Vol 26, No 3 (2019)
Published online: 2019-06-12

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Consensus document for invasive coronary physiologic assessment in Asia-Pacific countries

Hak Seung Lee1, Joo Myung Lee2, Chang-Wook Nam3, Eun-Seok Shin4, Joon-Hyung Doh5, Neng Dai6, Martin K.C. Ng7, Andy S.C. Yong8, Damras Tresukosol9, Ajit S.  Mullasari10, Rony Mathew11, Praveen Chandra12, Kuang-Te Wang13, Yundai Chen14, Jiyan Chen15, Kai-Hang Yiu16, Nils P. Johnson17, Bon-Kwon Koo1
Pubmed: 31225632
Cardiol J 2019;26(3):215-225.


Background: Currently, invasive physiologic assessment such as fractional flow reserve is widely used worldwide with different adoption rates around the globe. Patient characteristics and physician preferences often differ in the Asia-Pacific (APAC) region with respect to treatment strategy, techniques, lesion complexity, access to coronary physiology and imaging devices, as well as patient management. Thus, there is a need to construct a consensus document on recommendations for use of physiology-guided percutaneous coronary intervention (PCI) in APAC populations. This document serves as an overview of recommendations describing the best practices for APAC populations to achieve more consistent and optimal clinical outcomes. 

Methods and Results: A comprehensive multiple-choice questionnaire was provided to 20 interven- tional cardiologists from 10 countries in the APAC region. Clinical evidence, tips and techniques, and clinical situations for the use of physiology-guided PCI in APAC were reviewed and used to propose key recommendations. There are suggestions to continue to develop evidence for lesion and patient types that will benefit from physiology, develop directions for future research in health economics and local data, develop appropriate use criteria in different countries, and emphasize the importance of education of all stakeholders. A consensus recommendation to enhance the penetration of invasive physiology-based therapy was to adopt the 5E approach: Evidence, Education, Expand hardware, Economics and Expert consensus. 

Conclusions: This consensus document and recommendations support interventional fellows and cardiologists, hospital administrators, patients, and medical device companies to build confidence and encourage wider implementation of invasive coronary physiology-guided therapy in the APAC region. 

