Noninvasive FFR Derived From Coronary CT Angiography. Management and Outcomes in the PROMISE Trial

Michael T. Lu, Maros Ferencik, Rhonda S. Roberts, Kerry L. Lee, Alexander Ivanov, Elizabeth Adami, Daniel B. Mark, Farouc A. Jaffer, Jonathon A. Leipsic, Pamela S. Douglas, Udo Hoffmann

    Research output: Contribution to journalArticle

    43 Citations (Scopus)

    Abstract

    Objectives: The purpose of this study was to determine whether noninvasive fractional flow reserve derived from computed tomography (FFRCT) predicts coronary revascularization and outcomes and whether its addition improves efficiency of referral to invasive coronary angiography (ICA) after coronary computed tomography angiography (CTA). Background: FFRCT may improve the efficiency of an anatomic CTA strategy for stable chest pain. Methods: This observational cohort study included patients with stable chest pain in the PROMISE trial (PROspective Multicenter Imaging Study for Evaluation of Chest Pain) referred to ICA within 90 days after CTA. FFRCT was measured at a blinded core laboratory, and FFRCT results were unavailable to caregivers. We determined the agreement of FFRCT (positive if ≤0.80) with stenosis on CTA and ICA (positive if ≥50% left main or ≥70% other coronary artery), and predictive value for a composite of coronary revascularization or major adverse cardiac events (death, myocardial infarction, or unstable angina). We retrospectively assessed whether adding FFRCT ≤0.80 as a gatekeeper could improve efficiency of referral to ICA, defined as decreased rate of ICA without ≥50% stenosis and increased ICA leading to revascularization. Results: FFRCT was calculated in 67% (181/271) of eligible patients (mean age 62 years; 36% women). FFRCT was discordant with stenosis in 31% (57/181) for CTA and 29% (52/181) for ICA. Most patients undergoing coronary revascularization had an FFRCT of ≤0.80 (91%; 80/88). An FFRCT of ≤0.80 was a significantly better predictor for revascularization or major adverse cardiac events than severe CTA stenosis (HR: 4.3 [95% confidence interval [CI]: 2.4 to 8.9] vs. 2.9 [95% CI: 1.8 to 5.1]; p = 0.033). Reserving ICA for patients with an FFRCT of ≤0.80 could decrease ICA without ≥50% stenosis by 44%, and increase the proportion of ICA leading to revascularization by 24%. Conclusions: In this hypothesis-generating study of patients with stable chest pain referred to ICA from CTA, an FFRCT of ≤0.80 was a better predictor of revascularization or major adverse cardiac events than severe stenosis on CTA. Adding FFRCT may improve efficiency of referral to ICA from CTA alone.

    Original languageEnglish (US)
    JournalJACC: Cardiovascular Imaging
    DOIs
    StateAccepted/In press - Jun 30 2016

    Fingerprint

    Coronary Angiography
    Tomography
    Pathologic Constriction
    Chest Pain
    Referral and Consultation
    Computed Tomography Angiography
    Confidence Intervals
    Unstable Angina
    Caregivers
    Multicenter Studies
    Observational Studies
    Coronary Vessels
    Cohort Studies
    Myocardial Infarction

    Keywords

    • Computational fluid dynamics
    • Coronary angiography
    • Coronary artery disease
    • Coronary computed tomography angiography
    • Fractional flow reserve

    ASJC Scopus subject areas

    • Radiology Nuclear Medicine and imaging
    • Cardiology and Cardiovascular Medicine

    Cite this

    Noninvasive FFR Derived From Coronary CT Angiography. Management and Outcomes in the PROMISE Trial. / Lu, Michael T.; Ferencik, Maros; Roberts, Rhonda S.; Lee, Kerry L.; Ivanov, Alexander; Adami, Elizabeth; Mark, Daniel B.; Jaffer, Farouc A.; Leipsic, Jonathon A.; Douglas, Pamela S.; Hoffmann, Udo.

    In: JACC: Cardiovascular Imaging, 30.06.2016.

