Temporal increase in resting coronary blood flow causes an impairment of coronary flow reserve after coronary angioplasty

doi:10.1016/0002-8703(92)90743-F

American Heart Journal

Volume 123, Issue 1, January 1992, Pages 28-36

https://doi.org/10.1016/0002-8703(92)90743-F Get rights and content

Abstract

Impaired coronary flow reserve immediately after coronary angioplasty may be attributed to an increase in resting coronary blood flow. To test this hypothesis we measured great cardiac venous flow (GCVF) at rest and during rapid atrial pacing before and immediately after angioplasty in 22 patients with significant narrowing of the left anterior descending artery and 12 patients (control group) with minimal narrowing. A follow-up (6 months) study was also done in seven patients. Immediately after angioplasty the coronary flow reserve (peak GCVF during pacing/resting GCVF) was not fully restored (1.5 ± 0.36 before angioplasty, 1.76 ± 0.42 after angioplasty, and 2.13 ± 0.33 in the control group). Resting coronary vascular resistance (2.4 ± 0.9 mm Hg/ml/min) was significantly decreased after angioplasty (2.0 ± 0.8 mm Hg/ml/min), whereas coronary vascular resistance during rapid pacing was fully restored to normal. Resting hyperemia was restored 6 months later, whereas coronary vascular resistance during pacing was unaltered. In five patients, however, slight ischemic ST-T changes were observed during rapid pacing, even after successful angioplasty associated with a decrease in the lactate extraction ratio. These results indicate that the impaired coronary flow reserve immediately after angioplasty may be attributed mainly to the temporal but significant increase in resting coronary flow, although impaired coronary vascular response to augmented myocardial oxygen demand may also be partially involved.

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Cited by (53)

