Evaluation of Coronary Artery Stenosis by Quantitative Flow Ratio During Invasive Coronary Angiography

Westra, Jelmer; Tu, Shengxian; Winther, Simon; Nissen, Louise; Vestergaard, Mikkel; Andersen, B. Bech; Holck, Emil Nielsen; Maule, Camilla Fox; Johansen, Jane Kirk; Andreasen, Lene Nyhus; Simonsen, Jo; Zhang, Yimin; Kristensen, Steen Dalby; Mæng, Michael; Kaltoft, Anne; Terkelsen, Christian Juhl; Krusell, Lars Romer; Jakobsen, Lars; Reiber, Johan H. C.; Lassen, Jens Flensted; Bøttcher, Morten; Bøtker, Hans Erik; Christiansen, Evald Høj; Holm, Niels Ramsing

doi:10.1161/circimaging.117.007107

Cited by 191 publications

(213 citation statements)

References 32 publications

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“…The diagnostic performance of QFR with FFR as reference is well documented in patients with stable angina . Our data indicate that QFR might also be a valuable tool in the evaluation of NCLs in patients with acute STEMI undergoing primary PCI.…”

Section: Discussionmentioning

confidence: 56%

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Quantitative flow ratio for immediate assessment of nonculprit lesions in patients with ST‐segment elevation myocardial infarction—An iSTEMI substudy

Sejr-Hansen

Thim

Christiansen

et al. 2019

Cathet Cardio Intervent

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Objectives We evaluated the diagnostic performance of quantitative flow ratio (QFR) assessment of nonculprit lesions (NCLs) based on acute setting angiograms obtained in patients with ST‐segment elevation myocardial infarction (STEMI) with QFR, fractional flow reserve (FFR), and instantaneous wave‐free ratio (iFR) in the staged setting as reference. Background QFR is an angiography‐based approach for the functional evaluation of coronary artery lesions. Methods This was a post‐hoc analysis of the iSTEMI study. NCLs were assessed with iFR in the acute setting and with iFR and FFR at staged (median 13 days) follow‐up. Acute and staged QFR values were computed in a core laboratory based on the coronary angiography recordings. Diagnostic cut‐off values were ≤0.80 for QFR and FFR, and ≤0.89 for iFR. Results Staged iFR and FFR data were available for 146 NCLs in 112 patients in the iSTEMI study. Among these, QFR analysis was feasible in 103 (71%) lesions assessed in the acute setting with a mean QFR value of 0.82 (IQR: 0.73–0.91). Staged QFR, FFR, and iFR were 0.80 (IQR: 0.70–0.90), 0.81 (IQR: 0.71–0.88), and 0.91 (IQR: 0.87–0.96), respectively. Classification agreement of acute and staged QFR was 93% (95%Cl: 87–99). The classification agreement of acute QFR was 84% (95%CI: 76–90) using staged FFR as reference and 74% (95%CI: 65–83) using staged iFR as reference. Conclusions Acute QFR showed a very good diagnostic performance with staged QFR as reference, a good diagnostic performance with staged FFR as reference, and a moderate diagnostic performance with staged iFR as reference.

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Section: Discussionmentioning

confidence: 56%

“…The complete list of anatomical and angiographic exclusion criteria is presented in Supporting Information Table S1. These criteria for QFR analysis match those of prior QFR studies …”

Section: Methodsmentioning

confidence: 86%

Quantitative flow ratio for immediate assessment of nonculprit lesions in patients with ST‐segment elevation myocardial infarction—An iSTEMI substudy

Sejr-Hansen

Thim

Christiansen

et al. 2019

Cathet Cardio Intervent

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“…The higher accuracy (92.7%) in FAVOR II China may be explained by the smaller number of lesions with FFR values close to the FFR 0.80 cutpoint. Results in both studies showed improved performance of QFR compared with early validation studies on offline computation of QFR 11, 15. The improved precision may be facilitated by the online analysis setup with instant feedback between operator and analyst.…”

Section: Discussionmentioning

confidence: 86%

Diagnostic Performance of In‐Procedure Angiography‐Derived Quantitative Flow Reserve Compared to Pressure‐Derived Fractional Flow Reserve: The FAVOR II Europe‐Japan Study

