It is not only the path that you choose to revascularize, that is, to restore blood and oxygen to the heart. The team can choose whether to focus on the traditional surgical route with the by-pass or proceed with an angioplasty, with the balloon that dilates the vessel and if necessary the stent, the mesh that keeps it open, or even focus on drugs. But it is increasingly important to ensure that the choice of treatment or not is targeted on the individual case, and coronary angiography (the examination that allows you to “visualize” the coronary tree) may not be sufficient, since the interpretation depends by the operator.
In some cases, when there is no stenosis greater than 80% or if the narrowing is minimal, it takes means to choose whether to proceed with the treatment when the coronary arteries are partially obstructed or in case of alterations in the microcirculation, or small vessels that run inside the heart tissue.
Analyze the lesion
“In the case of intermediate stenosis we must demonstrate that this lesion significantly reduces the flow, otherwise the intervention, whatever it is, has no meaning – he explains. Giovanni Espositopresident GISE – Italian Society of Interventional Cardiology -. In case of intermediate coronary stenosis, the measurement of the pressure upstream and downstream of the obstruction, through the FFR index, allows to obtain a numerical parameter. If you go below a certain value, you need to revascularize the patient because if you don’t proceed with this approach there will be a very high probability of major cardiovascular events. Thanks to this parameter, many strictures are reclassified, whether significant or not: we therefore have an appropriateness index that is currently used on average only in about 10% of cases “.
Survey methods
Not enough: there are also other methodologies, such as IMR, which also allow to consider the vessels inside the heart, the so-called microcirculation, which can indicate alterations at this level in case of chest pain that cannot be explained by significant obstructions of the coronary arteries. Thanks to these systems, according to GISE data, savings of over 37 million euros have been obtained in three years, favoring the appropriateness of treatments.
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More and more precise results
In short: the level of precision with which to select candidates for coronary angioplasty can be increased by resorting to the measurement of some physiological indices, recommended by the international guidelines on myocardial revascularization. The method is called fractional flow reserve (FFR or iFR), which can be performed, simultaneously with coronary angiography, by inserting an intracoronary pressure guide. The FFR / iFR / IMR allow to estimate the ability of the lesion to induce myocardial ischemia even in doubtful situations and in the presence of multivessel disease as well as to measure the dysfunction of the microcirculation.
An issue of the magazine is dedicated to the topic Italian Health Policy Brief (IHPB). FFR, in particular, has been included in the European myocardial revascularization guidelines with the highest level of recommendation and evidence. Studies show that FFR optimizes the assessment of lesion significance and, therefore, subsequent clinical decisions, showing reclassification rates from 26% to 47%. According to GISE estimates, FFR-guided assessment allows treating fewer vessels in a high percentage of patients and avoids angioplasty treatment altogether in 12% of patients.
Photographing the risk
“A revascularization guided by physiological indices guarantees a better clinical outcome, reduces the number of subsequent revascularizations, allows the identification of those high-risk clinical scenarios, called coronary microcirculation dysfunction (CMD), characterized by the absence of stenosis even in the presence of symptoms anginosa – confirms Ciro Indolfi, President SIC – Italian Society of Cardiologythe Scientific Society which together with GISE works on the implementation of technical-scientific innovations in accordance with the most recent guidelines “.” The management of patients in the field of cardiovascular diseases – underlines Enrico CoscioniPresident AGENAS – it is still too heterogeneous despite the technological innovation and clinical knowledge at our disposal. Today the conditions exist for a paradigm shift in terms of care, which can lead to the revision of some health policies and the adoption of diagnostic and therapeutic strategies, capable of guaranteeing the sustainability and quality of patient care “.
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