High Coronary Shear Stress in Patients With Coronary Artery Disease Predicts Myocardial Infarction

J Am Coll Cardiol. 2018 Oct 16;72(16):1926-1935. doi: 10.1016/j.jacc.2018.07.075.


Background: Coronary lesions with low fractional flow reserve (FFR) that are treated medically are associated with higher revascularization rates. High wall shear stress (WSS) has been linked with increased plaque vulnerability.

Objectives: This study investigated the prognostic value of WSS measured in the proximal segments of lesions (WSSprox) to predict myocardial infarction (MI) in patients with stable coronary artery disease (CAD) and hemodynamically significant lesions. The authors hypothesized that in patients with low FFR and stable CAD, higher WSSprox would predict MI.

Methods: Among 441 patients in the FAME II (Fractional Flow Reserve Versus Angiography for Multivessel Evaluation II) trial with FFR ≤0.80 who were randomized to medical therapy alone, 34 (8%) had subsequent MI within 3 years. Patients with vessel-related MI and adequate angiograms for 3-dimensional reconstruction (n = 29) were propensity matched to a control group with no MI (n = 29) by using demographic and clinical variables. Coronary lesions were divided into proximal, middle, and distal, along with 5-mm upstream and downstream segments. WSS was calculated for each segment.

Results: Median age was 62 years, and 46 (79%) were male. In the marginal Cox model, whereas lower FFR showed a trend (hazard ratio: 0.084; p = 0.064), higher WSSprox (hazard ratio: 1.234; p = 0.002, C-index = 0.65) predicted MI. Adding WSSprox to FFR resulted in a significant increase in global chi-square for predicting MI (p = 0.045), a net reclassification improvement of 0.69 (p = 0.005), and an integrated discrimination index of 0.11 (p = 0.010).

Conclusions: In patients with stable CAD and hemodynamically significant lesions, higher WSS in the proximal segments of atherosclerotic lesions is predictive of MI and has incremental prognostic value over FFR.

Keywords: fractional flow reserve; high wall shear stress; proximal segment; stable coronary artery disease; vessel-related myocardial infarction.

Publication types

  • Randomized Controlled Trial

MeSH terms

  • Coronary Angiography / methods
  • Coronary Artery Disease* / pathology
  • Coronary Artery Disease* / physiopathology
  • Coronary Artery Disease* / therapy
  • Coronary Vessels* / diagnostic imaging
  • Coronary Vessels* / pathology
  • Female
  • Fractional Flow Reserve, Myocardial*
  • Humans
  • Male
  • Middle Aged
  • Myocardial Infarction / diagnosis*
  • Myocardial Infarction / etiology
  • Myocardial Revascularization / adverse effects
  • Myocardial Revascularization / methods
  • Plaque, Atherosclerotic / diagnostic imaging*
  • Prognosis
  • Risk Adjustment
  • Risk Factors
  • Treatment Outcome