Stress Myocardial Perfusion Imaging vs Coronary Computed Tomographic Angiography for Diagnosis of Invasive Vessel-Specific Coronary Physiology
JAMA Cardiology, vol. 5, pp. 1338
Abstract
Importance: Stress 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 Measures: The primary end point was invasive FFR of 0.80 or less. Results: Of 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 (≥2 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 Relevance: A 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. Trial Registration: ClinicalTrials.gov Identifier: NCT02173275.
Authors 41
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NewYork–Presbyterian Hospital · Weill Cornell Medicine · Amsterdam UMC Location Vrije Universiteit Amsterdam
Affiliation as printed
Amsterdam University Medical Center, VU University Medical Center, Amsterdam, the Netherlands
Dalio Institute of Cardiovascular Imaging, Department of Radiology, New York-Presbyterian Hospital and the Weill Cornell Medical College, New York
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NewYork–Presbyterian Hospital · Leiden University Medical Center · Weill Cornell Medicine
Affiliation as printed
Dalio Institute of Cardiovascular Imaging, Department of Radiology, New York-Presbyterian Hospital and the Weill Cornell Medical College, New York
Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
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NewYork–Presbyterian Hospital · Weill Cornell Medicine
Affiliation as printed
Dalio Institute of Cardiovascular Imaging, Department of Radiology, New York-Presbyterian Hospital and the Weill Cornell Medical College, New York
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Yonsei University · Severance Hospital · Yonsei University Health System
Affiliation as printed
Division of Cardiology, Severance Cardiovascular Hospital and Severance Biomedical Science Institute, Yonsei University College of Medicine, Yonsei University Health System, Seoul, South Korea
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NewYork–Presbyterian Hospital · Leiden University Medical Center · Weill Cornell Medicine
Affiliation as printed
Dalio Institute of Cardiovascular Imaging, Department of Radiology, New York-Presbyterian Hospital and the Weill Cornell Medical College, New York
Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
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NewYork–Presbyterian Hospital · University of Pavia · Weill Cornell Medicine
Affiliation as printed
Dalio Institute of Cardiovascular Imaging, Department of Radiology, New York-Presbyterian Hospital and the Weill Cornell Medical College, New York
Department of Molecular Medicine, Section of Cardiology, University of Pavia, Pavia, Italy
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Pusan National University Hospital
Affiliation as printed
Pusan National University Hospital, Busan, South Korea
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Inje University Ilsan Paik Hospital
Affiliation as printed
Division of Cardiology, Inje University Ilsan Paik Hospital, Goyang, South Korea
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Kangwon National University · Kangwon National University Hospital
Affiliation as printed
Kang Won National University Hospital, Chuncheon, South Korea
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Seoul National University · Seoul National University Hospital
Affiliation as printed
Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
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Keimyung University Dongsan Hospital
Affiliation as printed
Cardiovascular Center, Keimyung University Dongsan Hospital, Daegu, South Korea
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Catholic Kwandong University International St. Mary's Hospital · Catholic Kwandong University
Affiliation as printed
Division of Cardiology, Department of Internal Medicine, International St Mary's Hospital, Catholic Kwandong University College of Medicine, Incheon, South Korea
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Ewha Womans University · Ewha Womans University Seoul Hospital
Affiliation as printed
Division of Cardiology, Department of Internal Medicine, Ewha Women’s University Seoul Hospital, Seoul, South Korea
Division of Cardiology, Department of Internal Medicine, Ewha Women's University Seoul Hospital, Seoul, South Korea
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Cardiovascular Research Associates
Affiliation as printed
Mobile Cardiology Associates, Mobile, Alabama
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Fondazione Toscana Gabriele Monasterio
Affiliation as printed
Department of Imaging, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
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Affiliation as printed
Cardiac Center of Texas, McKinney
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Fu Wai Hospital · State Key Laboratory of Cardiovascular Disease
Affiliation as printed
State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Beijing, China
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Fu Wai Hospital · State Key Laboratory of Cardiovascular Disease
Affiliation as printed
State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Beijing, China
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Affiliation as printed
Houston Methodist Hospital, Houston, Texas
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St. Luke's International Hospital
Affiliation as printed
Cardiovascular Center, St. Luke’s International Hospital, Tokyo, Japan
Cardiovascular Center, St. Luke's International Hospital, Tokyo, Japan
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Medical University of South Carolina
Affiliation as printed
Medical University of South Carolina, Charleston
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Amsterdam UMC Location Vrije Universiteit Amsterdam
Affiliation as printed
Amsterdam University Medical Center, VU University Medical Center, Amsterdam, the Netherlands
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Amsterdam UMC Location Vrije Universiteit Amsterdam
Affiliation as printed
Amsterdam University Medical Center, VU University Medical Center, Amsterdam, the Netherlands
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Affiliation as printed
St Luke's Mid America Heart Institute, Kansas City, Missouri
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Kaiser Permanente · Kaiser Permanente Oakland Medical Center
Affiliation as printed
Kaiser Permanente Hospital, Oakland, California
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Affiliation as printed
Heart Center Research, LLC, Huntsville, Alabama
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Affiliation as printed
Renown Heart and Vascular Institute, Reno, Nevada
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Affiliation as printed
Oconee Heart and Vascular Center, St Mary’s Hospital, Athens, Georgia
Oconee Heart and Vascular Center, St Mary's Hospital, Athens, Georgia
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Affiliation as printed
Gagnon Cardiovascular Institute at Morristown Medical Center, Morristown, New Jersey
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Amsterdam UMC Location Vrije Universiteit Amsterdam
Affiliation as printed
Amsterdam University Medical Center, VU University Medical Center, Amsterdam, the Netherlands
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Amsterdam UMC Location Vrije Universiteit Amsterdam
Affiliation as printed
Amsterdam University Medical Center, VU University Medical Center, Amsterdam, the Netherlands
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Affiliation as printed
Centro Cardiologico Monzino, IRCCS Milan, Italy
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Affiliation as printed
Centro Cardiologico Monzino, IRCCS Milan, Italy
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Affiliation as printed
Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas
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NewYork–Presbyterian Hospital · Weill Cornell Medicine
Affiliation as printed
Dalio Institute of Cardiovascular Imaging, Department of Radiology, New York-Presbyterian Hospital and the Weill Cornell Medical College, New York
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Affiliation as printed
Department of Imaging and Medicine, Cedars Sinai Medical Center, Los Angeles, California
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Icahn School of Medicine at Mount Sinai
Affiliation as printed
Mount Sinai Heart, Zena and Michael A. Wiener Cardiovascular Institute, Marie-Josée and Henry R. Kravis Center for Cardiovascular Health, Icahn School of Medicine at Mount Sinai, New York, New York
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NewYork–Presbyterian Hospital · Weill Cornell Medicine
Affiliation as printed
Dalio Institute of Cardiovascular Imaging, Department of Radiology, New York-Presbyterian Hospital and the Weill Cornell Medical College, New York
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Leiden University Medical Center
Affiliation as printed
Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
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Leslee J. Shaw corresponding
NewYork–Presbyterian Hospital · Weill Cornell Medicine
Affiliation as printed
Dalio Institute of Cardiovascular Imaging, Department of Radiology, New York-Presbyterian Hospital and the Weill Cornell Medical College, New York
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