Archive for the ‘Coronary artery assessment’ Category

Metaregression of FFR trials: clinical end-points.T

The paper here explores clinical end-point relationship with continuous FFR from FFR trials using metaregression.




Journal Club 30 July 2014


Revascularisation versus medical treatment in patients with stable coronary artery disease: network meta-analysis





To investigate whether revascularisation improves prognosis
compared with medical treatment among patients with stable coronary
artery disease.


Bayesian network meta-analyses to combine direct within trial
comparisons between treatments with indirect evidence from other trials
while maintaining randomisation.
Eligibility criteria for selecting studies A strategy of initial medical
treatment compared with revascularisation by coronary artery bypass
grafting or Food and Drug Administration approved techniques for
percutaneous revascularization: balloon angioplasty, bare metal stent,
early generation paclitaxel eluting stent, sirolimus eluting stent, and
zotarolimus eluting (Endeavor) stent, and new generation everolimus
eluting stent, and zotarolimus eluting (Resolute) stent among patients
with stable coronary artery disease.
Data sources Medline and Embase from 1980 to 2013 for randomised
trials comparing medical treatment with revascularisation.
Main outcome measure All cause mortality.


100 trials in 93 553 patients with 262 090 patient years of
follow-up were included. Coronary artery bypass grafting was associated
with a survival benefit (rate ratio 0.80, 95% credibility interval 0.70 to
0.91) compared with medical treatment. New generation drug eluting
stents (everolimus: 0.75, 0.59 to 0.96; zotarolimus (Resolute): 0.65, 0.42
to 1.00) but not balloon angioplasty (0.85, 0.68 to 1.04), bare metal
stents (0.92, 0.79 to 1.05), or early generation drug eluting stents
(paclitaxel: 0.92, 0.75 to 1.12; sirolimus: 0.91, 0.75 to 1.10; zotarolimus
(Endeavor): 0.88, 0.69 to 1.10) were associated with improved survival
compared with medical treatment. Coronary artery bypass grafting
reduced the risk of myocardial infarction compared with medical treatment
(0.79, 0.63 to 0.99), and everolimus eluting stents showed a trend
towards a reduced risk of myocardial infarction (0.75, 0.55 to 1.01). The
risk of subsequent revascularisation was noticeably reduced by coronary
artery bypass grafting (0.16, 0.13 to 0.20) followed by new generation
drug eluting stents (zotarolimus (Resolute): 0.26, 0.17 to 0.40;
everolimus: 0.27, 0.21 to 0.35), early generation drug eluting stents
(zotarolimus (Endeavor): 0.37, 0.28 to 0.50; sirolimus: 0.29, 0.24 to 0.36;
paclitaxel: 0.44, 0.35 to 0.54), and bare metal stents (0.69, 0.59 to 0.81)
compared with medical treatment.


Among patients with stable coronary artery disease,
coronary artery bypass grafting reduces the risk of death, myocardial
infarction, and subsequent revascularisation compared with medical
treatment. All stent based coronary revascularisation technologies reduce
the need for revascularisation to a variable degree. Our results provide
evidence for improved survival with new generation drug eluting stents
but no other percutaneous revascularisation technology compared with
medical treatment.

Supplmentary Material

Visualization of the revascularization strategies by end-point sensitivity analysis that is tabulated in the paper is available here.

Journal Club 16 October 2013


Predictors of normal coronary arteries at coronary angiography





Coronary angiograms are important in the diagnostic workup of patients with suspected coronary artery
disease. However, little is known about the clinical predictors of normal angiograms and whether this rate varies across
different cardiac centers in Ontario.


We conducted a study using the Cardiac Care Network Variations in Revascularization Practice in Ontario
database of 2,718 patients undergoing an index cardiac catheterization for an indication of stable angina between April
2006 and March 2007 at one of 17 cardiac hospitals in Ontario. We determined predictors of normal coronary angiograms
(0% coronary stenosis) and compared rates of patients with normal catheterizations across centers.


Overall, 41.9% of patients with stable angina had a normal catheterization. A multivariate model demonstrated
female gender to be the strongest predictor of a normal angiogram (odds ratio 3.55, 95% CI 2.93-4.28). In addition, atypical
ischemic symptoms or no symptoms, the absence of diabetes, hyperlipidemia, smoking history, peripheral vascular disease,
and angiography performed at a nonteaching site were associated with higher rates of normal catheterization. The rate of
normal angiograms studied varied from 18.4% to 76.9% across hospitals and was more common in community compared
with academic settings (47.1% vs 35.4%, P b .001).


The absence of traditional cardiac risk factors, female gender, and lack of typical angina symptoms are all
associated with a higher frequency of normal cardiac catheterizations. The wide variation in Ontario in the frequency of
normal angiograms in patients with stable angina suggests that there are opportunities to improve patient case selection.

