Role of incremental doses of intracoronary adenosine for fractional flow reserve assessment

Background: The achievement of maximal vasodilatation of the coronary microvessels is mandatory for the accurate determination of fractional flow reserve (FFR); the optimal dosing to achieve maximal vasodilation is unclear. This study was designed to address the hypothesis that incremental doses of intracoronary adenosine are necessary to ensure complete vasodilatation of the coronary microcirculation and accurate assessment of FFR. We also examined the relationship between FFR and coronary artery disease risk factors. Methods: A total of 191 patients (215 vessels) with intermediate coronary lesions were examined. FFR was measured during cardiac catheterization with a pressure monitoring wire. Incremental doses of intracoronary adenosine (12-42 μg, left coronary artery; 12-48 μg, right coronary artery) were administered. Results: Diabetes mellitus was present in 23% of patients, hypertension was present in 65% of patients, and prior myocardial infarction had occurred in 25% of patients. The average percent stenosis in vessels was 57% ± 15%. Vessels were subdivided on the basis of initial FFR (group 1, <0.75; group II, 0.75-0.79; group III, 0.80-0.89; group IV, ≥0.9). Five of the 24 (21%) vessels with an initial FFR in the 0.75 to 0.80 range had a subsequent FFR of <0.75. There was no difference in FFR or doses of adenosine in the patients with coronary artery disease risk factors. The average adenosine dose given at the achievement of minimal FFR was 26 μg in the right coronary artery (RCA) and 34 μg in the left coronary artery (LCA). The average maximum dose of intracoronary adenosine administered was 29 μg for the RCA and 37 μg for the LCA. The maximum dose of adenosine ever required to achieve minimum FFR was 42 μg in both the LCA and RCA. Conclusion: This study suggests that a single high dose of 42 μg of intracoronary adenosine for both the RCA and LCA is sufficient to achieve maximum hyperemia and accurate FFR in most patients, independent of risk factors. Alternatively, when a lower initial dose is administered and FFR is in the 0.75 to 0.90 range, incremental doses of adenosine should be administered to ensure maximal hyperemia.