1.8 94 94 96
Heller 100 Ex thall <1.7 89 92 92
Danzi 30 Dipy echo <2.0 91 84 87
Schulman 35 Ex ECG <2.0 95 71 86
Akasaka 59 Ex thall <2.0 92 88 92
Chamuleau 127 Spec MIBI <2.0 - - 85
rCVR
El Shafei 48 Ex Thall/Mibi <0.80 63 88 87
Verberne 37 Spect Mibi <0.65 - - 85
Chamuleau 127 Spec MIBI <0.65 - - 85
The resting gradient is not nearly enough
but it’s all I have now.
Aortic Pressure, PA
Coronary wire pressure, Pd
Aortic Pressure, PA
Coronary wire pressure, Pd
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Functional Assessment
FFR detects ischemia
Pressure
5
4
3
2
1
FFR=
Qs
QN
max
max
Qs
QN
Q base
Qs
Q base
max
CFR=
Differences between FFR and CFR
ETT
Thallium
Stress
Echo
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Fractional Flow ReserveThresholds for Reversible Myocardial Ischemia
FFR as a Surrogate for Non-Invasive Stress Testing
NO INDUCIBLE ISCHEMIA
INDUCIBLE ISCHEMIA
ISCHEMIA AT REST OR NECROSIS
Positive Noninvasive
Stress Testing
Negative Noninvasive
Stress Testing
FFR
0.75
0.80
0.20
1.0
FFR Gray Zone ?
Limitations of Non-Invasive Stress Testing for detecting ischemia
1. Intermediate lesion
2. During and after acute coronary syndromes
3. Valvular Disease
4. Left main stenosis
5. Multivessel disease
6. Bundle branch blocks, LVH, LV asynchrony, Poor LV function...
7. General problems: obesity, orthopedic problems, elderly...
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Ref Diam (mm)
% Stenosis for an Cross Sectional Area of 4 mm²
< 4 mm² = significant stenosis ?
025502
3
4
5
Q: Why can we not use IVUS/OCT for functional assessment?A: A single cross-sectional area does not mean the same thing everywhere.
Title(Year) N=
Study Design Question Outcome Journal
FAME
(2009)
750 Prospective
Multicenter
Registry
FFR guide PCI vs. Angio
guided for MVD
Less MACE*,
lower cost
w FFR
FAME II
(2012)
1,220 Prospective
Multicenter
Randomized
Abn FFR treated with
PCI+OMT vs OMT alone
Less MACE
with FFR
DEFER
(2007)
325 Prospective
Multicenter
Randomized
Is it safe to defer FFR
normal intermediate
lesions?
Less MACE
in FFR normal
when rx’d
medically
Mayo
(2013)
7,358 Retrospective
Registry
FFR guide PCI vs Angio
guided for MVD in routine
practice
Less MACE
when using
FFR
Ischemia-Guided PC bests Angio-
Guided PCI
There is considerable uncertainty in various
Angiographic presentations.
Q: Shouldn’t Interventions be ischemia driven?
• Intermediate Stenosis, no evidence
ischemia
• Left Main Stenosis
• Multivessel CAD
• Serial Lesions
• Ostial and Branch Disease
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71 yo Man with typical angina, pos stress, CAD risk factors
What’s your best approach?
FFR CFX
FFR CFX=0.88
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After Stent, remaining LAD narrowing? All done?
?
FFR = 0.68
FFR summary:
1. Appropriate need
for Stents
2. Objective info re
ischemia
3. Eliminates operator
uncertainty
Without FFR, this patient would have had one
unnecessary stent (CFX) and would not have
had one necessary stent, (LAD2)
PCI of Functionally Non-
significant Stenosis 5y FU in
the DEFER Study
Pijls NHJ et al J Am Coll Cardiol 2007;49:2105–11
Does Stenosis Severity of Native
Vessels Influence Bypass Graft
Patency? A Prospective FFR–
Guided Study
Botman CJ et al Ann Thorac Surg
2007;83:2093–7
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FAME I
PCI for MVD Guided by FFR or Angio
10
0
5
2 year
12.7
8.4
%
FFR-guided
Angio-guided
P= 0.03
9.5
6.1
P= 0.03
2 year(exclusion of small
periprocedural infarction)
Tonino et al, NEJM 2009, Pijls et al, JACC 2010
Death or MI MI
Incremental QALY
FFR Guidance Improves Outcomes
FFR GuidanceSaves
Resources
Inc
rem
en
tal
Co
st
[$]
DES
CABG
ROTO
BMS
Balloon
Economic Evaluation of FAME pts with MVD.
Fearon WF et al. Circ 2010;122:25450-2550
Nam, C.-W. et al. J Am Coll Cardiol 2011;58:1211-1218
Reducing the ischemic Burden by Functional (FFR+) Syntax Score
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FAME II – Ischemia directed PCI+OMT vs OMT alone
Stable patients scheduled for 1, 2 or 3 vessel DES stenting
FFR in all target lesions
When all FFR >0.80
OMT
At least 1 stenosiswith FFR ≤ 0.80
Randomisation 1:1
PCI + OMT OMT
Follow-up after 1, 6 months, 1, 2, 3, 4, and 5 years
Randomised Trial Registry
34
50% randomly assigned to FU
De Bruyne B et al. N Engl J Med 2012.
FAME II
Is Optimal medical therapy better than PCI + OMT for patient with
abnormal FFR (i.e. ischemia)?
Angiogram
Angiogram
Distal LAD Guide catheter
Distal LAD Guide catheter
Focal Stenosis
Diffuse disease
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DeBruyne et al, Circulation 2001 104: 2401 - 2406.
Diffuse CAD and Ischemia in the absence of significant
focal epicardial stenosis
FFR
J Am Coll Cardiol Intv. 2012;5(10):1013-1018.
Serial lesions?
Pre FFR (1+2) with
pullback
Lesion 1 large dP,
Stent
Recheck FFR
Treat lesion 2,
Final FFR
Assessment of the LM63 yo M w recent CP, 2y of fatigue. Cath 2005 100% RCA, 50% LAD,
50% CFX with collaterals to RCA. Normal LV function. LM now
significant?
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FFR across LAD
FFR across CFX
FFR=0.92
Hamilos, M. et al. Circulation 2009;120:1505-1512
LM FFR Assessment and 5 year outcomes
Survival MACE free survival
No CABG
CABG
FFR and Acute MI
• Culprit vessel – not for >5 days [De Bruyne et al,
Circulation 2001]
Pijls and Sels, JACC 2012;59:1045
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Class IIa Guidelines - ACC/ AHA/ SCAI
Class IA Guidelines - ESC
Physiologic (ischemia) Guidance is supported by
guidelines
Chest pain, No evidence ischemia
FFR
FFR FFR
FFR FFR FFR
FFR
FFR
FFR FFR FFR
FFR FFR
Asymptomatic Patients
FFR facilitates appropriate Interventions
Ischemia-Driven PCI Decisions
• Improves Outcomes and Appropriateness
• FFR is in-lab marker of specific ischemic
lesion.
• FFR Reduces Uncertainty
• If you’re not using FFR…
“Retool or Retire”