Coronary CTA superior to stress myocardial perfusion imaging for invasive FFR diagnosis
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Using coronary CTA for comprehensive anatomic interpretation was superior to functional imaging to determine fractional flow reserve, researchers found in the CREDENCE trial.
This prospective, multicenter diagnostic derivation-validation controlled trial was published in JAMA Cardiology.
Wijnand J. Stuijfzand, MD, research fellow at the Dalio Institute for Cardiovascular Imaging at NewYork-Presbyterian Hospital and Weill Cornell Medical College, and colleagues analyzed data from 612 patients (mean age, 64 years; 30% women) from 23 sites who were referred for nonemergent invasive coronary angiography from 2014 to 2017. All patients had stable symptoms and did not have a prior diagnosis of CAD. Patients were assigned to two subsets: derivation (n = 307) or validation (n = 305) data sets.
Invasive FFR was measured during invasive coronary angiography. Other measurements taken during this study included quantification by coronary CTA of atherosclerotic plaque, FFR by CT and scoring of rest/stress myocardial perfusion imaging with PET, MRI or single-photon emission CT.
The primary endpoint was invasive FFR of 0.8 or less.
In 1,727 epicardial coronary arteries, 26.5% had ischemia by FFR of 0.8 or less.
For patients in the derivation cohort, coronary CTA factors related to vessels that were associated with an FFR of 0.8 or less were percentage of noncalcified atheroma volume, stenosis severity, the number of lesions with high-risk plaque, lumen volume and the number of lesions with stenosis greater than 30%. FFR from CT did not contribute to this model, including atherosclerotic plaque and stenosis. Summed rest and difference scores were significant predictors for myocardial perfusion imaging.
For patients in the validation cohort, the optimized coronary CTA model (area under the receiver operating characteristic curve = 0.81; 95% CI, 0.78-0.84) was superior to the myocardial perfusion imaging model (AUC = 0.67; 95% CI, 0.63-0.71; P < .001) to diagnose abnormal FFR.
“The incorporation of whole-vessel quantification of epicardial coronary atherosclerosis provides a more comprehensive view of the underlying disease burden and vessel FFR compared with examination of a given focal stenosis alone,” Stuijfzand and colleagues wrote. “Future explorations including assimilation of the CREDENCE findings into clinical practice should support a broader inclusion of atherosclerotic plaque findings as meaningful to assess coronary physiology.”
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