Key result
Adenosine-free pressure indices, including whole cycle Pd/Pa, iFR, and contrast-FFR, demonstrated strong correlation and high diagnostic accuracy (AUC 0.92, 0.89, and 0.91, respectively) compared to FFR in intermediate coronary lesions.
Why the study?
While adenosine-induced FFR is the gold standard for functional assessment of intermediate coronary stenoses, the correlation of adenosine-free indices (Pd/Pa, iFR, and cFFR) with FFR required evaluation.
Do adenosine-free pressure indices (whole cycle Pd/Pa, iFR, and cFFR) accurately correlate with and predict adenosine-induced FFR ≤0.80 in patients with intermediate coronary lesions?
Observational (n=103)
Blinded
Yes
Do adenosine-free pressure indices (whole cycle Pd/Pa, iFR, and cFFR) accurately correlate with and predict adenosine-induced FFR ≤0.80 in patients with intermediate coronary lesions?
Effect estimate: AUC 0.89 (95% CI 0.81-0.97)
p-value: p=<0.001
Adenosine-free pressure indices (whole cycle Pd/Pa, iFR, and contrast-FFR) demonstrate strong correlation and high diagnostic accuracy compared to adenosine-FFR for evaluating intermediate coronary lesions, potentially reducing the need for adenosine administration.
May limit adenosine use in intermediate lesions; leaves open randomized outcome validation.
OBJECTIVE: Fractional flow reserve (FFR) using adenosine has been the gold standard in the functional assessment of intermediate coronary stenoses in the catheterization laboratory. We aim to study the correlation of adenosine-free indices such as whole cycle Pd/Pa [the ratio of mean distal coronary pressure (Pd) to the mean pressure observed in the aorta (Pa)], instantaneous wave-free ratio (iFR), and contrast-induced submaximal hyperemia (cFFR) with FFR. METHODS: This multicenter, prospective, observational study included patients with stable angina or acute coronary syndrome (>48 h since onset) with discrete intermediate coronary lesions (40-70% diameter stenosis). All patients underwent assessment of whole cycle Pd/Pa, iFR, cFFR, and FFR. We then evaluated the correlation of these indices with FFR and assessed the diagnostic efficiencies of them against FFR ≤0.80. RESULTS: Of the 103 patients from three different centers, 83 lesions were included for analysis. The correlation coefficient (r value) of whole cycle Pd/Pa, iFR, and cFFR in relation to FFR were +0.84, +0.77, and +0.70 (all p values < 0.001), respectively, and the c-statistic against FFR ≤0.80 were 0.92 (0.86-0.98), 0.89(0.81-0.97), and 0.91 (0.85-0.97) (all p values < 0.001), respectively. The best cut-off values identified by receiver-operator characteristic curve for whole cycle Pd/Pa, iFR, and cFFR were 0.94, 0.90, and 0.88, respectively, for an FFR ≤0.80. By the concept of "adenosine-free zone" (iFR = 0.86-0.93), 59% lesions in this study would not require adenosine. CONCLUSION: All the three adenosine-free indices had good correlation with FFR. There is no difference in the diagnostic accuracies among the indices in functional evaluation of discrete intermediate coronary stenoses. However, further validation is needed before adoption of adenosine-free pressure parameters into clinical practice.
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Raja et al. (2018) conducted an observational in Intermediate coronary lesions (n=103). Adenosine-free pressure indices (whole cycle Pd/Pa, iFR, contrast-FFR) vs. Adenosine-induced hyperemic fractional flow reserve (FFR) was evaluated on Diagnostic efficiency (c-statistic) of instantaneous wave-free ratio (iFR) against FFR ≤ 0.80 (AUC 0.89, 95% CI 0.81-0.97, p=<0.001). Adenosine-free pressure indices, including whole cycle Pd/Pa, iFR, and contrast-FFR, demonstrated strong correlation and high diagnostic accuracy (AUC 0.92, 0.89, and 0.91, respectively) compared to FFR in intermediate coronary lesions.
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