European Heart Journal Advance Access originally published online on October 24, 2007
European Heart Journal 2007 28(23):2951; doi:10.1093/eurheartj/ehm462
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Recurrent angina and the problem of inadequate/inappropriate revascularization
U.O. Emodinamica
Dipartimento di Medicina Interna Cardiovascolare e Geriatrica
Azienda Ospedaliera Universitaria Senese
Policlinico "Le Scotte" viale Bracci 53100 Siena,
Italy
U.O. Emodinamica
Dipartimento di Medicina Interna
Cardiovascolare e Geriatrica
Azienda Ospedaliera Universitaria Senese
Policlinico "Le Scotte"
Viale Bracci 53100 Siena,
Italy
Recurrent or persistent angina following revascularization procedures, whether this is CABG and/or PCI, is a relatively frequent, and surely challenging, clinical event. In a recent issue, Abbate et al.1 provided an effective and complete review on this problem; however, we believe that one further comment should be made regarding the ‘coronary’ causes of this clinical condition.
The concept behind every revascularization procedure is that evidence of inducible ischaemia in the myocardial territory downstream to a functionally significant stenosis can be demonstrated. However, it has to be acknowledged that there are at least two limitations to the clinical application of this concept in the real world: first, the spatial resolution of non-invasive tests, particularly in the case of multivascular disease. Secondly, while being considered the gold standard, coronary angiography is far from being a perfect tool for the investigation of stenosis. Angiography systematically underestimates eccentric stenoses, and, most importantly, provides no information regarding the functional importance of a coronary lesion (i.e. the existence of dynamic component and/or the cumulative haemodynamic effect of multiple or long lesions). The systematic use of more sensitive and specific tools, such as intravascular ultrasound and, particularly, the study of fractional flow reserve, dramatically reduces the quote of patients who would otherwise be categorized in the group of those ‘with suspected ischaemia and no evidence of coronary artery disease at angiography’.2
From this perspective, until these techniques will be more systematically used, patients with recurrent angina will often happen to belong to one of two categories: (i) those who received treatment for lesions that were significant at angiography, but were not functionally significant (i.e. lesions with a fractional flow reserve >0.75) and (ii) patients who did not receive treatment for lesions that were functionally, but not angiographically, significant (i.e. fractional flow reserve <0.75). In the first group, the persistence of angina could be because of microvascular disease or other non-coronary causes as described by Abbate et al.1; in the latter, to the failure to treat a source of ischaemia (i.e. inappropriate revascularization). We have to admit that such ‘failures’ are not remote possibilities as much as a daily clinical problem for interventional cardiologists. Therefore, we feel that the study of fractional flow reserve should be encouraged when re-evaluating patients for recurrent angina (Table 3 of Abbate et al.).
In sum, we would like to suggest that among the coronary causes of recurrent angina (Table 2 of Abbate et al.), besides incomplete revascularization, physicians should also be aware (and beware) of inappropriate revascularization. Admittedly, this condition is often the result of our incapacity, given the current technologies (and the cost of more accurate technologies), to identify adequately the functional significance of eccentric or complex stenoses.
References
- Abbate A, Biondi-Zoccai GG, Agostoni P, Lipinski MJ, Vetrovec GW. Recurrent angina after coronary revascularization: a clinical challenge. Eur Heart J (2007) 28:1057–1065.
[Abstract/Free Full Text] - Bech GJ, De Bruyne B, Pijls NH, de Muinck ED, Hoorntje JC, Escaned J, Stella PR, Boersma E, Bartunek J, Koolen JJ, Wijns W. Fractional flow reserve to determine the appropriateness of angioplasty in moderate coronary stenosis: a randomized trial. Circulation (2001) 103:2928–2934.
[Abstract/Free Full Text]
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