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Angiography-derived index of microcirculatory resistance (IMRangio) as a novel pressure-wire-free tool to assess coronary microvascular dysfunction in acute coronary syndromes and stable coronary artery disease

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Abstract

To investigate the diagnostic accuracy of (1) hyperaemic angiography-derived index of microcirculatory resistance (IMRangio) in defining coronary microvascular dysfunction (CMD) across patients with acute coronary syndromes (ST-elevation myocardial infarction [STEMI]; non-ST elevation acute coronary syndrome [NSTE-ACS]) and stable chronic coronary syndrome [CCS]) and (2) the accuracy of non-hyperaemic IMRangio (NH-IMRangio) to detect CMD in STEMI. 145 patients (STEMI = 66; NSTEMI = 43; CCS = 36) were enrolled. 246 pressure-wire IMR measurements were made in 189 coronary vessels. IMRangio and NH-IMRangio was derived using quantitative flow ratio. In patients with STEMI, cardiac magnetic resonance was performed to quantify microvascular obstruction (MVO). IMRangio was correlated with IMR (overall rho = 0.78, p < 0.0001; STEMI, rho = 0.85 p < 0.0001; NSTE-ACS and rho = 0.72, p < 0.0001; CCS, rho = 0.70, p < 0.0001) and demonstrated good diagnostic performance in predicting high IMR (STEMI AUCROC = 0.93 [0.88–0.98]; NSTE-ACS AUCROC = 0.77 [0.63–0.92]; CCS AUCROC = 0.88 [0.79–0.97]). Agreement between the two indices was evident on Bland Altman analysis. In STEMI, NH-IMRangio was also well correlated with IMR (rho = 0.64, p < 0.0001), with good diagnostic accuracy in predicting high invasive IMR (AUCROC = 0.82 [0.74–0.90]). Both IMRangio (AUCROC = 0.74 [0.59–0.89]) and NH-IMRangio (AUCROC = 0.76 [0.54–0.87]) were significantly associated with MVO in STEMI. In conclusions, IMRangio is a valid alternative to invasive IMR to detect CMD in patients with acute and stable coronary syndromes, whilst NH-IMRangio has a good diagnostic accuracy in STEMI where it could become a user-friendly diagnostic tool as it is adenosine-free.

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Data availability

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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Acknowledgements

We thank Ms Yujun Ng for her efforts in the study’s co-ordination.

Funding

This study was funded by grants from National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, British Heart Foundation Centre of Research Excellence, Oxford, (RG/13/1/30181) and British Heart Foundation, CH/16/1/32013.

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Author notes

  1. Roberto Scarsini and Mayooran Shanmuganathan have equally contributed to the manuscript.

Authors and Affiliations

  1. Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Headley Way, Oxford, OX39DU, UK

    Roberto Scarsini, Mayooran Shanmuganathan, Rafail A. Kotronias, Dimitrios Terentes-Printzios, Alessandra Borlotti, Jeremy P. Langrish, Andrew J. Lucking, Vanessa M. Ferreira, Keith M. Channon, Adrian P. Banning & Giovanni Luigi De Maria

  2. Cardiovascular Medicine, University of Oxford, Oxford, UK

    Mayooran Shanmuganathan, Rafail A. Kotronias, Alessandra Borlotti, Vanessa M. Ferreira, Keith M. Channon, Adrian P. Banning & Giovanni Luigi De Maria

  3. Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy

    Roberto Scarsini & Flavio Ribichini

  4. MedStar Washington Hospital Centre, Washington, DC, USA

    Hector M. Garcia-Garcia

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  1. Roberto Scarsini
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Consortia

OxAMI Study Investigators

Contributions

RS and MS co-ordinated the study, recruited patients, collected data, performed QFR analysis and prepared the manuscript. RS performed the statistical analysis. GLDM and APB conceived and designed the study, recruited patients and helped prepare the manuscript. AB performed CMR image analysis. RAK and DTP recruited patients, collected data and performed QFR analysis. JL, AL and KC contributed to study design, recruited patients and collected data. VMF helped design the study and supervised image analysis. HMGG and FR contributed to study’s conception and design. All authors critically appraised the manuscript.

Corresponding author

Correspondence to Giovanni Luigi De Maria.

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Conflict of interest

Dr RS is on the scientific advisory board for Abbott Laboratories. Dr GLDM has received grants for Abbott Laboratories and Miracor Medical SA. AB reports institutional funding for fellowship from Boston Scientific and speaker fees from Boston Scientific, Miracor Medical SA, Medtronic and Abbott. All other authors report no conflict.

Consent to participate

All patients provided informed consent for participation in the OxAMI study.

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All patients provided informed consent for anonymous publication of the results of the study.

Ethical approval

OxAMI study was approved by the Oxford University Hospitals ethics committee and conducted in accordance with the Declaration of Helsinki (REC number 10/H0408/24).

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Scarsini, R., Shanmuganathan, M., Kotronias, R.A. et al. Angiography-derived index of microcirculatory resistance (IMRangio) as a novel pressure-wire-free tool to assess coronary microvascular dysfunction in acute coronary syndromes and stable coronary artery disease. Int J Cardiovasc Imaging 37, 1801–1813 (2021). https://doi.org/10.1007/s10554-021-02254-8

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