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Non-hyperaemic coronary pressure measurements to guide coronary interventions

Nature Reviews Cardiology volume 17, pages 629–640 (2020)Cite this article

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Abstract

Evidence supporting the use of coronary physiology as an adjunct to coronary angiography to guide percutaneous coronary interventions has accumulated over the past 25 years. The fractional flow reserve has dominated this evolving physiological guidance of coronary intervention and its use is supported by large clinical outcome trials. However, despite clinical practice guidelines advocating its use in most patients with coronary stenosis who are eligible for coronary intervention, the uptake of a physiology-guided approach remains limited. The use of non-hyperaemic coronary pressure measurements to guide coronary interventions was introduced in an attempt to simplify the routine application of coronary physiology-guided intervention in daily practice. Over the past decade, a large scientific effort has focused on the development of several non-hyperaemic pressure ratios. In this Review, we detail the basic principles of coronary physiology in non-hyperaemic conditions, the rationale for the use of non-hyperaemic coronary pressure measurements for stenosis evaluation, the current evidence base for the available non-hyperaemic coronary pressure ratios, the basis for the discordance between non-hyperaemic coronary pressure ratios and fractional flow reserve, and the potential advantages of these new parameters over fractional flow reserve.

Key points

  • The loss of pressure across a coronary stenosis under non-hyperaemic conditions is intrinsically related to the vasodilatory capacity of the coronary circulation, which, in contrast to fractional flow reserve (FFR), is not informative about the degree of reduction in coronary flow attributable to the stenosis.

  • Non-hyperaemic coronary pressure ratios provide an equivalent diagnostic efficacy as the FFR to identify myocardial perfusion abnormalities on cardiac PET perfusion studies.

  • The use of the instantaneous wave-free ratio to guide coronary interventions results in fewer revascularizations, while maintaining non-inferior 1-year clinical outcomes, compared with the use of FFR.

  • Alternative non-hyperaemic coronary pressure ratios have very high diagnostic efficacy compared with the instantaneous wave-free ratio as well as a similar diagnostic agreement with FFR; however, these indices have not been prospectively studied in terms of clinical outcomes.

  • Non-hyperaemic pressure ratios might provide some benefits in the evaluation of serial coronary stenosis and diffuse epicardial coronary artery disease owing to the lack of stenosis crosstalk for a wide range of stenosis severities under non-hyperaemic conditions.

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Fig. 1: Structure and function of the coronary arterial circulation.
Fig. 2: The coronary pressure–flow relationship.
Fig. 3: Coronary flow reserve versus arteriographic percentage diameter stenosis in a dog experimental model.
Fig. 4: Relationship between lumen diameter stenosis, coronary flow, microvascular resistance, distal coronary pressure and trans-stenotic gradient.
Fig. 5: Definitions of different non-hyperaemic pressure ratios.
Fig. 6: Agreement of non-hyperaemic pressure ratios and FFR with PET-derived myocardial perfusion parameters.
Fig. 7: Stenosis crosstalk under resting and hyperaemic conditions.
Fig. 8: Coronary angiography and physiology co-registration.

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Authors and Affiliations

  1. Department of Clinical and Experimental Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands

    Tim P. van de Hoef & Jan J. Piek

  2. Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea

    Joo Myung Lee

  3. Hospital General ISSSTE Querétaro, Facultad de Medicina, Universidad Autónoma de Querétaro, Santiago de Querétaro, Mexico

    Mauro Echavarria-Pinto

  4. Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea

    Bon-Kwon Koo

  5. Department of Cardiovascular Medicine, Gifu Heart Center, Gifu, Japan

    Hitoshi Matsuo

  6. Division of Cardiology, Department of Medicine, Duke University Medical Center, Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA

    Manesh R. Patel

  7. Hammersmith Hospital, Imperial College London, London, UK

    Justin E. Davies

  8. Hospital Clínico San Carlos, IDISSC and Universidad Complutense de Madrid, Madrid, Spain

    Javier Escaned

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T.P.v.d.H. researched data and wrote the article. All the authors contributed to discussion of content and reviewed and edited the manuscript before submission.

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Correspondence to Tim P. van de Hoef.

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Competing interests

T.P.v.d.H. has been a speaker at educational events for Boston Scientific, Philips Volcano and St. Jude Medical (Abbott), and a consultant for Philips Volcano. J.M.L. has received research grant support from Philips Volcano and St. Jude Medical (Abbott). M.E.-P. has been a speaker at educational events for Abbott and Philips Volcano. B.-K.K. has received institutional research grant support from Philips Volcano and St. Jude Medical (Abbott). M.R.P. has received grants and personal fees from AstraZeneca, Janssen and Philips Volcano, and personal fees from Bayer. J.E.D. has received research funding from AstraZeneca and Philips Volcano, and consulting fees from Medtronic, Philips Volcano and ReCor Medical, and holds patents pertaining to the instantaneous wave-free ratio technology, which is under license to Volcano Corporation. J.E. has been a speaker at educational events and a consultant for Abbott, Boston Scientific and Philips Volcano. J.J.P. has received institutional research grant support from Philips Volcano and personal fees from Abbott, Miracor and Philips Volcano. H.M. declares no competing interests.

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van de Hoef, T.P., Lee, J.M., Echavarria-Pinto, M. et al. Non-hyperaemic coronary pressure measurements to guide coronary interventions. Nat Rev Cardiol 17, 629–640 (2020). https://doi.org/10.1038/s41569-020-0374-z

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