Westra

Andersen

Campo

et al. 2018

JAHA

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BackgroundQuantitative flow ratio (QFR) is a novel modality for physiological lesion assessment based on 3‐dimensional vessel reconstructions and contrast flow velocity estimates. We evaluated the value of online QFR during routine invasive coronary angiography for procedural feasibility, diagnostic performance, and agreement with pressure‐wire–derived fractional flow reserve (FFR) as a gold standard in an international multicenter study.Methods and Results FAVOR II E‐J (Functional Assessment by Various Flow Reconstructions II Europe‐Japan) was a prospective, observational, investigator‐initiated study. Patients with stable angina pectoris were enrolled in 11 international centers. FFR and online QFR computation were performed in all eligible lesions. An independent core lab performed 2‐dimensional quantitative coronary angiography (2D‐QCA) analysis of all lesions assessed with QFR and FFR. The primary comparison was sensitivity and specificity of QFR compared with 2D‐QCA using FFR as a reference standard. A total of 329 patients were enrolled. Paired assessment of FFR, QFR, and 2D‐QCA was available for 317 lesions. Mean FFR, QFR, and percent diameter stenosis were 0.83±0.09, 0.82±10, and 45±10%, respectively. FFR was ≤0.80 in 104 (33%) lesions. Sensitivity and specificity by QFR was significantly higher than by 2D‐QCA (sensitivity, 86.5% (78.4–92.4) versus 44.2% (34.5–54.3); P<0.001; specificity, 86.9% (81.6–91.1) versus 76.5% (70.3–82.0); P=0.002). Area under the receiver curve was significantly higher for QFR compared with 2D‐QCA (area under the receiver curve, 0.92 [0.89–0.96] versus 0.64 [0.57–0.70]; P<0.001). Median time to QFR was significantly lower than median time to FFR (time to QFR, 5.0 minutes [interquartile range, –6.1] versus time to FFR, 7.0 minutes [interquartile range, 5.0–10.0]; P<0.001).ConclusionsOnline computation of QFR in the catheterization laboratory is clinically feasible and is superior to angiographic assessment for evaluation of intermediary coronary artery stenosis using FFR as a reference standard.Clinical Trial Registration URL: https://www.clinicaltrials.gov. Unique identifier: NCT02959814.

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“…Secondary outcome measures included sensitivity; specificity; summary of the receiver‐operator characteristics curve (sROC); negative predictive value; positive predictive value, positive likelihood ratio; negative likelihood ratio, and identification of independent predictors for increased QFR‐FFR difference using predefined clinical and lesion characteristics: age; body mass index (BMI); diabetes mellitus; sex; hypertension; family history of coronary artery disease (CAD) previous myocardial infarction; previous PCI; current smoking; lesion location; FFR; % DS (two‐dimensional quantitative coronary angiography [2D‐QCA]); % DS (three‐dimensional quantitative coronary angiography [3D‐QCA]); lesion length (2D‐QCA), and 95% hybrid limits. The strategy for calculation of 95% hybrid limits was previously described in detail …”

Section: Methodsmentioning

confidence: 99%

“…To improve access to functional lesion evaluation during invasive coronary angiography, quantitative flow ratio (QFR) based on three‐dimensional reconstruction of coronary arteries and application of mathematical equations was recently developed. Validation of QFR in mid‐sized prospective studies showed good diagnostic accuracy of QFR in core‐lab and in‐procedure settings using FFR as the reference standard with an overall classification agreement ranging between 80 and 90% . In this systematic, individual participant data meta‐analysis based on prospective studies, we aimed to evaluate the diagnostic performance of the CE‐marked QFR algorithm (Medis medical imaging b.v. and Pulse Medical Imaging Technology Co.) and identify predictors for discrepancy between QFR and FFR.…”

Section: Introductionmentioning

confidence: 99%

Diagnostic performance of quantitative flow ratio in prospectively enrolled patients: An individual patient‐data meta‐analysis

Westra

Campo

et al. 2019

Cathet Cardio Intervent

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Objectives We aimed to provide robust performance estimates for quantitative flow ratio (QFR) in assessment of intermediary coronary lesions. Background Angiography‐based functional lesion assessment by QFR may appear as a cost saving and safe approach to expand the use of physiology‐guided percutaneous coronary interventions. QFR was proven feasible and showed good diagnostic performance in mid‐sized off‐line and on‐line studies with fractional flow reserve (FFR) as reference standard. Methods We performed a collaborative individual patient‐data meta‐analysis of all available prospective studies with paired assessment of QFR and FFR using the CE‐marked QFR application. The main outcome was agreement of QFR and FFR using a two‐step analysis strategy with a multilevel mixed model accounting for study and center level variation. Results Of 16 studies identified, four studies had prospective enrollment and provided patient level data reaching a total of 819 patients and 969 vessels with paired FFR and QFR: FAVOR Pilot (n = 73); WIFI II (n = 170); FAVOR II China (n = 304) and FAVOR II Europe‐Japan (n = 272). We found an overall agreement (mean difference 0.009 ± 0.068, I2 = 39.6) of QFR with FFR. The diagnostic performance was sensitivity 84% (95%CI: 77–90, I2 = 70.1), specificity 88% (95%CI: 84–91, I2 = 60.1); positive predictive value 80% (95%CI: 76–85, I2 = 33.4), and negative predictive value 95% (95%CI: 93–96, I2 = 75.9). Conclusions Diagnostic performance of QFR was good with FFR as reference in this meta‐analysis of high quality studies. QFR could provide an easy, safe, and cost‐effective solution for functional evaluation of coronary artery stenosis.

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Evaluation of Coronary Artery Stenosis by Quantitative Flow Ratio During Invasive Coronary Angiography

Abstract: Supplemental Digital Content is available in the text.

Cited by 191 publications

References 32 publications

Quantitative flow ratio for immediate assessment of nonculprit lesions in patients with ST‐segment elevation myocardial infarction—An iSTEMI substudy

Quantitative flow ratio for immediate assessment of nonculprit lesions in patients with ST‐segment elevation myocardial infarction—An iSTEMI substudy

Diagnostic Performance of In‐Procedure Angiography‐Derived Quantitative Flow Reserve Compared to Pressure‐Derived Fractional Flow Reserve: The FAVOR II Europe‐Japan Study

Diagnostic performance of quantitative flow ratio in prospectively enrolled patients: An individual patient‐data meta‐analysis

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