Stress Myocardial Perfusion Imaging vs Coronary Computed Tomographic Angiography for Diagnosis of Invasive Vessel-Specific Coronary Physiology

Abstract

IMPORTANCEStress imaging has been the standard for diagnosing functionally significant coronary artery disease. It is unknown whether novel, atherosclerotic plaque measures improve accuracy beyond coronary stenosis for diagnosing invasive fractional flow reserve (FFR) measurement.OBJECTIVE To compare the diagnostic accuracy of comprehensive anatomic (obstructive and nonobstructive atherosclerotic plaque) vs functional imaging measures for estimating vessel-specific FFR.DESIGN, SETTING, AND PARTICIPANTS Controlled clinical trial of diagnostic accuracy with a multicenter derivation-validation cohort of patients referred for nonemergent invasive coronary angiography. A total of 612 patients (64 [10] years; 30% women) with signs and symptoms suggestive of myocardial ischemia from 23 sites were included. Patients were recruited from 2014 to 2017. Data analysis began in August 2018.INTERVENTIONS Patients underwent invasive coronary angiography with measurement of invasive FFR, coronary computed tomographic angiography (CCTA) quantification of atherosclerotic plaque and FFR by CT (FFR-CT), and semiquantitative scoring of rest/stress myocardial perfusion imaging (by magnetic resonance, positron emission tomography, or single photon emission CT). Multivariable generalized linear mixed models were derived and validated calculating the area under the receiver operating characteristics curve. MAIN OUTCOMES AND MEASURESThe primary end point was invasive FFR of 0.80 or less. RESULTSOf the 612 patients, the mean (SD) age was 64 (10) years, and 426 (69.9%) were men. An invasive FFR of 0.80 or less was measured in 26.5% of 1727 vessels. In the derivation cohort, CCTA vessel-specific factors associated with FFR 0.80 or less were stenosis severity, percentage of noncalcified atheroma volume, lumen volume, the number of lesions with high-risk plaque (Ն2 of low attenuation plaque, positive remodeling, napkin ring sign, or spotty calcification), and the number of lesions with stenosis greater than 30%. Fractional flow reserve-CT was not additive to this model including stenosis and atherosclerotic plaque. Significant myocardial perfusion imaging predictors were the summed rest and difference scores. In the validation cohort, the areas under the receiver operating characteristic curve were 0.81 for CCTA vs 0.67 for myocardial perfusion imaging (P < .001). CONCLUSIONS AND RELEVANCEA comprehensive anatomic interpretation with CCTA, including quantification of obstructive and nonobstructive atherosclerotic plaque, was superior to functional imaging in the diagnosis of invasive FFR. Comprehensive CCTA measures improve prediction of vessel-specific coronary physiology more so than stress-induced alterations in myocardial perfusion.

2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

“…4,5,7,25,30 These plaque features have been associated with inducible ischemia, identified as precursors for ACS, and independently predict MACE. 5,6,31 Recently, Williams et al reported that a low attenuation plaque burden was associated with a >6-fold increase in incident MI for patients with nonobstructive CAD. 4 Controlled clinical trials reveal that FFR-CT improves diagnostic accuracy over and above obstructive CAD on CCTA when compared with invasive FFR.…”

Prognostic value of a novel artificial intelligence-based coronary computed tomography angiography-derived ischaemia algorithm for patients with suspected coronary artery disease

“…normal or abnormal AI-QCT ischaemia result ( Graphical Abstract ). AI-QCT ischaemia was trained against invasive FFR with cut-off 0.80, 9 , 15 using data from the CREDENCE ( Computed tomogRaphic Evaluation of atherosclerotic DEtermiNants of myocardial isChEmia ) 16 trial (50:50 derivation and internal validation) and has undergone external validation using data from the PACIFIC ( Prospective Comparison of Cardiac PET/CT, SPECT/CT Perfusion Imaging and CT Coronary Angiography With Invasive Coronary Angiography ) 17 trial.…”

Cardiac computed tomography: from anatomy to function

“…An important answer to this question has been provided by the results of the CREDENCE trial, 22 that demonstrated on a cohort of 612 patients that a comprehensive anatomic interpretation with CCTA (namely the quantification of obstructive and non-obstructive atherosclerotic plaque, percentage of non-calcified atheroma volume, lumen volume, the number of lesions with HRP and the number of lesions with stenosis greater than 30%) was superior to functional imaging in the diagnosis of invasive FFR (AUC 0.81 for CCTA vs. 0.67 respectively, P < 0.001).…”