Why the study?
Percutaneous coronary intervention targets ischaemia-causing stenoses in chronic coronary syndrome, but the accuracy of intracoronary ECG during pharmacological inotropic stress compared to quantitative angiographic stenosis, FFR, and iFR was unknown.
Does intracoronary ECG during pharmacological stress accurately determine functional coronary lesion severity compared to quantitative angiography, FFR, and iFR in patients with chronic coronary syndrome?
Does intracoronary ECG during pharmacological stress accurately determine functional coronary lesion severity compared to quantitative angiography, FFR, and iFR in patients with chronic coronary syndrome?
Hyperemic intracoronary ECG ST-segment shift detects structurally relevant coronary stenoses with high sensitivity, though FFR and iFR provide higher specificity and overall diagnostic accuracy.
icECG ST-shift may aid sensitive ischaemia detection in CCS; observational data leave open its role versus FFR/iFR.
INTRODUCTION: In patients with chronic coronary syndrome, percutaneous coronary intervention targets haemodynamically significant stenoses, that is, those thought to cause ischaemia. Intracoronary ECG (icECG) detects ischaemia directly where it occurs. Thus, the goal of this study was to test the accuracy of icECG during pharmacological inotropic stress to determine functional coronary lesion severity in comparison to the structural parameter of quantitative angiographic per cent diameter stenosis (%S), as well as to the haemodynamic indices of fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR). METHOD: The primary study endpoint of this prospective trial was the maximal change in icECG ST-segment shift during pharmacological inotropic stress induced by dobutamine plus atropine obtained within 1 min after reaching maximal heart rate(=220 - age). IcECG was acquired by attaching an alligator clamp to the angioplasty guidewire positioned downstream of the stenosis. For the pressure-derived stenosis severity ratios, coronary perfusion pressure and simultaneous aortic pressure were continuously recorded. Using a %S-threshold of ≥50% as the reference for structural stenosis relevance, receiver operating characteristics-analysis of absolute icECG ST-segment shift during hyperemia showed an area under the curve (AUC) of 0.678±0.054 (p=0.002; sensitivity=85%, specificity=50% at 0.34 mV). AUC for FFR was 0.854±0.037 (p<0.0001; sensitivity=64%, specificity=96% at 0.78), and for iFR it was 0.816±0.043 (p<0.0001;sensitivity=62%, specificity=96% at 0.83). CONCLUSIONS: Hyperaemic icECG ST-segment shift detects structurally relevant coronary stenotic lesions with high sensitivity, while they are identified highly specific by FFR and iFR.
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Bigler et al. (2021) studied this question.
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