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A: IC and IV adenosine induce equivalent hyperemia. There have been a couple of studies suggesting higher FFRs with IV than IC adenosine, but the differences were very small.14 In general, and in my lab, I recommend IV adenosine at 140mcg/kg/min for several reasons. It is weight-based. It is hands-free, i.e., the operator does not need to switch stop cocks and flush. It measures FFR at a steady state. IV adenosine is the standard everywhere in the world and was used by the developers of the technique, Drs. Pijls and DeBruyne. Central venous infusion is optimal, but a large peripheral arm vein (not hand vein) is adequate.7

It is curious that some FFR operators want to use very high IC bolus doses of adenosine (100, 200mcg etc). It seems to me that those who insist on using multiple higher doses when the FFR is 0.84 and unchanging are non-believers who want to treat the stenosis despite the non-ischemic value and keep raising the dose in hopes of lowering the FFR. The same might be said for IV adenosine at 170mcg/min/kg, which does not produce lower FFRs, but more side effects.

Q: I have not seen Lexiscan (regadenoson) in a comparative trial with adenosine. Do you have any experience with this drug in assessing FFR?

A: I have not seen the results of the ongoing trials of regadenoson and adenosine for FFR. Although our lab contributed to the flow velocity comparison studies of several A2A receptor blockers, we did not perform FFR in these patients, since they did not have significant coronary artery disease.16

One concern was that multiple A2A agonist dosing could minimize subsequent hyperemia. This issue has not yet been resolved. For the moment, I cannot recommend regadenoson replace adenosine.

I hope this discussion on FFR is helpful. I’ll look for more of your questions on this or any important cath lab topic in the coming year.


1. Pijls NHJ, Fearon WF, Tonino PAL, et al. Fractional flow reserve versus angiography for guiding percutaneous coronary intervention in patients with multivessel coronary artery disease: 2-year follow-up of the FAME (Fractional Flow Reserve Versus Angiography for Multivessel Evaluation) study. J Am Coll Cardiol 2010;56:177-184.

2. Tonino PAL, DeBruyne B, Pijls NHJ, et al. Fractional flow reserve versus angiography for guiding percutaneous coronary intervention. (FAME). New Engl J Med 2009;360:3:213-224.

3. Pijls NHJ, Van Schaardenburgh P, Manoharan G, et al. Percutaneous coronary intervention of functionally non-significant stenoses: 5 year follow-up of the DEFER study. J Am Coll Cardiol 2007; 49: 2105-2111.

4. Tonino PAL, Fearon WF, De Bruyne B, et al. Angiographic versus functional severity of coronary artery stenoses in the FAME study (Fractional Flow Reserve Versus Angiography in Multivessel Evaluation). J Am Coll Cardiol 2010;55:2816–2821.

5. Kern MJ, Samady H. Current concepts integrated coronary physiology in the cath lab. J Am Coll Cardiol 2010;55:173–185.

6. Hamilos M, Muller O, Cuisset T, et al. Long-term clinical outcome after fractional flow reserve-guided treatment in patients with angiographically equivocal left main coronary artery stenosis. Circulation 2009;120:1505-1512.

7. Pijls NHJ, Kern MJ, Yock PG, DeBruyne B. Practice and potential pitfalls of coronary pressure measurement. Cath Cardiovasc Interv 2000;49:1-16.

8. Iqbal MB, Shah N, Khan M, Wallis W. Reduction myocardial perfusion territory and its effect on the physiological severity of a coronary stenosis. Circ Cardiovasc Interv Feb 2010; 3: 89-90.

9. DeBruyne B, Pijls NHJ, Bartunek J, et al. Fractional flow reserve in patients with prior myocardial infarction. Circulation 2001;104:157-162.

10. Nam C-W, Yoon H-J, Cho Y-K, et al. Outcomes of percutaneous coronary intervention in intermediate coronary artery disease: fractional flow reserve-guided versus intravascular ultrasound–guided. J Am Coll Cardiol Intv 2010;3:812-817.

11. Magni V, Chieffo A, Colombo A. Evaluation of intermediate coronary stenosis with intravascular ultrasound and fractional flow reserve: its use and abuse. Catheter Cardiovasc Interv 2009;73:441-448.

12. Fearon WF, Shah M, Ng M, et al. Predictive value of the index of microcirculatory resistance in patients with ST-segment elevation myocardial infarction. J Am Coll Cardiol 2008;51:560-565.

13. Sahinarslan A, Kocaman SA, Olgun H, et al. The reliability of fractional flow reserve measurement in patients with diabetes mellitus. Coron Artery Dis 2009;20(5):317-321.

14. Jeremias A, Whitbourn RJ, Filardo SD, et al. Adequacy of intracoronary versus intravenous adenosine-induced maximal coronary hyperemia for fractional flow reserve measurements. Am Heart J 2000;140(4):651-657.

15. Parham WA, Bouhasin A, Ciaramita JP, et al. Coronary hyperemic dose responses to intracoronary sodium nitroprusside. Circulation 2004; 109:1236-1243.

16. Hodgson JMcB, Dib N, Kern MJ, et al. Coronary circulation responses to binodenoson, a selective adenosine A2a receptor agonist. Am J Cardiol 2007;99:1507-1512.


Disclosure: Dr. Kern reports that he is a speaker for Volcano Therapeutics and St. Jude Medical, and is a consultant for Merit Medical and InfraReDx, Inc.

Check out Dr. Kern’s latest book, “Notes from the Editor’s Corner of Cath Lab Digest” at www.mortonkernmd.com

Marysays: January 27.2014 at 14:25 pm

Are we required to speak to an RN when calling the units to pre-medicate a patient for cardiac cath? Our patients usually get Benadryl and Valium, and "DC Heparin on call to cath lab". There has been some discussion on whether we can tell the unit secretary, aide or LPN to have the patient pre-medicated.

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