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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Anatomical assessment of the severity of coronary stenosis by angiography has most often been used to guide the need for coronary revascularization&#46; However&#44; following the evidence of three landmark studies &#40;DEFER&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">1</span></a> FAME 1<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">2</span></a> and FAME 2<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">3</span></a>&#41;&#44; fractional flow reserve &#40;FFR&#41; has become the gold standard invasive diagnostic test to guide revascularization of intermediate coronary lesions&#44; especially in the presence of multivessel coronary artery disease&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">FFR-guided revascularization has been extensively validated in large clinical outcomes studies&#44;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">1&#8211;3</span></a> and has proved to be more cost-effective than angiography-based revascularization&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">4</span></a> In the current European revascularization guidelines&#44; it has a class I recommendation&#44; level of evidence A&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">5</span></a> However&#44; despite all the evidence and recommendations&#44; invasive physiological assessment to guide coronary intervention continues to be underused in Portuguese cath labs&#46; In the article by Raposo et al&#46; published in this issue of the <span class="elsevierStyleItalic">Journal</span>&#44;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">6</span></a> the overall adoption of physiology-guided revascularization in a large population &#40;40 821&#41; in two large-volume centers who underwent coronary angiography over a ten-year period &#40;2007-2018&#41; was very low &#40;0&#46;6-6&#37;&#41;&#46; This prompts reflection on the main barriers that hinder actions in line with the recommendations&#46; Other authors have identified factors that affect the likelihood that clinicians will follow clinical practice guidelines&#44; particularly their knowledge&#44; attitude and behavior&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">7</span></a> For each of these factors&#44; there may be barriers to adherence to the guidelines&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Regarding knowledge&#44; Raposo et al&#46;&#8217;s paper<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">6</span></a> demonstrates a relationship between rates of invasive physiology assessment over time and relevant landmark studies&#46; Adoption increased significantly from 0&#46;9&#37; to 4&#46;0&#37; after the publication of FAME 1&#44; and there was a significant 1&#46;67-fold increase in adoption rates in the setting of chronic coronary syndromes in the period following the publication of the 2014 European myocardial revascularization guidelines and long-term &#40;two-year&#41; results of the FAME 2 trial&#46; However&#44; although these publications influenced the adoption of invasive physiological assessment&#44; their impact was small and did not result in widespread use of FFR&#46; Thus&#44; other factors have been suggested as having limited the uptake of invasive physiology in clinical practice&#58; reimbursement&#44; the technical properties of pressure sensor-tipped guidewires that lead to drift and increase the complexity of the procedure&#44; and the need for hyperemic drugs that have the disadvantages of cost&#44; time and side effects&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">8</span></a> For the latter reason&#44; new non-hyperemic physiological indices have been developed&#44; of which the instantaneous wave-free ratio &#40;iFR&#41; has been the most studied in randomized controlled trials &#40;DEFINE-FLAIR<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">9</span></a> and iFR-SWEDEHEART<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">10</span></a>&#41; and has been shown to be non-inferior to FFR guidance in terms of clinical outcomes&#46; Additional evidence suggests that other diastolic pressure indices are numerically equivalent to iFR&#46; Theoretically&#44; due to the elimination of vasodilator drugs&#44; iFR entails lower procedure time&#44; drug side effects and costs&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">11</span></a> But these theoretical advantages did not translate into an increase in the use of invasive physiological assessment in Raposo et al&#46;&#8217;s study&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">6</span></a> Publication of iFR trials had no influence on coronary physiology adoption rates&#44; except for a higher proportion of iFR use&#46; The use of non-hyperemic physiological indices is feasible&#44; cost-effective and patient-friendly&#46; They are progressively replacing FFR&#44; but this is not reflected in an overall increase in the use of physiology-guided coronary revascularization&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">All the new wire-based indices share the same limitations&#44; such as susceptibility to pressure-sensor drift and poor guidewire handling&#46; Advances in technology have sought to respond to the limitations of invasive assessment of coronary physiology&#44; and new indices have been developed that may replace the traditional pressure wires and adenosine to assess FFR&#46; These include image-derived FFR&#44; such as noninvasive computed tomography imaging-derived FFR and angiography-derived FFR &#40;quantitative flow ratio&#44; vessel FFR or FFR-angio&#41; that can be performed while the patient is in the cath lab&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">11</span></a> Nevertheless&#44; I believe that these remarkable technologies are not sufficient to ensure the widespread use of physiology-guided revascularization&#44; because the greatest problem is not so much of knowledge or external barriers that constrain behavior&#44; it is a problem of attitude&#46; The barriers are not cognitive&#59; they are in fact affective&#46; Certainly&#44; it is not the case that interventional cardiologists are unfamiliar with the evidence supporting the role of FFR or with the most up-to-date practice guidelines&#46; They may not agree with the recommendations&#44; may have low outcome expectancy&#44; lack motivation&#44; or suffer from inertia due to their previous practices&#46; The greatest barrier to the use of coronary physiology is still physicians&#8217; perception that it is not needed&#44; as some remain wedded to &#8216;eyeball&#8217; estimation of coronary stenosis on the angiogram for therapeutic decision-making in intermediate coronary lesions&#46; However&#44; visual assessment of lesion severity does not always reflect the hemodynamics of coronary artery stenosis&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Less invasive technologies to assess coronary physiology may help to change the scenario in the near future&#44; but the main contribution must be from a change in attitude&#44; which will come more easily to younger generations&#46; To change the mindset of operators from anatomy to physiology&#44; we need to change attitudes&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0030" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare&#46;</p></span></span>"
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Coronary physiology in clinical practice in Portugal: A problem of technology or a question of attitude?
Fisiologia coronária na nossa prática: um problema de tecnologia ou uma questão de atitude?