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  1. Topol EJ, Nissen SE. Our preoccupation with coronary luminology. The dissociation between clinical and angiographic findings in ischemic heart disease. Circulation. 1995; 92(8): 2333–2342.
  2. Yamagishi M, Hosokawa H, Saito S, et al. Coronary disease morphology and distribution determined by quantitative angiography and intravascular ultrasound--re-evaluation in a cooperative multicenter intravascular ultrasound study (COMIUS). Circ J. 2002; 66(8): 735–740.
  3. Toth G, Hamilos M, Pyxaras S, et al. Evolving concepts of angiogram: fractional flow reserve discordances in 4000 coronary stenoses. Eur Heart J. 2014; 35(40): 2831–2838.
  4. Pijls NH, Van Gelder B, Van der Voort P, et al. Fractional flow reserve. A useful index to evaluate the influence of an epicardial coronary stenosis on myocardial blood flow. Circulation. 1995; 92(11): 3183–3193.
  5. Toth GG, Toth B, De Vroey F, et al. Revascularization decisions in patients with stable angina and intermediate lesions: results of the international survey on interventional strategy. Circ Cardiovasc Interv. 2014; 7(6): 751–759.
  6. Zaleska M, Kołtowski Ł, Maksym J, et al. Alternative methods for functional assessment of intermediate coronary lesions. Cardiol J. 2019 [Epub ahead of print].
  7. Lee JM, Kato D, Oi M, et al. Safety and efficacy of intracoronary nicorandil as hyperaemic agent for invasive physiological assessment: a patient-level pooled analysis. EuroIntervention. 2016; 12(2): e208–e215.
  8. Jang HJ, Koo BK, Lee HS, et al. Safety and efficacy of a novel hyperaemic agent, intracoronary nicorandil, for invasive physiological assessments in the cardiac catheterization laboratory. Eur Heart J. 2013; 34(27): 2055–2062.
  9. Neumann FJ, Sousa-Uva M, Ahlsson A, et al. Considerations for the choice between coronary artery bypass grafting and percutaneous coronary intervention as revascularization strategies in major categories of patients with stable multivessel coronary artery disease: an accompanying article of the task force of the 2018 ESC/EACTS guidelines on myocardial revascularization. Eur Heart J. 2019; 40(2): 204–212.
  10. Fihn SD, Blankenship JC, Alexander KP, et al. American College of Cardiology/Americal Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons. 2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, and the American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Thorac Cardiovasc Surg. 2015; 149(3): e5–23.
  11. Lachance P, Déry JP, Rodés-Cabau J, et al. Impact of fractional flow reserve measurement on the clinical management of patients with coronary artery disease evaluated with noninvasive stress tests prior to cardiac catheterization. Cardiovasc Revasc Med. 2008; 9(4): 229–234.
  12. Van Belle E, Gil R, Klauss V, et al. Impact of routine invasive physiology at Time of angiography in patients with multivessel coronary artery disease on reclassification of revascularization strategy: results from the DEFINE REAL study. JACC Cardiovasc Interv. 2018; 11(4): 354–365.
  13. Van Belle E, Baptista SB, Raposo L, et al. Impact of Routine Fractional Flow Reserve on Management Decision and 1-Year Clinical Outcome of Patients With Acute Coronary Syndromes: PRIME-FFR (Insights From the POST-IT [Portuguese Study on the Evaluation of FFR-Guided Treatment of Coronary Disease] and R3F [French FFR Registry] Integrated Multicenter Registries - Implementation of FFR [Fractional Flow Reserve] in Routine Practice). Circ Cardiovasc Interv. 2017; 10(6).
  14. Layland J, Oldroyd KG, Curzen N, et al. Fractional flow reserve vs. angiography in guiding management to optimize outcomes in non-ST-segment elevation myocardial infarction: the British Heart Foundation FAMOUS-NSTEMI randomized trial. Eur Heart J. 2015; 36(2): 100–111.
  15. Nakamura M, Yamagishi M, Ueno T, et al. Modification of treatment strategy after FFR measurement: CVIT-DEFER registry. Cardiovasc Interv Ther. 2015; 30(1): 12–21.
  16. Van Belle E, Rioufol G, Pouillot C, et al. Outcome impact of coronary revascularization strategy reclassification with fractional flow reserve at time of diagnostic angiography: insights from a large French multicenter fractional flow reserve registry. Circulation. 2014; 129(2): 173–185.
  17. Curzen N, Rana O, Nicholas Z, et al. Does routine pressure wire assessment influence management strategy at coronary angiography for diagnosis of chest pain?: the RIPCORD study. Circ Cardiovasc Interv. 2014; 7(2): 248–255.
  18. Zimmermann FM, Ferrara A, Johnson NP, et al. Deferral vs. performance of percutaneous coronary intervention of functionally non-significant coronary stenosis: 15-year follow-up of the DEFER trial. Eur Heart J. 2015; 36(45): 3182–3188.
  19. Park SH, Jeon KH, Lee JM, et al. Long-Term Clinical Outcomes of Fractional Flow Reserve-Guided Versus Routine Drug-Eluting Stent Implantation in Patients With Intermediate Coronary Stenosis: Five-Year Clinical Outcomes of DEFER-DES Trial. Circ Cardiovasc Interv. 2015; 8(12): e002442.
  20. van Nunen LX, Zimmermann FM, Tonino PAL, et al. Fractional flow reserve versus angiography for guidance of PCI in patients with multivessel coronary artery disease (FAME): 5-year follow-up of a randomised controlled trial. Lancet. 2015; 386(10006): 1853–1860.
  21. Xaplanteris P, Fournier S, Pijls NHJ, et al. Five-Year Outcomes with PCI Guided by Fractional Flow Reserve. N Engl J Med. 2018; 379(3): 250–259.
