State-of-the-Art Paper
Anatomic Versus Physiologic Assessment of Coronary Artery Disease: Role of Coronary Flow Reserve, Fractional Flow Reserve, and Positron Emission Tomography Imaging in Revascularization Decision-Making

https://doi.org/10.1016/j.jacc.2013.07.076Get rights and content
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Angiographic severity of coronary artery stenosis has historically been the primary guide to revascularization or medical management of coronary artery disease. However, physiologic severity defined by coronary pressure and/or flow has resurged into clinical prominence as a potential, fundamental change from anatomically to physiologically guided management. This review addresses clinical coronary physiology—pressure and flow—as clinical tools for treating patients. We clarify the basic concepts that hold true for whatever technology measures coronary physiology directly and reliably, here focusing on positron emission tomography and its interplay with intracoronary measurements.

Key Words

coronary flow
coronary physiology
ischemia
PET perfusion imaging
revascularization

Abbreviations and Acronyms

CAD
coronary artery disease
CFR
coronary flow reserve
ECG
electrocardiographic/electrocardiography
FFR
fractional flow reserve
PCI
percutaneous intervention
PET
positron emission tomography
MI
myocardial infarction
SPECT
single-photon emission computed tomography

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Dr. Gould received internal funding from the Weatherhead PET Center for Preventing and Reversing Atherosclerosis; the 510(k) applicant for cfrQuant approved by the FDA; and he has arranged that all his royalties permanently go to a University of Texas scholarship fund. UT has a commercial nonexclusive agreement with Positron Corporation to distribute and market cfrQuant in exchange for royalties; however, Dr. Gould retains the ability to distribute cost-free versions to selected collaborators for research. Additionally, Dr. Gould has signed a nonfinancial, mutual nondisclosure agreement with Volcano Corporation (maker of FFR pressure wires) to discuss coronary physiology projects. Dr. Johnson has received internal funding from the Weatherhead PET Center for Preventing and Reversing Atherosclerosis; and has signed a nonfinancial, mutual nondisclosure agreement with Volcano Corporation (maker of FFR pressure wires) to discuss coronary physiology projects. Dr. Bateman has received research grants from Bracco, Philips, GE, SpectrumDynamics, and Astellas; is on advisory boards of Astellas, GE, SpectrumDynamics; receives royalties from ImagenPro/MD/Q; and has ownership of CVIT. Dr. Beanlands is a career investigator supported by the Heart and Stroke Foundation of Ontario; is a tier 1 University of Ottawa Chair in Cardiovascular Research; consults with Jubilant DRAXImage and Lantheus; has received grant funding from a government/industry program (partners: GE Healthcare, Nordion, Lantheus Medical Imaging, DRAXImage); consults for Lantheus Medical Imaging and has received grant funding from Genentech; and has received more than $10,000 for research grants. Dr. Bengel has received research grants from GE Healthcare, Bracco Diagnostics, and Lantheus Medical Imaging; and speaker honoraria from Siemens Medical Solutions. Dr. Cerqueira consults for Astellas Pharma US, Cardinal Health, CoreLab Partners, GE Healthcare, and Lantheus Medical Imaging; is on the speakers bureau for Astellas Pharma US and GE Healthcare; and has received research funding from Perceptive Informatics. Dr. Chow is a consultant for GE Healthcare and TeraRecon. Dr. Di Carli receives research grant support from Toshiba Medical Systems and Gilead. Dr. Dorbala has received research grants from Astellas Pharma and stock holdings from General Electric. Dr. Gewirtz has received financial support from the Wild Family Foundation and FluoroPharma, Inc. Dr. Gropler consults for Molecular Insight Pharmaceuticals and Lantheus Medical Imaging; and has received NIH research funding. Dr. Kaufmann is supported by a fund of the Swiss National Science Foundation and the Zurich Center for Integrative Human Physiology, University of Zurich, Zurich, Switzerland. University Hospital Zurich holds a research grant with GE Healthcare. Dr. Knuuti is supported by Academy of Finland Centre of Excellence in Molecular Imaging in Cardiovascular and Metabolic Research, Helsinki, Finland; has received grant support from Gilead Inc.; and is a consultant to Lantheus Inc. Dr. Merhige is the medical director of and owns stock in Positron Corporation. Dr. Ruddy has received grant support and honoraria from GE Healthcare and MDS Nordion. Dr. Schwaiger has received research grants from Siemens and Lantheus. Dr. Sdringola has received internal funding from the Weatherhead PET Center for Preventing and Reversing Atherosclerosis. Dr. Williams consults and speaks for Astellas Healthcare, Inc. Dr. Gordon is a consultant for Bracco Diagnostics. Dr. Dilsizian is a consultant for and has received research funding from Molecular Insight Pharmaceuticals. Dr. Narula has received research grants and honoraria from GE Healthcare and Philips Healthcare. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. William E. Boden, MD, acted as Guest Editor for this article.