Coronary Flow Reserve and Ventricular Function Following Regenerative Treatment in Patients With Revascularized Acute Anterior Myocardial Infarction
2018, Revista Espanola de Cardiologia
Las células madre de médula ósea pueden regenerar el miocardio infartado por distintos mecanismos. La relación entre la recuperación de la función muscular y microvascular después del tratamiento regenerativo ha sido poco estudiada. El objetivo es analizar la relación entre los cambios en función ventricular y función microvascular en pacientes con infarto agudo que reciben la terapia.
Se analizó a 88 pacientes con infarto anterior revascularizado incluidos en 2 ensayos clínicos y 1 estudio piloto que evaluaban la eficacia de la terapia celular. El estudio de la reserva coronaria y la función ventricular se analizaron con la misma metodología en todos ellos. Se administraron células mononucleares derivadas de médula ósea autóloga (n = 40), factor estimulante de colonias granulocíticas (n = 14) o la combinación de ambos (n = 10). Hubo un grupo control (n = 24) que solo recibió revascularización convencional.
La media de fracción de eyección se incrementó del 37 ± 8% al 46 ± 12% (p < 0,05). La media de incremento de la reserva de flujo coronario fue de 1,6 ± 0,5 a 2,3 ± 0,9 (p < 0,05). No hubo correlación entre los parámetros de función muscular y los parámetros de función microvascular al seguimiento.
Hay cambios favorables en el miocardio tras el tratamiento con terapia regenerativa después de un infarto, aunque no se ha encontrado correlación entre los cambios de función muscular y microvascular.
Bone marrow stem cells may reconstruct infarcted myocardium through distinct mechanisms. However, little is known on the relationship between recovery of muscular and microvascular function after regenerative treatments. Our objective was to analyze the relationship between changes in left ventricular and microvascular function in patients with anterior acute myocardial infarction receiving regenerative treatment.
We performed a pooled analysis of 2 clinical trials and a pilot study evaluating stem cell therapy in 88 patients with revascularized acute anterior myocardial infarction. Coronary flow reserve and left ventricular function were analyzed with identical methods in all patients. Patients treated with regenerative treatment received intracoronary bone–marrow-derived mononuclear cell transplant (n = 40), subcutaneous administration of granulocyte colony-stimulating factor (n = 14), or a combination of both (n = 10). A control group of 24 patients was treated with conventional revascularization.
Mean ejection fraction increased from 37% ± 8% to 46% ± 12%, (P < .05). Mean coronary flow reserve increased from 1.6 ± 0.5 to 2.3 ± 0.9 (P < .05). However, there was no correlation between parameters of left ventricular function and microvascular parameters at follow-up.
Left ventricular function shows favorable changes after regenerative treatment of infarction. However, no correlation was found between changes in microvascular and myocardial function after regenerative therapy.
Full English text available from: www.revespcardiol.org/en
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2006, International Journal of Cardiology
Percutaneous coronary intervention (PCI) with stent placement induces epicardial coronary vasoconstriction, which is resolved by intracoronary (IC) nitroglycerine (NTG). The effect of stenting on microvascular coronary circulation and coronary blood flow (CBF) is less well established, and the effect of NTG on CBF following stenting is unknown. We examined the time course, extent, and influence of NTG, on PCI induced coronary vasoconstriction. Secondarily we also did an explorative analysis to evaluate the effect of increased levels of low density lipoprotein cholesterol (LDL-Cholesterol) on CBF after stenting.
Single vessel PCI stent was performed in 19 patients (age 62 ± 10 years). Immediately after PCI, a 0.014 Doppler flow-wire was positioned distal to the stent, and IC NTG 0.2 mg was given. Quantitative coronary angiography (QCA) and CBF measurements were taken at baseline, and at 10, 20 and 30 min following PCI. Further IC NTG 200 μg was given after the measurement at 30 min, and the measurements were repeated at 31 and 33 min. Coronary flow velocity reserve (CFVR) was measured with adenosine IC bolus.
Compared to baseline, there were significant reductions in CBF (24.5 ± 18.3%), (35 ± 30 vs. 28 ± 25 ml/min, p = 0.001) and coronary arterial diameter (5.1 ± 5.4%) (2.63 ± 0.54 vs. 2.50 mm ± 0.53, p = 0.008) within 30 min following PCI. Subsequent IC NTG reversed both small (28 ± 25 vs. 44 ± 30 ml/min, p < 0.001) and large (2.50 ± 0.53 vs. 2.80 ± 0.59 mm, p = 0.001) vessel PCI induced vasoconstriction. LDL-cholesterol was significantly correlated to the percent reduction of blood-flow within 30 min (r = 0.515, p = 0.024, n = 19) and to the maximal CBF after NTG (r = 0.520, p = 0.022, n = 19).
Following PCI, both large and small vessel vasoconstriction are seen as manifest by a reduction in coronary conduit vessel diameter and in CBF. These effects are reversed by NTG. Serum levels of LDL are modestly related to the reduction of CBF and to the degree of NTG induced vasodilatation of coronary micro-vasculature.
Coronary microembolization
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Atherosclerotic plaque rupture is a key event in the pathogenesis of acute coronary syndromes and during coronary interventions. Atherosclerotic plaque rupture does not always result in complete thrombotic occlusion of the entire epicardial coronary artery with subsequent acute myocardial infarction, but may in milder forms result in the embolization of atherosclerotic and thrombotic debris into the coronary microcirculation. This review summarizes the available morphological evidence for coronary microembolization in patients who died from coronary artery disease, most notably from sudden death. Then the experimental pathophysiology of coronary microembolization in animal models of acute coronary syndromes is detailed. Finally, the review presents the available clinical evidence for coronary microembolization in patients, highlights its key features—arrhythmias, contractile dysfunction, microinfarcts and reduced coronary reserve—, compares these features to those of the experimental model and addresses its prevention by mechanical protection devices and glycoprotein IIb/IIIa antagonism.
Late recovery of coronary flow reserve in patients successfully treated with a percutaneous procedure
2003, Revista Espanola de Cardiologia
El estudio Doppler intracoronario es una de las técnicas propuestas para resolver algunas de las limitaciones de la angiografía. Una reserva coronaria > 2–2,5 después de un procedimiento de revascularización se considera un buen resultado fisiológico y, en general, no se recomienda una optimización adicional en el procedimiento. Sin embargo, la recuperación de la reserva coronaria podría no ser siempre inmediata y completa. El objetivo de nuestro estudio es evaluar la evolución de la recuperación de la reserva coronaria después de una revascularización realizada con éxito.
