“Functional assessment with pressures guide will continue to become more common”
Brilliant interview with the cardiologist Alfonso Jurado in which he explains the use of pressure guides to treat multivessel disease
“Pressure guides and new non-hyperemic indices will be increasingly used in the future”. This is the opinion of Alfonso Jurado Román, an interventional cardiologist at the Ciudad Real University General Hospital, who participated in a case report on the ‘Usefulness of pressure guides in the treatment of complex multivessel disease’. This report describes the case of fractional flow reserve-guided percutaneous coronary revascularisation and its value as a diagnostic tool in this context. Jurado discusses his interest in the topic with Redacción Médica.
What is the significance of the results obtained in this case report? What have been the most important findings?
This case is quite comprehensive as it addresses several of the advantages of the functional assessment of coronary stenoses over conventional angiography. Probably, the main finding is that by using a pressure guide in this context, it possible to reclassify a patient with hypothetical multivessel disease to a functionally significant single-vessel disease. This has important prognostic and therapeutic implications.
What does this new technique offer over the other diagnostic methods used today?
Measuring the fractional flow reserve (FFR) with pressure guides is the benchmark technique for assessing moderate coronary stenoses in patients who have not undergone a non-invasive ischaemic detection test. It has also proven useful in cases of multivessel disease. Both indications coexist in our patient.
Coronary lesions are usually assessed through visual measurement of angiographic stenoses. However, multiple studies have shown that visual angiographic assessment of stenoses is subject to great variability. Furthermore, there is a high degree of variability in the haemodynamic relevance of visually moderate stenoses. In fact, in some of these studies, such as ‘FAME‘, only 35% of the stenoses of 50-70% diameter were haemodynamically relevant. In addition, 20% of angiographic stenoses of 70-90% diameter were not haemodynamically significant. Therefore, assessing lesions visually leads to error.
There are other intracoronary imaging techniques, such as intravascular ultrasound (IVUS) and optical coherence tomography (OCT), which also provide information about dubious lesions. However, above all, they offer anatomical information compared with the functional information provided by a pressure guide. They are complementary techniques.
For what type of patients and lesions is it indicated?
Measuring the fractional flow reserve with pressure guides is the benchmark technique for the functional assessment of patients with angiographically moderate lesions who have not undergone non-invasive ischaemic detection tests, or in patients who have multivessel disease.
What would have happened if stents had been implanted in the patient?
It would probably have gone well. However, we must base our therapies on the current scientific evidence that is available to us. And, in fact, the data from studies carried out with large numbers of many patients with chronic ischaemic heart disease indicate that revascularisation is only a better option than optimal medical treatment when there are clear signs of significant ischaemia.
Although the results of a coronary angioplasty with the latest generation stents are positive, since we currently have a success rate of over 95% and a low rate of complications during the procedure, stents present higher rates of restenosis and thrombosis, which, although low, must be taken into consideration. Without a doubt, deciding not to implant a stent is more reasonable in cases in which a good prognosis with conservative medical treatment has been demonstrated (patients with FFR>0.8).
This patient also had a bifurcated lesion. Percutaneous treatment of these lesions shows worse results than for bifurcated lesions. The pressure guide was useful to determine if this injury actually required revascularisation. Therefore, FFR-guided revascularisation was a key factor to deciding which lesions we did and didn’t have to treat.
How do you see the future of using pressure guides?
Functional assessment with presure guides is becoming more common according to the data of the Haemodynamics Section (SHCI) of the Spanish Cardiology Society (SEC), which indicates a 23.2% increase in the last year (7003 procedures with pressure guides in 2017 compared with 5686 in the previous year).
In the future, new indices that are comparable to FFR will be increasingly used for functional assessment. Maximal hyperemia is required for FFR assessment, which is usually achieved with drugs such as adenosine. The administration of these drugs is associated with a low rate of side effects and a higher cost. New “non-hyperemic” indices, such as iFR and RFR, do not require maximal hyperemia, which simplifies the procedure. Current studies (especially with iFR) show that the functional assessment is not inferior to FFR assessment. In conclusion, most likely, pressure guides and new non-hyperemic indices will be increasingly used in the future.
Many thanks to Dr Jurado for this interview. For more information on pressure guides, please click here