冠心病临界病变冠状动脉血流储备降低的临床特点与冠状动脉造影特点
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摘要
目的探讨冠心病临界病变冠状动脉血流储备(CFR)降低的临床与冠状动脉造影特点。方法入选北京友谊医院行冠状动脉造影的冠心病临界病变患者,行冠状动脉生理学检测,包括血流储备分数(FFR)、CFR、微循环阻力指数(IMR)测定。将FFR> 0.8的患者根据CFR <2与CFR≥2分为两组,比较两组患者临床与冠状动脉造影特点。对FFR> 0.8且CFR <2的患者,根据IMR≥23与IMR <23再分为两个亚组,比较两亚组患者临床与冠状动脉造影特点。结果研究从完成冠状动脉内生理学检测的89例冠状动脉临界病变中共入选FFR> 0.8的患者52例,其中CFR <2组19例(36.5%)。CFR <2组高血压病(89.5%比42.4%,P <0.001)、糖尿病(52.6%比18.2%,P=0.011)、吸烟(36.8%比9.0%,P=0.031)和右冠状动脉比例(57.9%比15.2%,P=0.002)、IMR[(26.7±3.7)比(17.3±5.0),P <0.001]明显高于CFR≥2组。IMR≥23亚组血清C反应蛋白[(8.37±1.67)mg/L比(3.85±1.01)mg/L,P <0.001]、中性粒细胞与淋巴细胞比值[(3.94±0.87)比(2.04±0.43),P <0.001]明显高于IMR <23亚组。结论冠状动脉临界病变CFR降低更常见于有高血压病、糖尿病、吸烟史的患者,右冠状动脉评估时更常见、易合并IMR升高。
Objective To explore the clinical and coronary angiography characteristics of coronary flow reserve decrease in intermittent stenosis in patients with coronary heart disease. Methods Patients with intermittent coronary stenosis who received complete physiological evaluation including fractional flow reserve(FFR), coronary flow reserve(CFR) and index of microcirculatory resistance(IMR) were screened in our study. Then, patients with FFR > 0.8 were enrolled and were divided into decreased CFR group(CFR < 2)and normal CFR group(CFR ≥ 2). Clinical and coronary angiography characteristics were evaluated between the two groups. For patients with CFR < 2, they were subdivided into the increased IMR group(IMR ≥ 23)and normal IMR group(IMR < 23).All clinical and coronary angiography characteristics were evaluated. Results A total of 89 patients with intermittent coronary stenosis and coronary physiological evaluation were screened and 52 patients were eventually enrolled with FFR > 0.8. 19 patients(36.5%) with decreased CFR and 33 patients(63.5%) with normal CFR were observed in patients with FFR > 0.8. Comorbidities of hypertension, diabetes and smoking were higher in the decreased CFR group than in the normal CFR group(allP <0.05), and higher rates of right coronary artery lesions(P <0.05). IMR value was higher in the decreased CFR group than in the normalized CFR group[(26.7±3.7) vs.(17.3±5.0),P < 0.001]. Serum C reactive protein(CRP) levels and ratio of neutrophil/lymphocyte were higher in the increased IMR group than that in the normal IMR group in patients with decreased CFR(both P < 0.001). Conclusions Decreased CFR was more common in patients with hypertension, diabetes and history of smoking, which was often found in right coronary artery lesions and commonly combined with increased IMR.
Objective To explore the clinical and coronary angiography characteristics of coronary flow reserve decrease in intermittent stenosis in patients with coronary heart disease. Methods Patients with intermittent coronary stenosis who received complete physiological evaluation including fractional flow reserve(FFR), coronary flow reserve(CFR) and index of microcirculatory resistance(IMR) were screened in our study. Then, patients with FFR > 0.8 were enrolled and were divided into decreased CFR group(CFR < 2)and normal CFR group(CFR ≥ 2). Clinical and coronary angiography characteristics were evaluated between the two groups. For patients with CFR < 2, they were subdivided into the increased IMR group(IMR ≥ 23)and normal IMR group(IMR < 23).All clinical and coronary angiography characteristics were evaluated. Results A total of 89 patients with intermittent coronary stenosis and coronary physiological evaluation were screened and 52 patients were eventually enrolled with FFR > 0.8. 19 patients(36.5%) with decreased CFR and 33 patients(63.5%) with normal CFR were observed in patients with FFR > 0.8. Comorbidities of hypertension, diabetes and smoking were higher in the decreased CFR group than in the normal CFR group(allP <0.05), and higher rates of right coronary artery lesions(P <0.05). IMR value was higher in the decreased CFR group than in the normalized CFR group[(26.7±3.7) vs.(17.3±5.0),P < 0.001]. Serum C reactive protein(CRP) levels and ratio of neutrophil/lymphocyte were higher in the increased IMR group than that in the normal IMR group in patients with decreased CFR(both P < 0.001). Conclusions Decreased CFR was more common in patients with hypertension, diabetes and history of smoking, which was often found in right coronary artery lesions and commonly combined with increased IMR.
