Application of the DILEMMA score to improve lesion selection for invasive physiological assessment

Michael Michail, Hakim Moulay Dehbi, Nitesh Nerlekar, Justin E. Davies, Andrew S.P. Sharp, Suneel Talwar, James D. Cameron, Adam J. Brown, Dennis T. Wong, Anthony Mathur, Alun D. Hughes, Om Narayan

Research output: Contribution to journalArticleResearchpeer-review

1 Citation (Scopus)

Abstract

Objectives: We sought to assess the validity of the DILEMMA score against instantaneous wave-free ratio (iFR) and evaluate its utility in rationalizing the number of patients referred for invasive physiological assessment. Background: The DILEMMA score is a validated angiographic scoring tool incorporating minimal lumen diameter, lesion length and subtended myocardial area that has been shown to predict the functional significance of lesions as assessed by fractional flow reserve (FFR). Methods: Patients in the DEFINE-FLAIR study who had coronary stenosis of intermediate severity were randomized to either FFR or iFR. DILEMMA score was calculated retrospectively on a subset of this cohort by operators blinded to FFR or iFR values. Results: Three hundred and forty-six lesions (181 assessed by FFR; 165 by iFR) from 259 patients (mean age 66.0 years, 79% male) were included. A DILEMMA score ≤ 2 had a negative predictive value of 96.3% and 95.7% for identifying lesions with FFR >0.80 and iFR >0.89, respectively. A DILEMMA score ≥ 9 had a positive predictive value of 88.9% and 100% for identifying lesions with FFR ≤0.80 and iFR ≤0.89, respectively. The receiver operating characteristic area under the curve values for DILEMMA score to predict FFR ≤0.80 and iFR ≤0.89 were 0.83 (95% CI 0.77–0.90) and 0.82 (0.75–0.89) respectively. A DILEMMA score ≤ 2 or ≥9 occurred in 172 of the 346 lesions (49.7%). Conclusions: Using DILEMMA score in patients with coronary stenosis of intermediate severity may reduce the need for pressure wire use, offering potential cost-savings and minimizing the risks associated with invasive physiological lesion assessment.

Original languageEnglish
Number of pages8
JournalCatheterization and Cardiovascular Interventions
DOIs
Publication statusAccepted/In press - 1 Jan 2019
Externally publishedYes

Keywords

  • angiography, coronary
  • coronary artery disease
  • coronary blood flow/physiology/microvascular function
  • fractional flow reserve
  • percutaneous coronary intervention

Cite this

@article{609c1536f3af44f59b98814e586b7a09,
title = "Application of the DILEMMA score to improve lesion selection for invasive physiological assessment",
abstract = "Objectives: We sought to assess the validity of the DILEMMA score against instantaneous wave-free ratio (iFR) and evaluate its utility in rationalizing the number of patients referred for invasive physiological assessment. Background: The DILEMMA score is a validated angiographic scoring tool incorporating minimal lumen diameter, lesion length and subtended myocardial area that has been shown to predict the functional significance of lesions as assessed by fractional flow reserve (FFR). Methods: Patients in the DEFINE-FLAIR study who had coronary stenosis of intermediate severity were randomized to either FFR or iFR. DILEMMA score was calculated retrospectively on a subset of this cohort by operators blinded to FFR or iFR values. Results: Three hundred and forty-six lesions (181 assessed by FFR; 165 by iFR) from 259 patients (mean age 66.0 years, 79{\%} male) were included. A DILEMMA score ≤ 2 had a negative predictive value of 96.3{\%} and 95.7{\%} for identifying lesions with FFR >0.80 and iFR >0.89, respectively. A DILEMMA score ≥ 9 had a positive predictive value of 88.9{\%} and 100{\%} for identifying lesions with FFR ≤0.80 and iFR ≤0.89, respectively. The receiver operating characteristic area under the curve values for DILEMMA score to predict FFR ≤0.80 and iFR ≤0.89 were 0.83 (95{\%} CI 0.77–0.90) and 0.82 (0.75–0.89) respectively. A DILEMMA score ≤ 2 or ≥9 occurred in 172 of the 346 lesions (49.7{\%}). Conclusions: Using DILEMMA score in patients with coronary stenosis of intermediate severity may reduce the need for pressure wire use, offering potential cost-savings and minimizing the risks associated with invasive physiological lesion assessment.",
keywords = "angiography, coronary, coronary artery disease, coronary blood flow/physiology/microvascular function, fractional flow reserve, percutaneous coronary intervention",
author = "Michael Michail and Dehbi, {Hakim Moulay} and Nitesh Nerlekar and Davies, {Justin E.} and Sharp, {Andrew S.P.} and Suneel Talwar and Cameron, {James D.} and Brown, {Adam J.} and Wong, {Dennis T.} and Anthony Mathur and Hughes, {Alun D.} and Om Narayan",
year = "2019",
month = "1",
day = "1",
doi = "10.1002/ccd.28054",
language = "English",
journal = "Catheterization and Cardiovascular Interventions",
issn = "1522-1946",
publisher = "Wiley-Blackwell",

}

Application of the DILEMMA score to improve lesion selection for invasive physiological assessment. / Michail, Michael; Dehbi, Hakim Moulay; Nerlekar, Nitesh; Davies, Justin E.; Sharp, Andrew S.P.; Talwar, Suneel; Cameron, James D.; Brown, Adam J.; Wong, Dennis T.; Mathur, Anthony; Hughes, Alun D.; Narayan, Om.

