| Background:Fractional flow reserve(FFR)is the gold standard to identify coronary lesions that are responsible for significant ischemia,and the premise of propriate FFR measurement is to achieve the maximal hyperemia by drugs.At present,the regular application method of inducing hyperemia is intravenous ATP or intracoronary sodium nitroprusside,however,sodium nitroprusside has a great influence on blood pressure,and ATP requires repuncture of the major vein,which significantly increases the operation time and limits clinical application in part.A large number of previous studies on the treatment of No-reflow phenomenon in the coronary artery have shown that intracoronary diltiazem can significantly dilate the coronary artery,improve microcirculation and be safe for patients,however,whether it can be applied for FFR is unclear.Objective:In this study,we compared the effect of intracoronary diltiazem with intravenous ATP or intracoronary sodium nitroprusside on FFR,to explore the safety and feasibility of diltiazem in FFR,and to explore the best dosage.Methods:Thirty-seven coronary arteries with stenosis between 50%and 90% in 32 patients were selected as the study objects,each lesion was self controlled,and drugs were successively applied for FFR in group A,group B,group C and group D according to the fixed order,each group was administered at least 5 minutes apart,and the next group of drugs was used after the mean arterial pressure,FFR values and heart rate were completely restored to the baseline level.Among them,the drug administration schemes of group A,group B and group C were as follows:diltiazem 800?g,sodium nitroprusside 150?g and diltiazem 1000?g were shot into the coronary arteries in each group,after administration,6ml of normal saline was injected into the coronary artery quickly to ensure that the drug could be in the coronary artery completely;in group D,ATP(167?g/(kg · min))was pumped into the median cubital vein.The drug effect-acting period,maintenance time,mean arterial pressure,heart rate,heart rhythm,effectiveminimum FFR and intraoperative drug-related adverse reactions were recorded.Results:1.The effective lowest FFR value: the lowest FFR value of group A,B,C and D were(0.86 ± 0.06),(0.81 ± 0.08),(0.81 ± 0.10)and(0.82 ± 0.09),respectively,the difference among the four groups was statistically significant(P<0.05);pairwise comparison shows the lowest FFR value of group A was higher than that of group B,group C and group D,and the difference was statistically significant(P<0.008),However,there was no statistically significant difference in the lowest FFR value between group B,group C and group D(P>0.008).2.Drug effect-acting period: drug effect-acting period in group A,group B,group C and group D were(6.2±0.5)s,(6.1±0.7)s,(6.0±0.6)s and(36.3±1.6)s,respectively,the difference among the four groups was statistically significant(P<0.05),pairwise comparison shows group D was longer than group A,group B and group C,while the difference among group A,group B and group C was not statistically significant(P>0.008).3.Duration of drug action: the duration of drug action in group A,group B and group C was(83.2±14.3)s,(88.6±14.8)s,(96.8±19.6)s,respectively,the difference among the three groups was statistically significant(P<0.05),pairwise comparison shows the duration of drug action in group C was longer than that in group A and group B(P<0.008),there was no significant difference between group A and group B(P>0.008).4.Effects of drugs on mean arterial pressure and heart rate: There was no significant difference in the mean arterial pressure before administration among the four groups(P>0.05).The difference of mean arterial pressure at baseline and after administration in different drug groups was statistically significant(P<0.05),after administration,the mean arterial pressure of each group decreased in different degrees.the difference of the mean arterial pressure variety at baseline and after administration was statistically significant among the four groups(P<0.05),pairwise comparison shows that both group B and group D were greater than group A and group C,and the difference was statistically significant(P<0.008),there was no significant difference between group B and group D(P>0.008).There was no significant difference in heart rate among the four groups before administration(P>0.05).The difference of heart rate at baseline and after administration in different drug groups was statistically significant(P<0.05),the heart rate of group A and group C decreased after administration,while the heart rate of group B and group D increased after administration.the absolute value of heart rate variety at baseline and after administration was statistically significant among the four groups(P<0.05),pairwise comparison shows the absolute value of heart rate in group D was higher than that in group A,group B and group C,and the difference was statistically significant(P<0.008),There was no significant difference between group B and group C(P>0.008).5.The heart rate changes of diltiazem 800?g were(3.6±0.9)bpm(left coronary artery route administration)and(6.0±5.9)bpm(right coronary artery route administration)respectively after administration through left coronary artery and right coronary artery,there was no significant difference in heart rate changes(P>0.05);The heart rate changes of diltiazem 1000?g were(6.6±1.3)bpm and(8.1±2.1)bpm respectively after administration through the left coronary artery and right coronary artery,the difference of heart rate change value was statistically significant(P<0.05),during the operation,the heart rate of the right coronary artery using diltiazem 1000?g decreased significantly compared with the left coronary artery.6.Adverse drug reactions during operation: In ATP group,there were 15 cases with adverse reactions:7 cases with chest distress,5 cases with dyspnea,1 case with palpitation and 1 case with facial flushing,One patient rapidly developed a 4:1atrioventricular block after intraoperative pumping of ATP,the ventricular rate dropped to 20 bpm,the blood pressure dropped to 65/38 mmhg,the drug pumping was stopped immediately,and the vital signs recovered after the rescue with atropine and other drugs.Because the FFR measurement could not be completed with ATP,the patient was finally removed from the study.One case of sudden drop of heart rate occurred in 800?g diltiazem group: after 800?g diltiazem was applied in the right coronary artery of the patient,the ventricular rate dropped from 70 bpm to 50 bpm,and the heart rhythm did not change(sinus rhythm at baseline and after administration).After several seconds,the heart rate rose rapidly and stabilized at 72-76 times/min(without special treatment),during which the patient did not complain of special discomfort.Conclusion:Compared with the currently standard regimen(intracoronary sodium nitroprusside and intravenous ATP)for inducing maximal hyperemia,the plan of intracoronary diltiazem at a dose of 1000?g is safe and feasible,and the FFR value obtained is accurate and credible,at the same time,the diltiazem,which is expected to be a new substitute for FFR in patients with single borderline lesion in the same coronary artery,takes effect quickly,lasts for a perfect length of time and has little effect on blood pressure and heart rate. |
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