LETTER TO THE EDITOR
All allusions to the great war aside ...
Jan J. Piek, MDa
a Department of Cardiology,Academic Medical Center,University of Amsterdam,Meibergdreef 9,1105 AZ Amsterdam,The Netherlands,
Steven A. J. Chaumuleau, MDa,
Berthe L. F. van Eck-Smit, MDa and
Jan G. P. Tijssen, PhDa
j.j.piek{at}amc.uva.nl
All allusions to the Great War aside, Miller (1) defends the value of perfusion scintigraphy for risk stratification in patients with coronary artery disease (CAD) in an editorial comment on the Intermediate Lesions: Intracoronary Flow Assessment versus 99mTc-MIBI SPECT (ILIAS) study. The ILIAS was a Dutch multicenter study designed as a direct comparison between perfusion scintigraphy and intracoronary Doppler flow measurements for clinical decision making in patients with intermediate coronary lesions in the presence of multivessel disease (2). The patients were included following a diagnostic catheterization that documented multivessel CAD with one severe coronary narrowing, eligible for percutaneous transluminal coronary angioplasty (PTCA), and one intermediate lesion. A perfusion scintigraphy stress test was considered mandatory for evaluation of the intermediate lesion in those patients already scheduled for PTCA of the severe coronary narrowing.
The results of the ILIAS trial show that it is safe to defer an angioplasty of the intermediate lesions if the coronary flow velocity reserve is above 2.0. This finding accords with previous small-sized single-center experiences. Moreover, the Doppler flow measurements appeared to be a better predictor for the occurrence of major adverse cardiac events (i.e., the need for coronary revascularization) related to the intermediate lesion than perfusion scintigraphy. This latter finding is relevant for daily clinical practice in interventional cardiology concerning decision making in intermediate coronary narrowings. It may avoid the need for additional scintigraphic stress testing following diagnostic procedures and facilitates ad hoc PTCA.
Miller’s editorial (1) underscores the contribution of perfusion scintigraphy for risk stratification in patients with CAD—that is, patients with large-sized perfusion defects have a worse clinical outcome compared to patients with smaller-sized perfusion defects (3). These studies indicated that global assessment of myocardial perfusion yields prognostic information. However, this is not in contrast with the findings of the ILIAS trial, which demonstrated the value of intracoronary physiologic parameters for evaluation of regional myocardial perfusion (2). This latter finding relates presumably to the difficulty to allocate reversible perfusion defects to vascular territories, whereas intracoronary measurements allow selective evaluation distal to coronary narrowings. Miller’s conclusion (1) is correct, namely that it would have been a physiological bridge too far if the contribution of intracoronary evaluation of coronary narrowings measurements was interpreted to replace perfusion scintigraphy for risk stratification. The ILIAS trial provides complementary information relevant for clinical decision making in patients already scheduled for cardiac catheterization. The contribution of intracoronary physiologic testing should be considered as a bridge (rather than a bridge too far) between noninvasive stress testing providing prognostic information in patients with multivessel disease, and appropriate use of percutaneous interventions based on accurate invasive evaluation of regional myocardial perfusion.
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1. Miller DD. Coronary flow studies for risk stratification in multivessel disease: a physiologic bridge too far? J Am Coll Cardiol. 2002;39:859–863[Free Full Text]
2. Chamuleau SAJ, Tio RA, de Cock CC, et al. Prognostic value of coronary blood flow velocity and myocardial perfusion in intermediate coronary narrowings and multivessel disease. J Am Coll Cardiol. 2002;39:852–858[Abstract/Free Full Text]
3. Hachamovitch R, Berman DS, Kiat H, Cohen I, Friedman JD, Shaw LJ. Value of stress myocardial perfusion single-photon emission computed tomography in patients with normal resting electrocardiograms: an evaluation of incremental prognostic value and cost-effectiveness. Circulation. 2002;105:823–829[Abstract/Free Full Text]
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