    Research output: Contribution to journalArticle

    Lu, MT, Ferencik, M, Roberts, RS, Lee, KL, Ivanov, A, Adami, E, Mark, DB, Jaffer, FA, Leipsic, JA, Douglas, PS & Hoffmann, U 2016, 'Noninvasive FFR Derived From Coronary CT Angiography. Management and Outcomes in the PROMISE Trial', JACC: Cardiovascular Imaging. https://doi.org/10.1016/j.jcmg.2016.11.024
    Lu, Michael T. ; Ferencik, Maros ; Roberts, Rhonda S. ; Lee, Kerry L. ; Ivanov, Alexander ; Adami, Elizabeth ; Mark, Daniel B. ; Jaffer, Farouc A. ; Leipsic, Jonathon A. ; Douglas, Pamela S. ; Hoffmann, Udo. / Noninvasive FFR Derived From Coronary CT Angiography. Management and Outcomes in the PROMISE Trial. In: JACC: Cardiovascular Imaging. 2016.
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    title = "Noninvasive FFR Derived From Coronary CT Angiography. Management and Outcomes in the PROMISE Trial",
    abstract = "Objectives: The purpose of this study was to determine whether noninvasive fractional flow reserve derived from computed tomography (FFRCT) predicts coronary revascularization and outcomes and whether its addition improves efficiency of referral to invasive coronary angiography (ICA) after coronary computed tomography angiography (CTA). Background: FFRCT may improve the efficiency of an anatomic CTA strategy for stable chest pain. Methods: This observational cohort study included patients with stable chest pain in the PROMISE trial (PROspective Multicenter Imaging Study for Evaluation of Chest Pain) referred to ICA within 90 days after CTA. FFRCT was measured at a blinded core laboratory, and FFRCT results were unavailable to caregivers. We determined the agreement of FFRCT (positive if ≤0.80) with stenosis on CTA and ICA (positive if ≥50{\%} left main or ≥70{\%} other coronary artery), and predictive value for a composite of coronary revascularization or major adverse cardiac events (death, myocardial infarction, or unstable angina). We retrospectively assessed whether adding FFRCT ≤0.80 as a gatekeeper could improve efficiency of referral to ICA, defined as decreased rate of ICA without ≥50{\%} stenosis and increased ICA leading to revascularization. Results: FFRCT was calculated in 67{\%} (181/271) of eligible patients (mean age 62 years; 36{\%} women). FFRCT was discordant with stenosis in 31{\%} (57/181) for CTA and 29{\%} (52/181) for ICA. Most patients undergoing coronary revascularization had an FFRCT of ≤0.80 (91{\%}; 80/88). An FFRCT of ≤0.80 was a significantly better predictor for revascularization or major adverse cardiac events than severe CTA stenosis (HR: 4.3 [95{\%} confidence interval [CI]: 2.4 to 8.9] vs. 2.9 [95{\%} CI: 1.8 to 5.1]; p = 0.033). Reserving ICA for patients with an FFRCT of ≤0.80 could decrease ICA without ≥50{\%} stenosis by 44{\%}, and increase the proportion of ICA leading to revascularization by 24{\%}. Conclusions: In this hypothesis-generating study of patients with stable chest pain referred to ICA from CTA, an FFRCT of ≤0.80 was a better predictor of revascularization or major adverse cardiac events than severe stenosis on CTA. Adding FFRCT may improve efficiency of referral to ICA from CTA alone.",
    keywords = "Computational fluid dynamics, Coronary angiography, Coronary artery disease, Coronary computed tomography angiography, Fractional flow reserve",
    author = "Lu, {Michael T.} and Maros Ferencik and Roberts, {Rhonda S.} and Lee, {Kerry L.} and Alexander Ivanov and Elizabeth Adami and Mark, {Daniel B.} and Jaffer, {Farouc A.} and Leipsic, {Jonathon A.} and Douglas, {Pamela S.} and Udo Hoffmann",
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    T1 - Noninvasive FFR Derived From Coronary CT Angiography. Management and Outcomes in the PROMISE Trial

    AU - Lu, Michael T.

    AU - Ferencik, Maros

    AU - Roberts, Rhonda S.

    AU - Lee, Kerry L.

    AU - Ivanov, Alexander

    AU - Adami, Elizabeth

    AU - Mark, Daniel B.

    AU - Jaffer, Farouc A.

    AU - Leipsic, Jonathon A.

    AU - Douglas, Pamela S.

