Novel Contrast-Derived Indices of Coronary Microvascular Function: Potential Clinical and Cost Benefits.

Robert A Sykes, Richard I S Good, Arvind Sood, Angie Ghattas, Keith E Robertson, C Aengus Murphy, Andrew P Apps, J Paul Rocchiccioli, Peter J McCartney, Richard A Brogan, Andy Jong, Anna L Kamdar, Conor Bradley, David Carrick, Ross J McGeoch, Damien G Collison, Daniel T Y Ang, Alex McConnachie, Colin Berry, Francis R Joshi, Hany Eteiba, Brian O'Rourke, M Mitchell Lindsay, Aadil Shaukat, David A MacDougall

Journal: Circulation. Cardiovascular interventions 2025;18(6):e015058

PMID: 40308206

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Abstract

BACKGROUND

Intravenous adenosine induces stable myocardial hyperemia for coronary microvascular function testing. Iodinated radiographic contrast media induce transient, submaximal hyperemia. We assessed the feasibility, diagnostic value, and potential cost-effectiveness of contrast-derived indices of microvascular function.

METHODS

Coronary flow reserve, index of microvascular resistance, and microvascular resistance reserve were assessed using a diagnostic guidewire. Intracoronary bolus thermodilution injections were performed at rest, immediately after an 8-mL bolus of iohexol, repeated after a second 8-mL bolus, and during intravenous adenosine infusion. Receiver operating characteristic analyses assessed the discriminatory ability of the contrast-derived indices (contrast-derived coronary flow reserve, contrast-derived index of microcirculatory resistance, contrast-derived microvascular resistance reserve) to detect abnormal adenosine-derived indices (coronary flow reserve <2.0, index of microvascular resistance ≥25, and microvascular resistance reserve <2.1).

RESULTS

Among 106 coronary arteries from 93 patients (median age 63 years; 62% women; 13% with diabetes), 88% of assessments were undertaken in the left anterior descending artery. Median fractional flow reserve was 0.88 (interquartile range, 0.85-0.92). Contrast-derived coronary flow reserve <2.0 (area under the curve 0.81; sensitivity 67%, specificity 80%, positive predictive value 40%, negative predictive value 92%), contrast-derived index of microcirculatory resistance >47 (area under the curve 0.82; 80%, 79%, 60%, 91%), and contrast-derived microvascular resistance reserve <1.9 (area under the curve 0.82; 67%, 89%, 35%, 97%) were best for predicting their adenosine-derived counterpart indices. There was good correlation on repeatability testing from the second contrast bolus. A hybrid approach reduced adenosine use by 40%, saving $30 800 (USA) or £8000 (UK) per 1000 vessels assessed.

CONCLUSIONS

Contrast-derived indices have high specificity and negative predictive value, enabling rapid exclusion of microvascular dysfunction. This method is feasible, clinically useful and cost-saving compared with routine adenosine testing.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT04674449.

Address: West of Scotland Regional Heart and Lung Centre, Golden Jubilee University National Hospital, Clydebank, United Kingdom (D.T.Y.A., D.G.C., R.A.S., C. Bradley, R.A.B., P.J.M.C., J.P.R., A.P.A., K.E.R., A. Shaukat, A.G., F.R.J., R.I.S.G., H.E., M.M.L., C. Berry).; British Heart Foundation Glasgow Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health, University of Glasgow, United Kingdom (D.T.Y.A., R.A.S., A.L.K., R.I.S.G., C. Berry).; University Hospital Hairmyres, Lanarkshire, United Kingdom (D.T.Y.A., R.J.M.G., D. Carrick, A.J., D.A.M.D., C.A.M., A. Sood, B.O.R.).; West of Scotland Regional Heart and Lung Centre, Golden Jubilee University National Hospital, Clydebank, United Kingdom (D.T.Y.A., D.G.C., R.A.S., C. Bradley, R.A.B., P.J.M.C., J.P.R., A.P.A., K.E.R., A. Shaukat, A.G., F.R.J., R.I.S.G., H.E., M.M.L., C. Berry).; University Hospital Hairmyres, Lanarkshire, United Kingdom (D.T.Y.A., R.J.M.G., D. Carrick, A.J., D.A.M.D., C.A.M., A. Sood, B.O.R.).; West of Scotland Regional Heart and Lung Centre, Golden Jubilee University National Hospital, Clydebank, United Kingdom (D.T.Y.A., D.G.C., R.A.S., C. Bradley, R.A.B., P.J.M.C., J.P.R., A.P.A., K.E.R., A. Shaukat, A.G., F.R.J., R.I.S.G., H.E., M.M.L., C. Berry).; British Heart Foundation Glasgow Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health, University of Glasgow, United Kingdom (D.T.Y.A., R.A.S., A.L.K., R.I.S.G., C. Berry).; British Heart Foundation Glasgow Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health, University of Glasgow, United Kingdom (D.T.Y.A., R.A.S., A.L.K., R.I.S.G., C. Berry).; Robertson Centre for Biostatistics, School of Health and Wellbeing, University of Glasgow, United Kingdom (A.M.C.).

DOI: 10.1161/CIRCINTERVENTIONS.124.015058

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MeSH Terms: Aged, Female, Humans, Male, Middle Aged, Adenosine, Cardiac Catheterization, Contrast Media, Coronary Angiography, Coronary Artery Disease, Coronary Circulation, Coronary Vessels, Cost-Benefit Analysis, Feasibility Studies, Fractional Flow Reserve, Myocardial, Hyperemia, Iohexol, Microcirculation, Microvessels, Myocardial Perfusion Imaging, Predictive Value of Tests, Prospective Studies, Reproducibility of Results, Thermodilution, Vascular Resistance, Vasodilator Agents