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Hyperemic Pullback Gradient for Coronary Atherosclerosis
Study Questions:
What are pathophysiological patterns of coronary artery disease (CAD), as defined by using an invasive hyperemic pressure pullback gradient?
Methods:
Patients presenting with stable angina and undergoing coronary angiography underwent a pressure-wire pullback using a device set to pull back at a speed of 1 mm/s. Based on coronary angiography and on the fractional flow reserve (FFR) pullback curve, the patterns of CAD were adjudicated as focal, diffuse, or a combination of both. The distribution of epicardial resistance was characterized using the hyperemic pullback pressure gradients (PPGs). The PPG index, a continuous metric based on the magnitude of pressure drop over 20 mm and on the extent of functional disease, was computed to determine the pattern of CAD. PPG value closer to 1.0 represents focal disease and close to 0 diffuse disease.
Results:
A total of 158 vessels (n = 117) were included and used to generate 100 FFR pullback curves. Using coronary physiology, 36% of the vessel disease patterns were reclassified compared to angiography. The median of maximal PPG over 20 mm was 0.083 (interquartile range, 0.063-0.118) FFR units, and the mean extent of functional disease was 39.3 ± 21.3 mm. The mean PPG index was 0.58 ± 0.18 and differentiated pathophysiological focal and diffuse disease (p < 0.001).
Conclusions:
Hyperemic PPG can help characterize patterns of CAD and potentially discriminate between focal or diffuse disease. FFR pullback reclassified one-third of the vessels’ disease pattern compared to conventional angiography.
Perspective:
This was a proof of concept study evaluating a new index, pullback pressure gradient (PPG), which may help quantify extent of epicardial resistance and discriminate between focal and diffuse disease. This study is another reminder of the limitations of angiography alone based on assessment of coronary disease. Although clinical application and implications are not yet known, PPG in theory could help to further refine a clinical approach to revascularization strategies. Further study (PRECISE PCI) is ongoing.
Clinical Topics: Cardiac Surgery, Cardiovascular Care Team, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Stable Ischemic Heart Disease, Vascular Medicine, Atherosclerotic Disease (CAD/PAD), Aortic Surgery, Cardiac Surgery and SIHD, Interventions and Coronary Artery Disease, Interventions and Imaging, Interventions and Vascular Medicine, Angiography, Nuclear Imaging, Chronic Angina
Keywords: Angiography, Atherosclerosis, Coronary Angiography, Angina, Stable, Coronary Artery Disease, Fractional Flow Reserve, Myocardial, Hyperemia, Myocardial Revascularization, Percutaneous Coronary Intervention, Physiology
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