Comparison between invasive and noninvasive methods to estimate subendocardial oxygen supply and demand imbalance

Paolo Salvi*, Corrado Baldi, Filippo Scalise, Andrea Grillo, Lucia Salvi, Isabella Tan, Lorenzo De Censi, Antonio Sorropago, Francesco Moretti, Giovanni Sorropago, Lan Gao, Matteo Rovina, Giulia Simon, Bruno Fabris, Renzo Carretta, Alberto P. Avolio, Gianfranco Parati

*Corresponding author for this work

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    BACKGROUND: Estimation of the balance between subendocardial oxygen supply and demand could be a useful parameter to assess the risk of myocardial ischemia. Evaluation of the subendocardial viability ratio (SEVR, also known as Buckberg index) by invasive recording of left ventricular and aortic pressure curves represents a valid method to estimate the degree of myocardial perfusion relative to left ventricular workload. However, routine clinical use of this parameter requires its noninvasive estimation and the demonstration of its reliability. METHODS AND RESULTS: Arterial applanation tonometry allows a noninvasive estimation of SEVR as the ratio of the areas directly beneath the central aortic pressure curves obtained during diastole (myocardial oxygen supply) and during systole (myocardial oxygen demand). However, this “traditional” method does not account for the intra-ventricular diastolic pressure and proper allocation to systole and diastole of left ventricular isometric contraction and relaxation, respectively, resulting in an overestimation of the SEVR values. These issues are considered in the novel method for SEVR assessment tested in this study. SEVR values estimated with carotid tonometry by "traditional” and "new” method were compared with those evaluated invasively by cardiac catheterization. The “traditional” method provided significantly higher SEVR values than the reference invasive SEVR: average of differences±SD= 44±11% (limits of agreement: 23% – 65%). The noninvasive “new” method showed a much better agreement with the invasive determination of SEVR: average of differences±SD= 0±8% (limits of agreement:-15% to 16%). CONCLUSIONS: Carotid applanation tonometry provides valid noninvasive SEVR values only when all the main factors determining myocardial supply and demand flow are considered.

    Original languageEnglish
    Article numbere021207
    Pages (from-to)1-20
    Number of pages20
    JournalJournal of the American Heart Association
    Issue number17
    Publication statusPublished - 7 Sept 2021

    Bibliographical note

    Copyright the Author(s) 2021. Version archived for private and non-commercial use with the permission of the author/s and according to publisher conditions. For further rights please contact the publisher.


    • Arterial stiffness
    • Cardiovascular prevention
    • Myocardial ischemia
    • Myocardial oxygen demand
    • Subendocardial viability ratio


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