Implementation of Coronary Physiology in complex clinical and angiographic scenarios
Cronary angiography was, for many years, the only available tool to diagnose and assess the consequences of coronary atherosclerosis, becoming the standard reference in the study of ischemic heart disease allowing to routinely describe the severity of coronary stenosis or the severity of the disease...
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| Tipo de recurso: | tesis doctoral |
| Fecha de publicación: | 2021 |
| País: | España |
| Institución: | Universidad Complutense de Madrid (UCM) |
| Repositorio: | Docta Complutense |
| Idioma: | inglés |
| OAI Identifier: | oai:docta.ucm.es:20.500.14352/5503 |
| Acceso en línea: | https://hdl.handle.net/20.500.14352/5503 |
| Access Level: | acceso abierto |
| Palabra clave: | 616.13/.14-073.75(043.2) Coronary Physiology Cronary angiography Fisiología Coronaria Angiografía coronaria Sistema cardiovascular 2411.03 Fisiología Cardiovascular |
| Sumario: | Cronary angiography was, for many years, the only available tool to diagnose and assess the consequences of coronary atherosclerosis, becoming the standard reference in the study of ischemic heart disease allowing to routinely describe the severity of coronary stenosis or the severity of the disease based on the number of vessels affected. Subsequently, the introduction of invasive methods to assess coronary physiology allowed to obtain a precise assessment regarding the physiological impact of epicardial coronary stenoses, while demonstrating the poor diagnostic performance of angiography to assess the functional impact these stenoses. Among the coronary physiology techniques, the fractional flow reserve (FFR) and the instantaneous wave-free ratio (iFR) are the most used and are currently recommended in clinical practice to decide whether coronary revascularization is indicated. Both techniques received the highest grade of recommendation in the latest European guidelines for myocardial revascularization in the context of intermediate or doubtful stenosis in patients with stable ischemic heart disease (SIHD). However, despite a growing body of evidence supporting the value of physiology in detecting ischemia, the large-scale adoption of this technique is still limited. It has been pointed out that one of the causes underlying the underuse of FFR is that it requires the induction of pharmacological stress through the use of vasodilator drugs such as adenosine, which potentially causes side effects and an additional cost, especially in a case of need of multiple interrogation in the same coronary tree. Besides, this is certainly due to the fact that the FFR validation was carried out mainly in specific clinical and anatomical subgroups, such as stenoses of intermediate severity and SIHD. The safety of revascularization deferral on the ground of FFR or other physiological indices is also limited in other common clinical settings, such as acute coronary syndromes (ACS), left main coronary artery (LMCA) disease or diabetic patients. Lastly, it should be noted that intracoronary pressure indices share an important limitation with coronary angiography: they do not provide information on the state of the coronary microcirculation. This obstacle not only prevents the diagnosis of non-obstructive causes of myocardial ischemia, but also hinders the advancement of knowledge of specific pharmacological treatments that can provide clinical benefit through the modification of this important domain of the coronary circulation... |
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