This article is more than 5 years old. Information may no longer be current.
Consensus statement outlines use of intracoronary diagnostic tools
Click Here to Manage Email Alerts
The Society for Cardiovascular Angiography and Interventions has published an expert consensus document that provides a set of recommendations to aid clinicians in using fractional flow reserve, IVUS and optical coherence tomography for the treatment of complex heart disease.
The authors suggested that since the 2011 guidelines from the American College of Cardiology Foundation, American Heart Association and SCAI, an increasing body of evidence supporting the use of physiology and anatomy to assess diagnostic lesions has emerged. The current statement offers recommendations for the use of FFR, IVUS and OCT in a number of clinical situations where angiography alone may be insufficient to make an assessment.
“The writing group concurs with current guidelines that these modalities are not indicated when non-invasive imaging and angiographic data are concordant or when the result of the additional procedure will not alter the planned treatment strategy or optimization of stent implantation,” the authors wrote.
Fractional flow reserve
FFR is definitely beneficial in cases where “noninvasive stress imaging is contraindicated, discordant, nondiagnostic or unavailable,” according to the statement. The modality should be used for the assessment of the functional significance of intermediate coronary stenoses (50%-70%) and more severe stenoses (<90%).
PCI guided by FFR was more useful than PCI guided by angiography alone in achieving outcomes in patients with multivessel coronary disease.
“In patients with three-vessel coronary disease, measuring FFR could allow reclassification of number of vessels diseased and/or SYNTAX score, thereby guiding decisions regarding revascularization by CABG or PCI,” the authors wrote.
Compared with medical intervention alone, PCI of lesions with FFR <0.8 improves symptom control and decreases inpatient urgent revascularization in stable ischemic heart disease. In addition, investigators noted that medical therapy is the standard of care for patients with stable ischemic heart disease and angiographically intermediate stenosis (left main coronary artery [LMCA] or non-LMCA) of unclear clinical significance when FFR >0.8.
According to the authors, FFR provides no proven benefit when used to measure the culprit vessel in STEMI or any unstable ACS.
IVUS and OCT
Evidence supports the use of IVUS in determining optimal stent deployment, which was described as complete stent expansion and apposition and lack of edge dissection or other complications after implantation. IVUS also is definitely beneficial in determining the size of the vessel undergoing stent implantation, according to the consensus statement.
Furthermore, IVUS is probably beneficial in appraising the significance of LMCA stenosis to assess whether revascularization is warranted when a cutoff minimal lumen area of 6 mm2 is employed, and has demonstrated possible benefit in assessing plaque morphology.
Regarding cases where IVUS has no proven value or should be discouraged, the authors wrote, “IVUS measurements for determination of non-LMCA lesion severity should not be relied upon, in the absence of additional functional evidence, for recommending revascularization.”
OCT demonstrates probable benefit for determining optimal stent deployment, which the investigators noted was sizing, apposition and lack of edge dissection. This modality showed improved resolution compared with IVUS.
Assessment of plaque morphology is the one area where OCT is possibly beneficial.
Lloyd W. Klein
However, the modality has no proven value and should be discouraged in determining the functional significance of stenosis.
The authors suggested that these techniques may influence decision making and optimize outcomes. They added that the modalities are not sufficiently utilized in current practice.
“Physicians will find these recommendations helpful as they apply these techniques to help patients with more complex cases or who have tests that contradict one another,” Lloyd W. Klein, MD, FSCAI, lead author and professor of medicine at Rush University Medical Center in Chicago, and Editorial Board member of Cardiology Today’s Intervention, said in a press release. “Many patients will not need these techniques in their care, but for those who will benefit from them, this guidance offers physicians the parameters to ensure they are put to use best.”
Disclosure: The researchers report no relevant financial disclosures.
Collapse
Click Here to Manage Email Alerts