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성균관대학교 의과대학, 삼성서울병원

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JACC-Cardiovasc. Interv., Mar 25 2024, 17 (6) S1936-8798(24)00010-4 | https://doi.org/10.1016/j.jcin.2024.01.008 Prognostic Implications of Microvascular Resistance Reserve in Symptomatic Patients With Intermediate Coronary Stenosis

Seung Hun Lee MD, PhD ^a,∗, Ki Hong Choi MD, PhD ^b,∗, David Hong MD^b, Doosup Shin MD^c, Hyun Sung Joh MD ^d, Hyun Kuk Kim MD, PhD^e, Taek Kyu Park MD, PhD ^b, Jeong Hoon Yang MD, PhD^b, Young Bin Song MD, PhD^b, Joo-Yong Hahn MD, PhD ^b, Seung-Hyuk Choi MD, PhD ^b, Hyeon-Cheol Gwon MD, PhD ^b, Joo Myung Lee MD, MPH, PhD^b

^aDivision of Cardiology, Department of Internal Medicine, Heart Center, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, South Korea

^bHeart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea

^cDivision of Cardiology, Department of Internal Medicine, St. Francis Hospital, Roslyn, New York, USA

^dSeoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, South Korea

^eDepartment of Internal Medicine and Cardiovascular Center, Chosun University Hospital, University of Chosun College of Medicine, Gwangju, South Korea

^∗Drs S.H. Lee and K.H. Choi contributed equally to this work as first authors.

Address for correspondence: Dr Joo Myung Lee

Abstract

Background: Microvascular resistance reserve (MRR) is a novel index reflecting coronary microcirculatory function, irrespective of epicardial coronary artery stenosis. There is limited evidence regarding whether MRR can be an independent prognostic tool in patients with stable ischemic heart disease (IHD).

Objectives: The aim of this study was to evaluate clinical outcomes according to MRR in patients with stable IHD accompanied with or without significant epicardial coronary artery stenosis.

Methods: The present study included 547 consecutive patients undergoing systematic echocardiographic and invasive physiological assessment for suspected stable IHD. Significant epicardial coronary artery stenosis was defined as fractional flow reserve (FFR) ≤0.80. Coronary microvascular dysfunction (CMD) was defined as MRR ≤3.0. The primary outcome was major adverse cardiovascular events (MACE), a composite of cardiovascular death, myocardial infarction, repeat revascularization, and admission for heart failure.

Results: Among the study group, 172 patients (31.4%) had FFR ≤0.80, and 200 patients (36.6%) had CMD defined by MRR ≤3.0. MRR showed no significant correlation with FFR (R = -0.031; P = 0.469), but it was significantly correlated with the index of microcirculatory resistance (R = -0.353; P < 0.001), N-terminal pro-B-type natriuretic peptide (R = -0.296; P < 0.001), left ventricular filling pressure (E/e' ratio) (R = -0.224; P < 0.001), and diastolic dysfunction grade (P < 0.001). During a median follow-up period of 3.3 years (Q1-Q3: 2.0-4.5 years), MRR was significantly associated with MACE risk (HR: 1.23 per 1-U decrease; 95% CI: 1.12-1.36; P < 0.001). CMD defined by MRR ≤3.0 was associated with an increased MACE risk for both FFR >0.80 (41.0% vs 26.0%; adjusted HR: 1.59; 95% CI: 1.07-2.35; P = 0.021) and FFR ≤0.80 (34.7% vs 14.8%; adjusted HR: 2.32; 95% CI: 1.12-4.82; P = 0.024).

Conclusions: Decreased MRR was associated with the presence of cardiac diastolic dysfunction as well as increased left ventricular filling pressure. The presence of CMD defined by MRR was independently associated with the risk for a composite of cardiovascular death, myocardial infarction, repeat revascularization, and admission for heart failure in patients with stable IHD, irrespective of significant epicardial coronary artery stenosis. (Prognostic Impact of Cardiac Diastolic Function and Coronary Microvascular Function [DIAST-CMD]; NCT05058833).

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