A 73-year-old Caucasian female presents to the emergency room with sudden onset typical angina of two-hour duration. Her prior medical history includes stage III chronic kidney disease, well controlled hypertension, and diabetes. She is a former smoker. Her medications include metformin, aspirin, and lisinopril. Physical exam was unremarkable. Electrocardiogram (ECG) shows sinus bradycardia with T wave inversions involving leads V3-V6, I and aVL. Echocardiogram reveals left ventricular ejection fraction of 40% and akinesis of entire apex. Laboratory data reveal serum troponin of 1.0 ng/ml (normal <0.04 ng/ml).
She is initiated on medical therapy, including aspirin, clopidogrel, metoprolol, intravenous heparin, lisinopril, and atorvastatin.
Coronary angiogram shows 95% stenosis of the mid left anterior descending artery (LAD), 70% stenosis of distal LAD. Mid LAD lesion is treated with 2.5 X 23 mm everolimus drug eluting stent. Distal LAD lesion is deferred based on fractional flow reserve assessment (FFR value of 0.87).
In this patient, which of the following clinical factors predict a higher risk for the deferred lesion intervention in the future?
Show Answer
The correct answer is: C. Chronic kidney disease and smoking status.
Fractional flow reserve (FFR) is a reliable and validated method for assessing the hemodynamic significance of coronary stenosis during angiography. An FFR-guided strategy wherein percutaneous coronary intervention (PCI) is deferred when FFR ≥0.75-0.8 has been shown to improve patient outcomes and is endorsed by the current ACC AHA guidelines.1 Though deferral of FFR-guided non-significant lesions is considered safe, the rates of deferred lesion intervention (DLI) are highly variable depending on the clinical characteristics, technical aspects, and FFR cutoff values utilized in individual studies.
Depta et al. studied the clinical risk predictors for deferred lesion intervention and developed a risk prediction tool.2 Various potential predictors have been assessed including age, gender, hypertension, hyperlipidemia, smoking status, prior coronary artery bypass graft surgery, history of coronary artery disease (CAD), history of prior PCI, congestive heart failure, creatinine, acute myocardial infarction, multivessel CAD, location of the lesion, myocardial jeopardy index score, and FFR value. Among those predictors only five clinical factors (younger age, higher creatinine, history of current or former smoking, multivessel CAD, and history of CAD/prior PCI) along with a lower FFR value, have been found to be associated with a higher risk for deferred lesion intervention within one year.
References
Depta JP, Patel JS, Novak E, et al. Risk model for estimating the 1-year risk of deferred lesion intervention following deferred revascularization after fractional flow reserve assessment. Eur Heart J 2014;36:509-15.
Levine GN, Bates ER, Blankenship JC, et al. 2011 ACCF/AHA/SCAI guideline for Percutaneous Coronary Intervention. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. J Am Coll Cardiol 2011;58:e44-e122.
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