Journal Club 12 September 2012

September 11, 2012 Leave a comment


Fractional Flow Reserve–Guided PCI versus Medical Therapy in Stable Coronary Disease





The preferred initial treatment for patients with stable coronary artery disease is the
best available medical therapy. We hypothesized that in patients with functionally
significant stenoses, as determined by measurement of fractional flow reserve (FFR),
percutaneous coronary intervention (PCI) plus the best available medical therapy
would be superior to the best available medical therapy alone.


In patients with stable coronary artery disease for whom PCI was being considered,
we assessed all stenoses by measuring FFR. Patients in whom at least one stenosis
was functionally significant (FFR, .0.80) were randomly assigned to FFR-guided
PCI plus the best available medical therapy (PCI group) or the best available medical
therapy alone (medical-therapy group). Patients in whom all stenoses had an FFR of
more than 0.80 were entered into a registry and received the best available medical
therapy. The primary end point was a composite of death, myocardial infarction, or
urgent revascularization.


Recruitment was halted prematurely after enrollment of 1220 patients (888 who
underwent randomization and 332 enrolled in the registry) because of a significant
between-group difference in the percentage of patients who had a primary endpoint
event: 4.3% in the PCI group and 12.7% in the medical-therapy group (hazard
ratio with PCI, 0.32; 95% confidence interval [CI], 0.19 to 0.53; P<0.001). The difference
was driven by a lower rate of urgent revascularization in the PCI group than
in the medical-therapy group (1.6% vs. 11.1%; hazard ratio, 0.13; 95% CI, 0.06 to 0.30;
P<0.001); in particular, in the PCI group, fewer urgent revascularizations were triggered
by a myocardial infarction or evidence of ischemia on electrocardiography
(hazard ratio, 0.13; 95% CI, 0.04 to 0.43; P<0.001). Among patients in the registry,
3.0% had a primary end-point event.


In patients with stable coronary artery disease and functionally significant stenoses,
FFR-guided PCI plus the best available medical therapy, as compared with the best
available medical therapy alone, decreased the need for urgent revascularization. In
patients without ischemia, the outcome appeared to be favorable with the best
available medical therapy alone.

Journal Club 9 May 2012


Morphometric Assessment of Coronary Stenosis Relevance With Optical Coherence Tomography
A Comparison With Fractional Flow Reserve and Intravascular Ultrasound




This paper compared optical coherence tomography and intravascular ultrasound anatomical measurements correlation with functional significance of intermediate coronary stenosis as assessed using fractional flow reserve


Patients scheduled for coronary angiography in whom 1 or more coronary stenoses with intermediate angiographic severity (40% to 70% diameter stenosis by quantitative coronary angiography [QCA])

Exclusions: Stenoses located in culprit vessels of acute coronary syndromes, serial stenoses, or diffuse coronary narrowings were excluded. Vessels providing circulation to previously infarct regions were also excluded. Other exclusion criteria were left main stenosis,
graft stenosis, contraindications to adenosine administration, hemodynamic instability, renal insufficiency, and anatomical
characteristics such as vessel tortuosity and severe calcification that do not allow the advancement of OCT and IVUS catheters.


Optical coherence tomography: minimal luminal area, minimal luminal diameter, area stenosis


Intravascular ultrasound: minimal luminal area, minimal luminal diameter, area stenosis


Correlation between the measures and FFR were determined.  Receiver operator characteristic curves were created and limits of agreement of the anatomical measures between IVUS and OCT were determined.


Angiographic stenosis severity was 50.9  8% diameter stenosis with 1.28  0.3 mm minimal lumen diameter.
FFR was 0.80 in 28 (45.9%) stenoses. An overall moderate diagnostic efficiency of OCT was found (area under
the curve [AUC]: 0.74; 95% confidence interval [CI]: 0.61 to 0.84), with sensitivity/specificity of 82%/63% associated
with an optimal cutoff value of 1.95 mm2. Comparison of the results in patients with simultaneous IVUS
and OCT imaging revealed no significant differences in the diagnostic efficiency of OCT (AUC: 0.70; 95% CI: 0.55
to 0.83) and IVUS (AUC. 0.63; 95% CI: 0.47 to 0.77; p  0.19). Sensitivity/specificity for IVUS was 67%/65% for
an optimal cutoff value of 2.36 mm2. In the subgroup of small vessels (reference diameter 3 mm) OCT
showed a significantly better diagnostic efficiency (AUC: 0.77; 95% CI: 0.60 to 0.89) than IVUS (AUC: 0.63; 95%
CI: 0.46 to 0.78) to identify functionally significant stenoses (p  0.04).

See also this post for further material.

Coronary stenosis measurement

March 19, 2012 3 comments