Coronary physiology indicators for assessing the stenosis functional significance in non-infarct-related arteries in patients with ST-segment elevation myocardial infarction

Aim. To study the informative value of invasive coronary physiology indices (fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR)) and to evaluate the safety of papaverine as a hyperemic agent to determine the hemodyna­mic significance of stenoses in non-infarction-related arteries (non-IRA) in patients with ST-seg­ment elevation myocardial infarction (STEMI) during the index procedure after primary percutaneous coronary intervention (PPCI).

Material and methods. This single-center prospective study included 32 patients over 18 years of age with STEMI and 50-85% stenosis in 38 non-IRA. After PPCI of the infarction-related artery, iFR, contrast-enhanced FFR, and (if there were no contraindications) FFR with papaverine were measured. Rehospitalization was performed 30-45 days later with follow-up coronary angiography and reassessment of physiological parameters. Statistical analysis included Spearman’s rank order coefficient (SRCC), intraclass correlation (ICC), Cohen’s kappa coefficient, Bland-Altman analysis, and McNemar’s test (α=0,05).

Results. Analysis of 38 non-IRAs (36 FFR tests with papaverine) demonstrated high reproducibility as follows: iFR — ρ=0,94 (p<0,001), ICC=0,95 (95% confidence interval (CI) 0,91-0,97), κ=0,73; clinical decision variance — 13,2%, without systematic bias (p=0,655); FFR — ρ=0,91 (p<0,001), ICC=0,92 (95% CI 0,85-0,96), κ=0,77; variance — 11,1% (p=1,000). All decision changes were noted in the range of borderline values (iFR 0,85-0,93; FFR 0,78-0,83). When measu­ring FFR, contraindications to papaverine administration were strictly taken into account, including hypotension (≤110/70 mm Hg) and prolonged QT (≥450 ms). Therefore, in 2 of 32 patients, only iFR was determined in 2 non-IRAs. In 30 patients, after papaverine administration to determine FFR in 36 non-IRAs, no compli­cations were observed.

Conclusion. FFR with papaverine and iFR can be safely and informatively used to assess the hemodynamic significance of non-IRA stenoses in hemodynamically stable patients during the first 24 hours after STEMI. The high stability of these parameters during repeated measurements confirms their suitability for dynamic monitoring. Borderline values require careful interpretation and possible use of additional ischemia verification methods.

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