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Impact of hyperaemic microvascular resistance on fractional flow reserve measurements in patients with stable coronary artery disease: insights from combined stenosis and microvascular resistance assessment
  1. Tim P van de Hoef1,2,3,
  2. Froukje Nolte2,
  3. Mauro EchavarrÍa-Pinto3,
  4. Martijn A van Lavieren1,
  5. Peter Damman1,
  6. Steven A J Chamuleau4,
  7. Michiel Voskuil4,
  8. Hein J Verberne5,
  9. José P S Henriques1,
  10. Berthe L F van Eck-Smit5,
  11. Karel T Koch1,
  12. Robbert J de Winter1,
  13. Jos A E Spaan2,
  14. Maria Siebes2,
  15. Jan G P Tijssen1,
  16. Martijn Meuwissen6,
  17. Jan J Piek1
  1. 1AMC Heartcentre, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
  2. 2Department of Biomedical Engineering and Physics, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
  3. 3Hospital Clínico San Carlos and Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain
  4. 4Department of Cardiology, University Medical Centre, Utrecht, The Netherlands
  5. 5Department of Nuclear Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
  6. 6Department of Cardiology, Amphia Hospital, Breda, The Netherlands
  1. Correspondence to Dr Tim P van de Hoef, Academic Medical Centre, University of Amsterdam, AMC Heartcentre, Room B2–213, Meibergdreef 9, Amsterdam 1105 AZ, The Netherlands; t.p.vandehoef{at}


Background Fractional flow reserve (FFR) aims to identify the extent of epicardial disease, but may be obscured by involvement of the coronary microvasculature. We documented the impact of hyperaemic stenosis resistance (HSR) and hyperaemic microvascular resistance (HMR) on FFR, and its relationship with myocardial ischaemia in patients with stable coronary artery disease.

Methods and results We evaluated 255 coronary arteries with stenoses of intermediate severity by means of intracoronary pressure and flow measurements to determine FFR, HSR and HMR. Myocardial perfusion scintigraphy (MPS) was performed to identify inducible myocardial ischaemia. In 178 patients, HMR was additionally determined in a reference coronary artery. Target vessel HMR was stratified according to reference vessel HMR tertiles. The diagnostic OR for inducible ischaemia on MPS of a positive compared with a negative FFR was significantly higher only in the presence of a high HMR (at the 0.75 and 0.80 FFR cut-off). Among stenoses with a positive FFR, the prevalence of ischaemia was significantly higher when HMR was high despite equivalent FFR across the HMR groups. This was paralleled by a concomitant significant increase in HSR with increasing HMR across groups. The relation between FFR and HSR (r2=0.54, p<0.001) was modulated by the magnitude of HMR, and improved substantially after adjustment for HMR (adjusted-r2=0.73, p<0.001), where, for epicardial disease of equivalent severity, FFR increased with increasing HMR.

Conclusions Identification of epicardial disease severity by FFR is partly obscured by the microvascular resistance, which illustrates the necessity of combined pressure and flow measurements in daily practice.

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