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Coronary circulation: Pressure/flow parameters for assessment of ischemic heart disease

  • Review Article
  • Published:
Journal of Nuclear Cardiology Aims and scope

Abstract

Both invasive and non-invasive parameters have been reported for assessment of the physiological status of the coronary circulation. Fractional flow reserve and coronary (or myocardial) flow reserve may be obtained by invasive or non-invasive means. These metrics of coronary stenosis severity have achieved wide clinical acceptance for guiding revascularization decisions and risk stratification. Other indices are obtained invasively (e.g., instantaneous wave-free ratio, iFR; hyperemic stenosis resistance) or non-invasively (e.g., PET absolute myocardial blood flow (mL/min/g)) and have been used for the same purposes. Both iFR, and whole-cycle distal coronary to aortic mean pressure (Pd/Pa) are measured under basal condition and used for assessment of hemodynamic stenosis severity as is index of basal stenosis resistance (BSR). These metrics typically are dichotomized at an empirically derived cut point into “normal” and “abnormal” categories for purposes of clinical decision making and data analysis. Once dichotomized the indices do not always point in the same direction and so confusion may arise. This review, therefore, will present basic principles relevant to understanding commonly employed metrics of the physiological status of the coronary circulation, potential strengths and weaknesses, and hopefully an improved appreciation of the clinical information provided by each.

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Abbreviations

Pa:

Mean aortic pressure

Pd:

Mean pressure distal to coronary stenosis

CBF:

Coronary blood flow

MBF:

Myocardial blood flow

CBF:

Thermodilution mean transit time (Tm ≃ k/CBF) or Doppler flow velocity (cm/s)

MBF:

PET (provides MBF as mL/min/g)

CCTA:

Coronary computed tomographic angiography

CFR and MFR:

Coronary or myocardial flow reserve: CBF or MBF with coronary vasodilator (e.g., adenosine)/CBF or MBF at rest. Defined as absolute flow reserve (see text) and differs from relative flow reserve (e.g., FFR and FFRpet)

FFR:

Fractional flow reserve: Pd/Pa. Obtained with coronary vasodilator stimulus. Considered relative flow reserve (see text)

FFRct :

FFR computed from modeled hyperemic pressure/flow CCTA data. CCTA obtained at rest

FFRpet :

MBF stenotic coronary artery/MBF normal coronary artery. Obtained with coronary vasodilator stimulus requires normal reference artery

iFR:

Instantaneous wave-free ratio (Figure 2). Pd/Pa. Obtained at rest pressures measured during wave-free interval in mid to late diastole

BSR:

Basal stenosis resistance (CBF at rest). Pa − Pd/CBF

HSR:

Hyperemic stenosis resistance (CBF with coronary vasodilator). Pa − Pd/CBF

IMR:

Index of microvascular resistance (CBF with coronary vasodilator). Pd/CBF

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    Henry Gewirtz MD

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Gewirtz, H. Coronary circulation: Pressure/flow parameters for assessment of ischemic heart disease. J. Nucl. Cardiol. 26, 459–470 (2019). https://doi.org/10.1007/s12350-018-1270-3

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