Angina Severity in Severe Aortic Stenosis with a Single Intermediate Left Anterior Descending Artery Lesion: Associations with Measured Aortic Valve Area and Epicardial Pressure-Derived Indices

Attributing exertional symptoms in patients with aortic stenosis (AS) and coronary artery disease is challenging. We performed a secondary analysis of a single-center prospective registry of 190 patients with severe high-gradient AS and a single intermediate left anterior descending lesion assessed with fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR). The primary outcome was angina severity (Canadian Cardiovascular Society [CCS] class III–IV vs. II); New York Heart Association (NYHA) class III–IV vs. II functional limitation was secondary and exploratory. Among 185 complete cases, older age (odds ratio [OR] 3.00 per decade, 95% confidence interval [CI] 1.84–4.87; p < 0.001) and smaller measured aortic valve area (AVA; OR 1.39 per 0.1 cm2 decrease, 95% CI 1.08–1.79; p = 0.009) were independently associated with severe angina, whereas lesion morphology, FFR, and iFR were not. No variable was independently associated with NYHA class III–IV limitation, although this analysis was underpowered. Because AVA is flow dependent and transvalvular flow and coronary microvascular function were not directly measured, the AVA association does not establish fixed valvular obstruction as the mechanism of angina. The lack of association with FFR/iFR pertains to symptom severity and does not invalidate their use for lesion-level hemodynamic assessment.