Hemos incluido a 34 pacientes con enfermedad coronaria tratados con éxito mediante implantación de stent (n = 26) o angioplastia con balón (n = 8). En todos los pacientes obtuvimos un estudio angiográfico y otro de velocidades de flujo coronario en 3 condiciones: a) antes del tratamiento; b) inmediatamente después, y c) a los 8 ± 3 meses del seguimiento.
La reserva coronaria basal fue de 1,3 ± 0, 4 y aumentó a 2,4 ± 0,8 tras el procedimiento (p < 0,01). A los 8 meses de seguimiento se produjo un aumento adicional significativo (3 ± 0,8; p < 0,01). Esta mejoría tardía de la reserva coronaria se asoció a una disminución en la velocidad basal obtenida en el estudio de seguimiento. Los pacientes con reserva coronaria disminuida tras el tratamiento (< 2) fueron los que tuvieron un mayor incremento de la misma en el seguimiento (1,4 ± 0,9 frente a 0,4 ± 0,6; p < 0,01).
Después de una intervención coronaria percutánea realizada con éxito, la reserva coronaria aumenta de forma inmediata. Sin embargo, algunos pacientes presentan mejoras adicionales en el seguimiento. Esta mejoría resultó mayor en los pacientes en los que la reserva no se recuperó inmediatamente tras el tratamiento. Nuestros datos sugieren que el uso de estos parámetros en la valoración inmediata de un procedimiento percutáneo tiene un valor limitado.
Coronary angiograms are of limited value for the assessment of the results of percutaneous interventions. Intracoronary Doppler studies have been used to overcome these difficulties. The achievement of a coronary flow reserve (CFR) > 2–2.5 after the procedure is considered a good result and further optimization is generally not required. However, coronary flow reserve may not recover immediately, despite optimal procedural results. The aim of this study is to assess the temporal course of the recovery of coronary flow reserve after successful revascularization.
We studied 34 patients with coronary heart disease who were successfully treated by balloon angioplasty (n = 8) or stent implantation (n = 26). In all patients, serial observations were made by quantitative angiography and intracoronary Doppler (0.014 = flow-wire). Patients were studied: a) before treatment; b) immediately after, and c) 8 ± 3 months later.
The baseline coronary flow reserve was 1.3 ± 0.4 and increased to 2.4 ± 0.8 after the procedure (p < 0.01). At 8 months follow-up there was a significant increase (3 ± 0.8; p < 0.01). This late improvement in coronary flow reserve was associated with a decline in average peak velocity at follow-up. Patients with impaired CFR immediately after treatment had a greater increase in CFR during followup than those with CFR > 2 after treatment (1.4 ± 0.9 vs 0.4 ± 0.6; p < 0.01).
After a successful coronary intervention, CFR increases immediately, but some patients may experience additional improvement during follow-up. This increase was greater in patients who showed less improvement in coronary flow reserve immediately after treatment. Our findings suggest that the use of Doppler parameters in the immediate assessment of percutaneous coronary intervention results have limitations.
Optimized stent implantation according to intracoronary Doppler-derived parameters
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Citation Excerpt :
The data show that a suboptimal result of BA, defined by angiographic and Doppler flow criteria, is due to both an enhanced baseline blood flow velocity and, presumably, residual lumen obstruction, as reflected by impaired relative CFR, as compared with an optimal result after BA. In the group of patients who did not meet the criteria for optimal BA, baseline blood flow velocity appeared to be elevated after the procedure, which confirms earlier studies (10–12). Coronary flow reserve was already impaired before PTCA in the subgroup of patients with a suboptimal result directly after PTCA, along with a normal relative CFR (and an equal degree of angiographic severity of epicardial stenosis in both groups).
This study was performed to evaluate hemodynamic alterations of stent implantation after Doppler flow–guided balloon angioplasty (BA).
There is controversy regarding the effect of stent implantation on coronary hemodynamics after suboptimal and optimal BA.
A total of 523 of 620 patients underwent Doppler-guided BA in the setting of a multicenter study and were analyzed before and after additional stent implantation. Balloon angioplasty was considered optimal when the diameter stenosis (DS) was ≤35% and coronary flow reserve (CFR) was >2.5 and suboptimal if these two criteria were not met. Coronary flow reserve was also measured in an angiographically normal artery to determine relative CFR. Patients were followed for 12 months to document major adverse cardiac events (MACE).
The main difference between patients with suboptimal BA (n = 195 [51%]) and optimal BA (n = 184 [49%]) was a more pronounced increase in baseline blood flow velocity (15 ± 8 to 22 ± 11 vs. 14 ± 8 to 16 ± 10 cm/s, p < 0.01). Coronary flow reserve improved after stent implantation in both patient groups, owing to a reduction in residual lumen obstruction, as determined by angiographic (%DS) and Doppler flow criteria (hyperemic blood flow velocity, relative CFR), and was associated with a decrease in MACE (16% vs. 7% in optimal BA group, p = 0.08; and 27% vs. 11% in suboptimal BA group, p = 0.007).
Stent implantation enhances CFR after suboptimal and optimal Doppler-guided BA, owing to a reduction in residual lumen obstruction—determined by angiographical and Doppler flow criteria—as the underlying mechanism for an improved clinical outcome.

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Temporal increase in resting coronary blood flow causes an impairment of coronary flow reserve after coronary angioplasty

Abstract

J Am Coll Cardiol

Am J Cardiol

J Am Coll Cardiol

Anal Biochem

Am J Cardiol

Am J Cardiol

J Phamacol Methods

Comparative long-term effects of coronary angioplasty on regional coronary flow reserve

Circulation

The effect of coronary angioplasty on coronary flow reserve

Circulation

Measurement of coronary sinus blood flow by continuous thermodilution in man

Circulation

Methods of enzymatic analysis

Measurements of coronary flow reserve: defining pathophysiology versus making decisions about patient care

Circulation

Maximal coronary flow and the concept of coronary vascular reserve

Circulation

Effect of percutaneous transluminal coronary angioplasty on coronary reserve

Clin Res

Measuring regional myocardial blood flow with 133Xe and the anger camera

Radiology

Origin of great cardiac vein and coronary sinus drainage within the left ventricle

Am J Physiol

Regional coronary hemodynamic effects of ergonovine in patients with and without variant angina

Circulation

Measuring regional myocardial blood flow with ¹³³Xe and the anger camera