Elsevier

American Heart Journal

Volume 257, March 2023, Pages 51-61
American Heart Journal

Review Articles
Impact of coronary disease patterns, anatomical factors, micro-vascular disease and non-coronary cardiac factors on invasive coronary physiology

https://doi.org/10.1016/j.ahj.2022.12.006Get rights and content

ABSTRACT

Invasive coronary physiology has been applied by interventional cardiologists to guide the management of coronary artery disease (CAD), with well-defined thresholds applied to determine whether CAD should be managed with optimal medical therapy (OMT) alone or OMT and percutaneous coronary intervention (PCI). There are multiple modalities in clinical use, including hyperaemic and non-hyperaemic indices. Despite endorsement in the major guidelines, there are various factors which impact and confound the readings of invasive coronary physiology, both within the coronary tree and beyond. This review article aims to summarise the mechanisms by which these factors impact invasive coronary physiology, and distinguish factors that contribute to ischaemia from confounding factors. The potential for mis-classification of ischaemic status is highlighted. Lastly, the authors identify targets for future research to improve the precision of physiology-guided management of CAD.

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Section snippets

Assessment of micro-vascular function and its impact on invasive coronary physiology

Coronary Flow Reserve (CFR) and Index of Micro-circulatory resistance (IMR) are invasive tools used to measure of micro-vascular function. CFR measures coronary blood flow at maximal hyperaemia compared to baseline flow, using either doppler flow or thermodilution.10 IMR applies thermodilution to measure the mean transit time of room temperature saline at maximal hyperaemia to derive microvascular resistance.11 Although these tools have some utility in the assessment of micro-vascular function,

Impact of plaque histology on invasive coronary physiology

Multiple studies have investigated the impact of plaque histology on invasive coronary physiology, with various imaging modalities used to classify plaque histology. This has included Computed Tomography Coronary Angiography (CTCA), Intra-Vascular Ultrasound (IVUS), and Optical Coherence Tomography (OCT). Histological sub-types which have been investigated include calcium, fibrous tissue, fibro-fatty tissue, lipid-rich plaque, necrotic core, and positive remodelling. Figure 4

The conclusion from

Minimal luminal area

According to Pouseuille's law of fluid dynamics, change in pressure through a coronary artery is influenced by blood viscosity (µ), coronary flow rate (Q), vessel length (L) and the radius of the lumen (dP =8µQL/πr4).35., 36., 37. Importantly, a study by Gould et al38 has validated the application of Pouseuille's law in vivo, by performing pressure/flow measurements and quantitative angiography in dogs. Changes in the radius alters pressure to the fourth power. Therefore, the minimal luminal

Proximal vs distal

Proximal vessels supply a larger myocardial territory, therefore there are higher increases in coronary blood flow when vasodilators are administered compared to the distal vessel. As a result, a proximal stenosis with a negative resting gradient may develop into a clinically significant FFR value with augmented flow during hyperaemia.20 This explains the phenomenon of iFR-FFR discordance is observed more in proximal versus distal lesions.

Myocardial supply area

Myocardial supply area is a major determinant of

Impact of coronary distensibility on invasive coronary physiology

The distensibility of the coronary artery reflects its ability to comply with changes in pressure within the artery. It has been hypothesised that distensibility both at the lesion site (DistensibilityMLA) and the reference vessel (DistensibilityRef), may impact coronary physiology. In a study by Yong et al,65 distensibility was assessed by analysing three-dimensional angiography images during end-systole and end-diastole. FFR correlated with both DistensibilityMLA (r = 0.36, P<0.001) and

Impact of non-coronary cardiac conditions on invasive coronary physiology

There are a broad range of conditions outside the coronary tree which effect coronary flow (resting or hyperaemic), the micro-circulation, and the reliability of invasive coronary physiology.18 Although the scope of these factors is vast, certain examples highlight the impact that non-coronary cardiac conditions may play, including aortic stenosis, atrial fibrillation and cardiomyopathy.

Clinical implications and future directions

This review article highlights the factors influencing coronary physiology, some of which lead to clinically significant ischaemia, and others which confound the results of invasive coronary physiology. These confounders may lead to mis-classification of ischaemic status, particularly when the pressure wire finding is borderline, with implications for clinical management.

Clinical outcome is the best adjudicator of the value of a test, with FFR and resting pressure values unequivocally linked to

Conclusions

There are numerous factors influencing invasive coronary physiology, some of which are linked to ischaemia, and others which represent confounders. Despite the clinical utility of invasive coronary physiology, clinicians should be mindful of the pitfalls of applying threshold-driven management to all vessels interrogated, and clinical research should focus on improving the precision of invasive coronary physiology.

Conflicts of interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Funding and support

No extramural funding was used to support this work. The authors are solely responsible for the design and conduct of this study, all study analyses, the drafting and editing of the paper and its final contents.

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