  22. Smits PC, Abdel-Wahab M, Neumann FJ, et al. Fractional flow reserve-guided multivessel angioplasty in myocardial infarction. N Engl J Med. 2017; 376(13): 1234–1244.
  23. Engstrøm T, Kelbæk H, Helqvist S, et al. Complete revascularisation versus treatment of the culprit lesion only in patients with ST-segment elevation myocardial infarction and multivessel disease (DANAMI-3—PRIMULTI): an open-label, randomised controlled trial. Lancet. 2015; 386(9994): 665–671.
  24. Davies JE, Sen S, Dehbi HM, et al. Use of the Instantaneous Wave-free Ratio or Fractional Flow Reserve in PCI. N Engl J Med. 2017; 376: 1824–1834.
  25. Götberg M, Christiansen EH, Gudmundsdottir IJ, et al. Instantaneous Wave-free Ratio versus Fractional Flow Reserve to Guide PCI. N Engl J Med. 2017; 376(19): 1813–1823.
  26. Lee JM, Hwang D, Park J, et al. Exploring coronary circulatory response to stenosis and its association with invasive physiologic indexes using absolute myocardial blood flow and coronary pressure. Circulation. 2017; 136(19): 1798–1808.
  27. Lee JM, Park J, Hwang D, et al. Similarity and Difference of Resting Distal to Aortic Coronary Pressure and Instantaneous Wave-Free Ratio. J Am Coll Cardiol. 2017; 70(17): 2114–2123.
  28. Lee JM, Doh JH, Nam CW, et al. Functional approach for coronary artery disease: filling the gap between evidence and practice. Korean Circ J. 2018; 48(3): 179–190.
  29. Lee J, Shin ES, Nam CW, et al. Clinical outcomes according to fractional flow reserve or instantaneous wave-free ratio in deferred lesions. JACC: Cardiovasc Interv. 2017; 10(24): 2502–2510.
  30. Lee JM, Shin ES, Nam CW, et al. Discrepancy between fractional flow reserve and instantaneous wave-free ratio: Clinical and angiographic characteristics. Int J Cardiol. 2017; 245: 63–68.
  31. Lee JM, Hwang D, Park J, et al. Physiologic mechanism of discordance between instantaneous wave-free ratio and fractional flow reserve: Insight from N-ammonium positron emission tomography. Int J Cardiol. 2017; 243: 91–94.
  32. Van't Veer M, Pijls NHJ, Hennigan B, et al. Comparison of Different Diastolic Resting Indexes to iFR: Are They All Equal? J Am Coll Cardiol. 2017; 70(25): 3088–3096.
  33. Svanerud J, Ahn JM, Jeremias A, et al. Validation of a novel non-hyperaemic index of coronary artery stenosis severity: the Resting Full-cycle Ratio (VALIDATE RFR) study. EuroIntervention. 2018; 14(7): 806–814.
  34. Lee JM, Layland J, Jung JH, et al. Integrated physiologic assessment of ischemic heart disease in real-world practice using index of microcirculatory resistance and fractional flow reserve: insights from the International Index of Microcirculatory Resistance Registry. Circ Cardiovasc Interv. 2015; 8(11): e002857.
  35. Lee JM, Jung JH, Hwang D, et al. Coronary flow reserve and microcirculatory resistance in patients with intermediate coronary stenosis. J Am Coll Cardiol. 2016; 67(10): 1158–1169.
  36. Grüntzig AR, Senning A, Siegenthaler WE. Nonoperative dilatation of coronary-artery stenosis: percutaneous transluminal coronary angioplasty. N Engl J Med. 1979; 301(2): 61–68.
  37. Pijls NH, van Son JA, Kirkeeide RL, et al. Experimental basis of determining maximum coronary, myocardial, and collateral blood flow by pressure measurements for assessing functional stenosis severity before and after percutaneous transluminal coronary angioplasty. Circulation. 1993; 87(4): 1354–1367.
  38. Johnson NP, Koo BK. Coronary psychology: do you believe? JACC Cardiovasc Interv. 2018; 11(15): 1492–1494.
  39. SWEDEHEART Annual Report. 2017.
  40. BCIS Audit Slide Deck. 2016.
  41. Dati di attività dei Laboratori di Emodinamica. 2016.
  42. Barbato E, Dudek D, Baumbach A, et al. Current trends in coronary interventions: an overview from the EAPCI registries. EuroIntervention. 2017; 13(Z): Z8–Z10.
  43. Desai NR, Bradley SM, Parzynski CS, et al. Appropriate Use Criteria for Coronary Revascularization and Trends in Utilization, Patient Selection, and Appropriateness of Percutaneous Coronary Intervention. JAMA. 2015; 314(19): 2045–2053.
  44. May AN, Kull A, Gunalingam B, et al. The uptake of coronary fractional flow reserve in Australia in the past decade. Med J Aust. 2016; 205(3): 127.
  45. Koo BK, Kang HJ, Youn TJ, et al. Physiologic assessment of jailed side branch lesions using fractional flow reserve. J Am Coll Cardiol. 2005; 46(4): 633–637.
  46. Koo BK, Park KW, Kang HJ, et al. Physiological evaluation of the provisional side-branch intervention strategy for bifurcation lesions using fractional flow reserve. Eur Heart J. 2008; 29(6): 726–732.
  47. Ahn JM, Park DW, Shin ES, et al. Fractional flow reserve and cardiac events in coronary artery disease: data from a prospective IRIS-FFR registry (interventional cardiology research incooperation society fractional flow reserve). Circulation. 2017; 135(23): 2241–2251.
  48. Lee JM, Koo BK, Shin ES, et al. Clinical implications of three-vessel fractional flow reserve measurement in patients with coronary artery disease. Eur Heart J. 2018; 39(11): 945–951.
  49. Chen SL, Zhang JJ, Han Y, et al. Double Kissing Crush Versus Provisional Stenting for Left Main Distal Bifurcation Lesions: DKCRUSH-V Randomized Trial. J Am Coll Cardiol. 2017; 70(21): 2605–2617.
  50. Li SJ, Ge Z, Kan J, et al. Cutoff value and long-term prediction of Clinical events by FFR measured immediately after implantation of a drug-eluting stent in patients with coronary artery disease: 1- to 3-year results from the DKCRUSH VII registry study. JACC Cardiovasc Interv. 2017; 10(10): 986–995.