引文
[1]中华医学会心血管病学分会介入心脏病学组,中国医师协会心血管内科医师分会血栓防治专业委员会,中华心血管病杂志编辑委员会.中国经皮冠状动脉介入治疗指南(2016).中华心血管病杂志,44(5):382-400.
[2]Tonino PA,Fearon WF,De Bruyne B,et al.Angiographic versus functional severity of coronary artery stenoses in the FAME study.JAm Coll Cardiol,2010,55(25):2816-2821.
[3]Lee JM,Jung JH,Hwang D,et al.Coronary flow reserve and microcirculatory resistance in patients with intermediate coronary stenosis.J Am Coll Cardiol,2016,67(10):1158-1169.
[4]van de Hoef TP,van Lavieren MA,Damman P,et al.Physiological basis and long-term clinical outcome of discordance between fractional flow reserve and coronary flow velocity reserve in coronary stenoses of intermediate severity.Circ Cardiovasc Interv,2014,7(3):301-311.
[5]Meuwissen M,Siebes M,Chamuleau SA,et al.Hyperemic stenosis resistance index for evaluation of functional coronary lesion severity.Circulation,2002,106(4):441-446.
[6]Meuwissen M,Chamuleau SA,Siebes M,et al.The prognostic value of combined intracoronary pressure and blood flow velocity measurements after deferral of percutaneous coronary intervention.Catheter Cardiovasc Interv,2008,71(3):291-297.
[7]Tonino PA,De Bruyne B,Pijls NH,et al.Fractional flow reserve versus angiography for guiding percutaneous coronary intervention.N Engl J Med,2009,360(3):213-224.
[8]Kern MJ,Lerman A,Bech JW,et al.Physiological assessment of coronary artery disease in the cardiac catheterization laboratory:a scientific statement from the American Heart Association Committee on Diagnostic and Interventional Cardiac Catheterization,Council on Clinical Cardiology.Circulation,2006,114(12):1321-1341.
[9]Echavarria-Pinto M,Escaned J,Macías E,et al.Disturbed coronary hemodynamics in vessels with intermediate stenoses evaluated with fractional flow reserve:a combined analysis of epicardial and microcirculatory involvement in ischemic heart disease.Circulation,2013,128(24):2557-2566.
[10]De Bruyne B,Hersbach F,Pijls NH,et al.Abnormal epicardial coronary resistance in patients with diffuse atherosclerosis but“Normal”coronary angiography.Circulation,2001,104(20):2401-2406.
[11]van de Hoef TP,Meuwissen M,Escaned J,et al.Fractional flow reserve as a surrogate for inducible myocardial ischaemia.Nat Rev Cardiol,2013,10(8):439-452.
[12]van Lavieren MA,van de Hoef TP,Sjauw KD,et al.How should I treat a patient with refractory angina and a single stenosis with normal FFR but abnormal CFR?EuroIntervention,2015,11(1):125-128.
[13]Erdogan D,Yildirim I,Ciftci O,et al.Effects of normal blood pressure,prehypertension,and hypertension on coronary microvascular function.Circulation,2007,115(5):593-599.
[14]Murthy VL,Naya M,Foster CR,et al.Association between coronary vascular dysfunction and cardiac mortality in patients with and without diabetes mellitus.Circulation,2012,126(15):1858-1868.
[15]Kaufmann PA,Gnecchi-Ruscone T,di Terlizzi M,et al.Coronary heart disease in smokers:vitamin C restores coronary microcirculatory function.Circulation,2000,102(11):1233-1238.
[16]Fearon WF,Balsam LB,Farouque HM,et al.Novel index for invasively assessing the coronary microcirculation.Circulation,2003,107(25):3129-3132.