In: Catheterization and Cardiovascular Interventions, 01.01.2019.

Research output: Contribution to journalArticleResearchpeer-review

TY - JOUR

T1 - Application of the DILEMMA score to improve lesion selection for invasive physiological assessment

AU - Michail, Michael

AU - Dehbi, Hakim Moulay

AU - Nerlekar, Nitesh

AU - Davies, Justin E.

AU - Sharp, Andrew S.P.

AU - Talwar, Suneel

AU - Cameron, James D.

AU - Brown, Adam J.

AU - Wong, Dennis T.

AU - Mathur, Anthony

AU - Hughes, Alun D.

AU - Narayan, Om

PY - 2019/1/1

Y1 - 2019/1/1

N2 - Objectives: We sought to assess the validity of the DILEMMA score against instantaneous wave-free ratio (iFR) and evaluate its utility in rationalizing the number of patients referred for invasive physiological assessment. Background: The DILEMMA score is a validated angiographic scoring tool incorporating minimal lumen diameter, lesion length and subtended myocardial area that has been shown to predict the functional significance of lesions as assessed by fractional flow reserve (FFR). Methods: Patients in the DEFINE-FLAIR study who had coronary stenosis of intermediate severity were randomized to either FFR or iFR. DILEMMA score was calculated retrospectively on a subset of this cohort by operators blinded to FFR or iFR values. Results: Three hundred and forty-six lesions (181 assessed by FFR; 165 by iFR) from 259 patients (mean age 66.0 years, 79% male) were included. A DILEMMA score ≤ 2 had a negative predictive value of 96.3% and 95.7% for identifying lesions with FFR >0.80 and iFR >0.89, respectively. A DILEMMA score ≥ 9 had a positive predictive value of 88.9% and 100% for identifying lesions with FFR ≤0.80 and iFR ≤0.89, respectively. The receiver operating characteristic area under the curve values for DILEMMA score to predict FFR ≤0.80 and iFR ≤0.89 were 0.83 (95% CI 0.77–0.90) and 0.82 (0.75–0.89) respectively. A DILEMMA score ≤ 2 or ≥9 occurred in 172 of the 346 lesions (49.7%). Conclusions: Using DILEMMA score in patients with coronary stenosis of intermediate severity may reduce the need for pressure wire use, offering potential cost-savings and minimizing the risks associated with invasive physiological lesion assessment.

AB - Objectives: We sought to assess the validity of the DILEMMA score against instantaneous wave-free ratio (iFR) and evaluate its utility in rationalizing the number of patients referred for invasive physiological assessment. Background: The DILEMMA score is a validated angiographic scoring tool incorporating minimal lumen diameter, lesion length and subtended myocardial area that has been shown to predict the functional significance of lesions as assessed by fractional flow reserve (FFR). Methods: Patients in the DEFINE-FLAIR study who had coronary stenosis of intermediate severity were randomized to either FFR or iFR. DILEMMA score was calculated retrospectively on a subset of this cohort by operators blinded to FFR or iFR values. Results: Three hundred and forty-six lesions (181 assessed by FFR; 165 by iFR) from 259 patients (mean age 66.0 years, 79% male) were included. A DILEMMA score ≤ 2 had a negative predictive value of 96.3% and 95.7% for identifying lesions with FFR >0.80 and iFR >0.89, respectively. A DILEMMA score ≥ 9 had a positive predictive value of 88.9% and 100% for identifying lesions with FFR ≤0.80 and iFR ≤0.89, respectively. The receiver operating characteristic area under the curve values for DILEMMA score to predict FFR ≤0.80 and iFR ≤0.89 were 0.83 (95% CI 0.77–0.90) and 0.82 (0.75–0.89) respectively. A DILEMMA score ≤ 2 or ≥9 occurred in 172 of the 346 lesions (49.7%). Conclusions: Using DILEMMA score in patients with coronary stenosis of intermediate severity may reduce the need for pressure wire use, offering potential cost-savings and minimizing the risks associated with invasive physiological lesion assessment.

KW - angiography, coronary

KW - coronary artery disease

KW - coronary blood flow/physiology/microvascular function

KW - fractional flow reserve

KW - percutaneous coronary intervention

UR - http://www.scopus.com/inward/record.url?scp=85059476180&partnerID=8YFLogxK

U2 - 10.1002/ccd.28054

DO - 10.1002/ccd.28054

M3 - Article

JO - Catheterization and Cardiovascular Interventions

JF - Catheterization and Cardiovascular Interventions

SN - 1522-1946

ER -