eISSN: 1896-9151
ISSN: 1734-1922
Archives of Medical Science
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1/2013
vol. 9
 
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abstract:

Editorial
The time has come to move from coronary angiography to physiological assessment of coronary lesions

Josef Veselka

Arch Med Sci 2013; 9, 1: 1-2
Online publish date: 2013/02/21
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In the past, revascularization for acute coronary syndromes was demonstrated to be a life-saving procedure [1]. Conversely, the efficacy of percutaneous coronary interventions (PCI) in patients with stable angina pectoris has been a matter of ongoing debate. Large randomized trials comparing revascularization with optimal medical therapy failed to demonstrate the benefit of the interventional approach [2]. Therefore, PCI has been performed mainly in patients with objective evidence of ischemia unresponsive to medical therapy.

In clinical practice, we mostly rely on the angiographic appearance of coronary lesions, and probably the majority of patients do not undergo stress testing prior to PCI [3, 4]. Based on this statement, one would presume that i) coronary angiography is the optimal method for evaluation of coronary artery disease; ii) coronary angiography demonstrates not only the coronary anatomy, but also the hemodynamic consequences of possible atherosclerotic lesions; iii) interventional therapy based on coronary angiography in stable patients is not only safe but effective in the long-term follow-up. Unfortunately, answers to these questions have been widely known for years and given a resounding NO.

In the past, two reliable methods leading to improvements in the accuracy of coronary angiography have been introduced. Interestingly, we demonstrated the first practical experience with intracoronary ultrasound more than a decade ago [5]. Since that time, virtual histology and optical coherence tomography have significantly improved our options for evaluation of coronary anatomy. Moreover, several studies have demonstrated that intravascular ultrasound guided interventions resulted in a reduced incidence of adverse clinical outcomes, especially in patients with proximal stenoses (left main coronary artery or proximal bifurcation lesions) [6]. On the other hand, evaluation of coronary anatomy and accurate morphology of coronary lesions have certain limitations, both with regard to hemodynamic significance and assessing the extent of ischemic myocardium, which is probably the key to choosing an optimal therapy. The only way currently to easily establish the hemodynamic significance of a borderline coronary lesion is a fractional flow reserve (FFR) measurement, which identifies ischemia-causing coronary stenoses with an accuracy of > 90% [7]. Fractional flow reserve is defined as the ratio between distal coronary pressure...


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