[17]刘兴邦,何立芸,郭丽君.冠状动脉微血管疾病评价技术现状与未来.中国介入心脏病学杂志,2018,26(3):173-176
[18]Crea F,Camici PG,Bairey Merz CN.Coronary microvascular dysfunction:an update.Eur Heart J,2014,35(17):1101-1111.
[19]Hoole SP,Brown AJ,Jaworski C,et al.Interpretation of fractional flow reserve in ST-elevation myocardial infarction culprit lesions.Coron Artery Dis,2015,26(6):495-502.
[2]Tonino PA,Fearon WF,De Bruyne B,et al.Angiographic versus functional severity of coronary artery stenoses in the FAME study.JAm Coll Cardiol,2010,55(25):2816-2821.
[3]Lee JM,Jung JH,Hwang D,et al.Coronary flow reserve and microcirculatory resistance in patients with intermediate coronary stenosis.J Am Coll Cardiol,2016,67(10):1158-1169.
[4]van de Hoef TP,van Lavieren MA,Damman P,et al.Physiological basis and long-term clinical outcome of discordance between fractional flow reserve and coronary flow velocity reserve in coronary stenoses of intermediate severity.Circ Cardiovasc Interv,2014,7(3):301-311.
[5]Meuwissen M,Siebes M,Chamuleau SA,et al.Hyperemic stenosis resistance index for evaluation of functional coronary lesion severity.Circulation,2002,106(4):441-446.
[6]Meuwissen M,Chamuleau SA,Siebes M,et al.The prognostic value of combined intracoronary pressure and blood flow velocity measurements after deferral of percutaneous coronary intervention.Catheter Cardiovasc Interv,2008,71(3):291-297.
[7]Tonino PA,De Bruyne B,Pijls NH,et al.Fractional flow reserve versus angiography for guiding percutaneous coronary intervention.N Engl J Med,2009,360(3):213-224.
[8]Kern MJ,Lerman A,Bech JW,et al.Physiological assessment of coronary artery disease in the cardiac catheterization laboratory:a scientific statement from the American Heart Association Committee on Diagnostic and Interventional Cardiac Catheterization,Council on Clinical Cardiology.Circulation,2006,114(12):1321-1341.
[9]Echavarria-Pinto M,Escaned J,Macías E,et al.Disturbed coronary hemodynamics in vessels with intermediate stenoses evaluated with fractional flow reserve:a combined analysis of epicardial and microcirculatory involvement in ischemic heart disease.Circulation,2013,128(24):2557-2566.
[10]De Bruyne B,Hersbach F,Pijls NH,et al.Abnormal epicardial coronary resistance in patients with diffuse atherosclerosis but“Normal”coronary angiography.Circulation,2001,104(20):2401-2406.
[11]van de Hoef TP,Meuwissen M,Escaned J,et al.Fractional flow reserve as a surrogate for inducible myocardial ischaemia.Nat Rev Cardiol,2013,10(8):439-452.
[12]van Lavieren MA,van de Hoef TP,Sjauw KD,et al.How should I treat a patient with refractory angina and a single stenosis with normal FFR but abnormal CFR?EuroIntervention,2015,11(1):125-128.
[13]Erdogan D,Yildirim I,Ciftci O,et al.Effects of normal blood pressure,prehypertension,and hypertension on coronary microvascular function.Circulation,2007,115(5):593-599.
[14]Murthy VL,Naya M,Foster CR,et al.Association between coronary vascular dysfunction and cardiac mortality in patients with and without diabetes mellitus.Circulation,2012,126(15):1858-1868.
[15]Kaufmann PA,Gnecchi-Ruscone T,di Terlizzi M,et al.Coronary heart disease in smokers:vitamin C restores coronary microcirculatory function.Circulation,2000,102(11):1233-1238.
[16]Fearon WF,Balsam LB,Farouque HM,et al.Novel index for invasively assessing the coronary microcirculation.Circulation,2003,107(25):3129-3132.
[17]刘兴邦,何立芸,郭丽君.冠状动脉微血管疾病评价技术现状与未来.中国介入心脏病学杂志,2018,26(3):173-176
[18]Crea F,Camici PG,Bairey Merz CN.Coronary microvascular dysfunction:an update.Eur Heart J,2014,35(17):1101-1111.
[19]Hoole SP,Brown AJ,Jaworski C,et al.Interpretation of fractional flow reserve in ST-elevation myocardial infarction culprit lesions.Coron Artery Dis,2015,26(6):495-502.