    AU - Hoffmann, Udo

    PY - 2016/6/30

    Y1 - 2016/6/30

    N2 - Objectives: The purpose of this study was to determine whether noninvasive fractional flow reserve derived from computed tomography (FFRCT) predicts coronary revascularization and outcomes and whether its addition improves efficiency of referral to invasive coronary angiography (ICA) after coronary computed tomography angiography (CTA). Background: FFRCT may improve the efficiency of an anatomic CTA strategy for stable chest pain. Methods: This observational cohort study included patients with stable chest pain in the PROMISE trial (PROspective Multicenter Imaging Study for Evaluation of Chest Pain) referred to ICA within 90 days after CTA. FFRCT was measured at a blinded core laboratory, and FFRCT results were unavailable to caregivers. We determined the agreement of FFRCT (positive if ≤0.80) with stenosis on CTA and ICA (positive if ≥50% left main or ≥70% other coronary artery), and predictive value for a composite of coronary revascularization or major adverse cardiac events (death, myocardial infarction, or unstable angina). We retrospectively assessed whether adding FFRCT ≤0.80 as a gatekeeper could improve efficiency of referral to ICA, defined as decreased rate of ICA without ≥50% stenosis and increased ICA leading to revascularization. Results: FFRCT was calculated in 67% (181/271) of eligible patients (mean age 62 years; 36% women). FFRCT was discordant with stenosis in 31% (57/181) for CTA and 29% (52/181) for ICA. Most patients undergoing coronary revascularization had an FFRCT of ≤0.80 (91%; 80/88). An FFRCT of ≤0.80 was a significantly better predictor for revascularization or major adverse cardiac events than severe CTA stenosis (HR: 4.3 [95% confidence interval [CI]: 2.4 to 8.9] vs. 2.9 [95% CI: 1.8 to 5.1]; p = 0.033). Reserving ICA for patients with an FFRCT of ≤0.80 could decrease ICA without ≥50% stenosis by 44%, and increase the proportion of ICA leading to revascularization by 24%. Conclusions: In this hypothesis-generating study of patients with stable chest pain referred to ICA from CTA, an FFRCT of ≤0.80 was a better predictor of revascularization or major adverse cardiac events than severe stenosis on CTA. Adding FFRCT may improve efficiency of referral to ICA from CTA alone.

    AB - Objectives: The purpose of this study was to determine whether noninvasive fractional flow reserve derived from computed tomography (FFRCT) predicts coronary revascularization and outcomes and whether its addition improves efficiency of referral to invasive coronary angiography (ICA) after coronary computed tomography angiography (CTA). Background: FFRCT may improve the efficiency of an anatomic CTA strategy for stable chest pain. Methods: This observational cohort study included patients with stable chest pain in the PROMISE trial (PROspective Multicenter Imaging Study for Evaluation of Chest Pain) referred to ICA within 90 days after CTA. FFRCT was measured at a blinded core laboratory, and FFRCT results were unavailable to caregivers. We determined the agreement of FFRCT (positive if ≤0.80) with stenosis on CTA and ICA (positive if ≥50% left main or ≥70% other coronary artery), and predictive value for a composite of coronary revascularization or major adverse cardiac events (death, myocardial infarction, or unstable angina). We retrospectively assessed whether adding FFRCT ≤0.80 as a gatekeeper could improve efficiency of referral to ICA, defined as decreased rate of ICA without ≥50% stenosis and increased ICA leading to revascularization. Results: FFRCT was calculated in 67% (181/271) of eligible patients (mean age 62 years; 36% women). FFRCT was discordant with stenosis in 31% (57/181) for CTA and 29% (52/181) for ICA. Most patients undergoing coronary revascularization had an FFRCT of ≤0.80 (91%; 80/88). An FFRCT of ≤0.80 was a significantly better predictor for revascularization or major adverse cardiac events than severe CTA stenosis (HR: 4.3 [95% confidence interval [CI]: 2.4 to 8.9] vs. 2.9 [95% CI: 1.8 to 5.1]; p = 0.033). Reserving ICA for patients with an FFRCT of ≤0.80 could decrease ICA without ≥50% stenosis by 44%, and increase the proportion of ICA leading to revascularization by 24%. Conclusions: In this hypothesis-generating study of patients with stable chest pain referred to ICA from CTA, an FFRCT of ≤0.80 was a better predictor of revascularization or major adverse cardiac events than severe stenosis on CTA. Adding FFRCT may improve efficiency of referral to ICA from CTA alone.

    KW - Computational fluid dynamics

    KW - Coronary angiography

    KW - Coronary artery disease

    KW - Coronary computed tomography angiography

    KW - Fractional flow reserve

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