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CLINICAL STUDY: MYOCARDIAL ISCHEMIA

Prognostic value of coronary blood flow velocity and myocardial perfusion in intermediate coronary narrowings and multivessel disease

Steven A. J. Chamuleau, MD^*, Rene A. Tio, MD, Carel C. de Cock, MD, Ebo D. de Muinck, MD, Nico H. J. Pijls, MD^||, Berthe L. F. van Eck-Smit, MD^#, Karel T. Koch, MD^*, Martijn Meuwissen, MD^*, Marcel G. W. Dijkgraaf, PhD^**, Angelina de Jong, MSc^*, Hein J. Verberne, MD^#, Rob A. M. van Liebergen, MD^*, Gert Jan Laarman, MD^¶, Jan G. P. Tijssen, PhD^*, Jan J. Piek, MD^*,* Intermediate Lesions: Intracoronary Flow Assessment versus ^99mTc-MIBI SPECT (ILIAS) Investigators

^* Departments of Cardiology, Academic Medical Center-University of Amsterdam, The Netherlands
University Hospital Groningen, The Netherlands
Free University Medical Center Amsterdam, The Netherlands
University Hospital Maastricht, The Netherlands
^|| Catharina Hospital Eindhoven, The Netherlands
^¶ OLVG Hospital Amsterdam, The Netherlands
^# Department of Nuclear Medicine, Academic Medical Center-University of Amsterdam, The Netherlands
^** Department of Clinical Epidemiology and Biostatistics, Academic Medical Center-University of Amsterdam, The Netherlands

Manuscript received June 28, 2001; revised manuscript received October 4, 2001, accepted December 12, 2001.

^* Reprint requests and correspondence: Dr. Jan J. Piek, Academic Medical Center, University of Amsterdam, Department of Cardiology, Room B2-108, Meibergdreef 9, P O Box 22660, 1100 DD, Amsterdam, The Netherlands.
s.a.chamuleau{at}amc.uva.nl

OBJECTIVES: This study aimed to investigate the roles of intracoronary derived coronary flow velocity reserve (CFVR) and myocardial perfusion scintigraphy (single photon emission computed tomography, or SPECT) for management of an intermediate lesion in patients with multivessel coronary artery disease.

BACKGROUND: Evaluation of the functional significance of intermediate coronary narrowings (40% to 70% diameter stenosis) is important for clinical decision making and risk stratification.

METHODS: In a prospective, multicenter study, SPECT was performed in 191 patients with stable angina and multivessel disease and scheduled for angioplasty (percutaneous transluminal coronary angioplasty, or PTCA) of a severe coronary narrowing. Coronary flow velocity reserve was determined selectively distal to an intermediate lesion in another artery using a Doppler guidewire. Percutaneous transluminal coronary angioplasty of the intermediate lesion was deferred when SPECT was negative or CFVR 2.0. Patients were followed for one year to document major cardiac events (death, infarction, revascularization), related to the intermediate lesion.

RESULTS: Reversible perfusion defects were documented in the area of the intermediate lesion in 30 (16%) patients; CFVR was positive in 46 (24%) patients. Percutaneous transluminal coronary angioplasty of the intermediate lesion was deferred in 182 patients. During follow-up, 19 events occurred (3 myocardial infarctions, 16 revascularizations). Coronary flow velocity reserve was a more accurate predictor of cardiac events than was SPECT; relative risk: CFVR 3.9 (1.7 to 9.1), p < 0.05; SPECT 0.5 (0.1 to 3.2), p = NS. Multivariate analysis revealed CFVR as the only significant predictor for cardiac events.

CONCLUSIONS: Deferral of PTCA of intermediate lesions in multivessel disease is safe when CFVR 2.0 (event rate 6%). This selective evaluation of coronary lesion severity during cardiac catheterization allows a more accurate risk stratification than does SPECT, which is important for clinical decision making in this patient cohort.

Abbreviations and Acronyms   SPECT   CFVR   coronary flow velocity reserve   ILIAS   Intermediate Lesions: Intracoronary Flow Assessment Versus 99mTc-MIBI SPECT study   LAD   left anterior descending coronary artery   LCx   left circumflex coronary artery   PTCA   percutaneous transluminal coronary angioplasty   QCA   quantitative coronary angiography   RCA   right coronary artery   SPECT   single photon emission computed tomography

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