Discordance between resting and hyperemic indices of coronary stenosis severity: the VERIFY 2 study (a comparative study of resting coronary pressure gradient, instantaneous wave-free ratio and fractional flow reserve in an unselected population referred for invasive angiography)

Hennigan, B. et al. (2016) Discordance between resting and hyperemic indices of coronary stenosis severity: the VERIFY 2 study (a comparative study of resting coronary pressure gradient, instantaneous wave-free ratio and fractional flow reserve in an unselected population referred for invasive angiography). Circulation: Cardiovascular Interventions, 9(11), e004016. (doi: 10.1161/CIRCINTERVENTIONS.116.004016) (PMID:27834663)

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Abstract

Background—Distal coronary to aortic pressure ratio (Pd/Pa) and instantaneous wave-free ratio (iFR) are indices of functional significance of a coronary stenosis measured without hyperemia. It has been suggested that iFR has superior diagnostic accuracy to Pd/Pa when compared with fractional flow reserve (FFR). We hypothesized that in comparison with FFR, revascularization decisions based on either binary cutoff values for iFR and Pd/Pa or hybrid strategies incorporating iFR or Pd/Pa will result in similar levels of disagreement. Methods and Results—This is a prospective study in consecutive patients undergoing FFR for clinical indications using proprietary software to calculate iFR. We measured Pd/Pa, iFR, FFR, and hyperemic iFR. Diagnostic accuracy versus FFR ≤0.80 was calculated using binary cutoff values of ≤0.90 for iFR and ≤0.92 for Pd/Pa, and adenosine zones for iFR of 0.86 to 0.93 and Pd/Pa of 0.87 to 0.94 in the hybrid strategy. One hundred ninety-seven patients with 257 stenoses (mean diameter stenosis 48%) were studied. Using binary cutoffs, diagnostic accuracy was similar for iFR and resting Pd/Pa with misclassification rates of 21% versus 20.2% (P=0.85). In the hybrid analysis, 54% of iFR cases and 53% of Pd/Pa cases were outside the adenosine zone and rates of misclassification were 9.4% versus 11.9% (P=0.55). Conclusions—Binary cutoff values for iFR and Pd/Pa result in misclassification of 1 in 5 lesions. Using a hybrid strategy, approximately half of the patients do not receive adenosine, but 1 in 10 lesions are still misclassified. The use of nonhyperemic indices of stenosis severity cannot be recommended for decision making in the catheterization laboratory. Clinical Trial Registration—URL: http://www.clinicaltrials.gov. Unique identifier: NCT02377310.

Item Type:Articles
Status:Published
Refereed:Yes
Glasgow Author(s) Enlighten ID:McCartney, Dr Peter and Hood, Dr Stuart and Hennigan, Dr Barry and Eteiba, Dr Hany and Petrie, Professor Mark and Oldroyd, Dr Keith and Berry, Professor Colin and McClure, Dr John
Authors: Hennigan, B., Oldroyd, K. G., Berry, C., Johnson, N., McClure, J., McCartney, P., McEntegart, M. B., Eteiba, H., Petrie, M. C., Rocchiccioli, P., Good, R., Lindsay, M. M., Hood, S., and Watkins, S.
College/School:College of Medical Veterinary and Life Sciences > School of Cardiovascular & Metabolic Health
College of Medical Veterinary and Life Sciences > School of Medicine, Dentistry & Nursing
Journal Name:Circulation: Cardiovascular Interventions
Publisher:American Heart Assocation
ISSN:1941-7640
Published Online:10 November 2016
Copyright Holders:Copyright © 2016 American Heart Association Inc.
First Published:First published in Circulation: Cardiovascular Interventions 9(11): e004016
Publisher Policy:Reproduced in accordance with the publisher copyright policy

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Project CodeAward NoProject NamePrincipal InvestigatorFunder's NameFunder RefLead Dept
617771BHF centre of excellenceRhian TouyzBritish Heart Foundation (BHF)RE/13/5/30177RI CARDIOVASCULAR & MEDICAL SCIENCES
692781A prospective comparison of the diagnostic utility of invasive coronary physiological indices and quantitative perfusion MRI in patients with coronary heart disease...Keith OldroydBritish Heart Foundation (BHF)PG/14/97/31263RI CARDIOVASCULAR & MEDICAL SCIENCES