Rita Calé
Serviço de Cardiologia do Hospital Garcia de Orta, Almada, Portugal
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Anatomical assessment of the severity of coronary stenosis by angiography has most often been used to guide the need for coronary revascularization&#46; However&#44; following the evidence of three landmark studies &#40;DEFER&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">1</span></a> FAME 1<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">2</span></a> and FAME 2<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">3</span></a>&#41;&#44; fractional flow reserve &#40;FFR&#41; has become the gold standard invasive diagnostic test to guide revascularization of intermediate coronary lesions&#44; especially in the presence of multivessel coronary artery disease&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">FFR-guided revascularization has been extensively validated in large clinical outcomes studies&#44;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">1&#8211;3</span></a> and has proved to be more cost-effective than angiography-based revascularization&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">4</span></a> In the current European revascularization guidelines&#44; it has a class I recommendation&#44; level of evidence A&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">5</span></a> However&#44; despite all the evidence and recommendations&#44; invasive physiological assessment to guide coronary intervention continues to be underused in Portuguese cath labs&#46; In the article by Raposo et al&#46; published in this issue of the <span class="elsevierStyleItalic">Journal</span>&#44;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">6</span></a> the overall adoption of physiology-guided revascularization in a large population &#40;40 821&#41; in two large-volume centers who underwent coronary angiography over a ten-year period &#40;2007-2018&#41; was very low &#40;0&#46;6-6&#37;&#41;&#46; This prompts reflection on the main barriers that hinder actions in line with the recommendations&#46; Other authors have identified factors that affect the likelihood that clinicians will follow clinical practice guidelines&#44; particularly their knowledge&#44; attitude and behavior&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">7</span></a> For each of these factors&#44; there may be barriers to adherence to the guidelines&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Regarding knowledge&#44; Raposo et al&#46;&#8217;s paper<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">6</span></a> demonstrates a relationship between rates of invasive physiology assessment over time and relevant landmark studies&#46; Adoption increased significantly from 0&#46;9&#37; to 4&#46;0&#37; after the publication of FAME 1&#44; and there was a significant 1&#46;67-fold increase in adoption rates in the setting of chronic coronary syndromes in the period following the publication of the 2014 European myocardial revascularization guidelines and long-term &#40;two-year&#41; results of the FAME 2 trial&#46; However&#44; although these publications influenced the adoption of invasive physiological assessment&#44; their impact was small and did not result in widespread use of FFR&#46; Thus&#44; other factors have been suggested as having limited the uptake of invasive physiology in clinical practice&#58; reimbursement&#44; the technical properties of pressure sensor-tipped guidewires that lead to drift and increase the complexity of the procedure&#44; and the need for hyperemic drugs that have the disadvantages of cost&#44; time and side effects&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">8</span></a> For the latter reason&#44; new non-hyperemic physiological indices have been developed&#44; of which the instantaneous wave-free ratio &#40;iFR&#41; has been the most studied in randomized controlled trials &#40;DEFINE-FLAIR<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">9</span></a> and iFR-SWEDEHEART<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">10</span></a>&#41; and has been shown to be non-inferior to FFR guidance in terms of clinical outcomes&#46; Additional evidence suggests that other diastolic pressure indices are numerically equivalent to iFR&#46; Theoretically&#44; due to the elimination of vasodilator drugs&#44; iFR entails lower procedure time&#44; drug side effects and costs&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">11</span></a> But these theoretical advantages did not translate into an increase in the use of invasive physiological assessment in Raposo et al&#46;&#8217;s study&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">6</span></a> Publication of iFR trials had no influence on coronary physiology adoption rates&#44; except for a higher proportion of iFR use&#46; The use of non-hyperemic physiological indices is feasible&#44; cost-effective and patient-friendly&#46; They are progressively replacing FFR&#44; but this is not reflected in an overall increase in the use of physiology-guided coronary revascularization&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">All the new wire-based indices share the same limitations&#44; such as susceptibility to pressure-sensor drift and poor guidewire handling&#46; Advances in technology have sought to respond to the limitations of invasive assessment of coronary physiology&#44; and new indices have been developed that may replace the traditional pressure wires and adenosine to assess FFR&#46; These include image-derived FFR&#44; such as noninvasive computed tomography imaging-derived FFR and angiography-derived FFR &#40;quantitative flow ratio&#44; vessel FFR or FFR-angio&#41; that can be performed while the patient is in the cath lab&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">11</span></a> Nevertheless&#44; I believe that these remarkable technologies are not sufficient to ensure the widespread use of physiology-guided revascularization&#44; because the greatest problem is not so much of knowledge or external barriers that constrain behavior&#44; it is a problem of attitude&#46; The barriers are not cognitive&#59; they are in fact affective&#46; Certainly&#44; it is not the case that interventional cardiologists are unfamiliar with the evidence supporting the role of FFR or with the most up-to-date practice guidelines&#46; They may not agree with the recommendations&#44; may have low outcome expectancy&#44; lack motivation&#44; or suffer from inertia due to their previous practices&#46; The greatest barrier to the use of coronary physiology is still physicians&#8217; perception that it is not needed&#44; as some remain wedded to &#8216;eyeball&#8217; estimation of coronary stenosis on the angiogram for therapeutic decision-making in intermediate coronary lesions&#46; However&#44; visual assessment of lesion severity does not always reflect the hemodynamics of coronary artery stenosis&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Less invasive technologies to assess coronary physiology may help to change the scenario in the near future&#44; but the main contribution must be from a change in attitude&#44; which will come more easily to younger generations&#46; To change the mindset of operators from anatomy to physiology&#44; we need to change attitudes&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0030" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare&#46;</p></span></span>"
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