Additional decrease in fractional flow reserve in the left anterior descending artery after hand-grip exercise during pharmacological coronary hyperemia

Maximal hyperemia at the time of fractional flow reserve (FFR) measurement is generally induced by vasodilators, even when hyperemia at the onset of angina symptoms is caused by exercise stress. This study was designed to evaluate whether pharmacological hyperemia could be used as a substitute for exercise-induced hyperemia during FFR measurement. Twenty-two patients with angiographically intermediate stenosis in the left anterior descending artery (LAD) were prospectively enrolled. FFR measurements were repeated in the following two conditions while the pressure-wire was positioned in the same segment; (1) during pharmacological hyperemia induced by intracoronary administration of 2 mg nicorandil, (2) immediately after isotonic hand-grip exercise for 90 s (50% of maximum voluntary contraction) followed by intracoronary administration of 2 mg nicorandil. Isotonic hand-grip exercise increased systolic blood pressure (130 ± 19 versus 150 ± 22 mmHg, p < 0.001), heart rate (71 ± 11 versus 79 ± 13 bpm, p < 0.001), and cardiac output (5.1 ± 1.2 versus 5.9 ± 1.5 L/min, p < 0.001), which indicated an increased afterload on the left ventricle. After the hand-grip exercise, FFR significantly decreased from 0.86 ± 0.06 to 0.84 ± 0.06 ( p < 0.001). A percent increase in systolic blood pressure and cardiac output after hand-grip exercise strongly correlated with ΔFFR ( r = − 0.65, p < 0.001 and r = − 0.55, p < 0.001, respectively). An increase in cardiac output with hand-grip exercise during pharmacological hyperemia could induce an additional decrease in FFR for lesions located in the LAD.