The Official Journal of EuroPCR and the European Association of Percutaneous Coronary Interventions (EAPCI)

Pressure-bounded coronary flow reserve to assess the extent of microvascular dysfunction in patients with ST-elevation acute myocardial infarction.

DOI: 10.4244/EIJ-D-19-00674

1. Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, UK; Division of Cardiology, Department of Medicine, University of Verona, Verona Italy
2. Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, UK
3. Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, UK; Oxford Centre for Clinical Magnetic Resonance Research, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford
4. Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, UK; Division of Cardiovascular Medicine, BHF Centre of Research Excellence, University of Oxford, Oxford UK
5. Division of Cardiology, Department of Medicine, University of Verona, Verona Italy
6. Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, UK; Acute Vascular Imaging Centre, Radcliffe Department of Medicine, University of Oxford, Oxford, UK, United Kingdom
7. Acute Vascular Imaging Centre, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
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Aims:. Assessment of microvascular function in patients with ST-elevation acute myocardial infarction (STEMI) may be useful to determine treatment strategy. The possible role of pressure-bounded coronary flow reserve (pb-CFR) in this setting has not been determined. 

Methods and results:. Thermodilution-pressure-wire assessment of the infarct-related artery was performed in 148 STEMI patients before stenting and/or at completion of primary percutaneous coronary intervention (PPCI). The extent of the myocardial injury was assessed with cardiovascular magnetic resonance imaging at 48-hours and 6-months after STEMI. Post-PPCI pb-CFR was impaired (<2) and normal (>2) in 69.9% and 9.0% of the cases respectively. In the remaining 21.1% of the patients, pb-CFR was “indeterminate”. In this cohort, pb-CFR correlated poorly with thermodilution-derived coronary flow reserve (k=0.03, p=0.39). The index of microcirculatory resistance (IMR) was significantly different across the pb-CFR subgroups. Similarly, significant differences were observed in microvascular obstruction (MVO), myocardium area-at-risk and 48-hours infarct-size (IS). A trend towards lower 6-month IS was observed in patients with high (>2) post-PPCI pb-CFR. Nevertheless, pb-CFR was inferior to IMR in predicting MVO and the extent of IS. 

Conclusions:. Pb-CFR can identify microvascular dysfunction in patients after STEMI and provided superior diagnostic performance compared to thermodilution-derived CFR in predicting MVO. However, IMR was superior to both pb-CFR and thermodilution-derived CFR and consequently, IMR was the most accurate in predicting all of the studied CMR endpoints of myocardial injury after PPCI.

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