Coronary CT Angiographic and Flow Reserve-Guided Management of Patients With Stable Ischemic Heart Disease

Bjarne L. Nørgaard, Christian J. Terkelsen, Ole N. Mathiassen, Erik L. Grove, Hans Erik Bøtker, Erik Parner, Jonathon Leipsic, Flemming H. Steffensen, Anders H. Riis, Kamilla Pedersen, Evald H. Christiansen, Michael Mæng, Lars R. Krusell, Steen D. Kristensen, Ashkan Eftekhari, Lars Jakobsen, Jesper M. Jensen

Publikation: Bidrag til tidsskriftTidsskriftartikelForskningpeer review

33 Downloads (Pure)

Resumé

Background: Clinical outcomes following coronary computed tomography–derived fractional flow reserve (FFR CT) testing in clinical practice are unknown. Objectives: This study sought to assess real-world clinical outcomes following a diagnostic strategy including first-line coronary computed tomography angiography (CTA) with selective FFR CT testing. Methods: The study reviewed the results of 3,674 consecutive patients with stable chest pain evaluated with CTA and FFR CT testing to guide downstream management in patients with intermediate stenosis (30% to 70%). The composite endpoint (all-cause death, myocardial infarction, hospitalization for unstable angina, and unplanned revascularization) was determined in 4 patient groups: 1) CTA stenosis <30%, optimal medical treatment (OMT), and no additional testing; 2) FFR CT >0.80, OMT, no additional testing; 3) FFR CT ≤0.80, OMT, no additional testing; and 4) FFR CT ≤0.80, OMT, and referral to invasive coronary angiography. Patients were followed for a median of 24 (range 8 to 41) months. Results: FFR CT was available in 677 patients, and the test result was negative (>0.80) in 410 (61%) patients. In 75% of the patients with FFR CT >0.80, maximum coronary stenosis was ≥50%. The cumulative incidence proportion (95% confidence interval [CI]) of the composite endpoint at the end of follow-up was comparable in groups 1 (2.8%; 95% CI: 1.4% to 4.9%) and 2 (3.9%; 95% CI: 2.0% to 6.9%) (p = 0.58) but was higher (when compared with group 1) in groups 3 (9.4%; p = 0.04) and 4 (6.6%; p = 0.08). Risk of myocardial infarction was lower in group 4 (1.3%) than in group 3 (8%; p < 0.001). Conclusions: In patients with intermediate-range coronary stenosis, FFR CT is effective in differentiating patients who do not require further diagnostic testing or intervention (FFR CT >0.80) from higher-risk patients (FFR CT ≤0.80) in whom further testing with invasive coronary angiography and possibly intervention may be needed. Further studies assessing the risk and optimal management strategy in patients undergoing first-line CTA with selective FFR CT testing are needed.

OriginalsprogEngelsk
TidsskriftJournal of the American College of Cardiology
Vol/bind72
Udgave nummer18
Sider (fra-til)2123-2134
ISSN0735-1097
DOI
StatusUdgivet - 2018

Fingeraftryk

Confidence Intervals
Coronary Angiography
Pathologic Constriction
Cause of Death
Referral and Consultation
Computed Tomography Angiography
Incidence

Citer dette

Nørgaard, B. L., Terkelsen, C. J., Mathiassen, O. N., Grove, E. L., Bøtker, H. E., Parner, E., ... Jensen, J. M. (2018). Coronary CT Angiographic and Flow Reserve-Guided Management of Patients With Stable Ischemic Heart Disease. Journal of the American College of Cardiology, 72(18), 2123-2134. https://doi.org/10.1016/j.jacc.2018.07.043
Nørgaard, Bjarne L. ; Terkelsen, Christian J. ; Mathiassen, Ole N. ; Grove, Erik L. ; Bøtker, Hans Erik ; Parner, Erik ; Leipsic, Jonathon ; Steffensen, Flemming H. ; Riis, Anders H. ; Pedersen, Kamilla ; Christiansen, Evald H. ; Mæng, Michael ; Krusell, Lars R. ; Kristensen, Steen D. ; Eftekhari, Ashkan ; Jakobsen, Lars ; Jensen, Jesper M. / Coronary CT Angiographic and Flow Reserve-Guided Management of Patients With Stable Ischemic Heart Disease. I: Journal of the American College of Cardiology. 2018 ; Bind 72, Nr. 18. s. 2123-2134.
@article{b304b2a0a3cf417a897a63794ac297e0,
title = "Coronary CT Angiographic and Flow Reserve-Guided Management of Patients With Stable Ischemic Heart Disease",
abstract = "Background: Clinical outcomes following coronary computed tomography–derived fractional flow reserve (FFR CT) testing in clinical practice are unknown. Objectives: This study sought to assess real-world clinical outcomes following a diagnostic strategy including first-line coronary computed tomography angiography (CTA) with selective FFR CT testing. Methods: The study reviewed the results of 3,674 consecutive patients with stable chest pain evaluated with CTA and FFR CT testing to guide downstream management in patients with intermediate stenosis (30{\%} to 70{\%}). The composite endpoint (all-cause death, myocardial infarction, hospitalization for unstable angina, and unplanned revascularization) was determined in 4 patient groups: 1) CTA stenosis <30{\%}, optimal medical treatment (OMT), and no additional testing; 2) FFR CT >0.80, OMT, no additional testing; 3) FFR CT ≤0.80, OMT, no additional testing; and 4) FFR CT ≤0.80, OMT, and referral to invasive coronary angiography. Patients were followed for a median of 24 (range 8 to 41) months. Results: FFR CT was available in 677 patients, and the test result was negative (>0.80) in 410 (61{\%}) patients. In 75{\%} of the patients with FFR CT >0.80, maximum coronary stenosis was ≥50{\%}. The cumulative incidence proportion (95{\%} confidence interval [CI]) of the composite endpoint at the end of follow-up was comparable in groups 1 (2.8{\%}; 95{\%} CI: 1.4{\%} to 4.9{\%}) and 2 (3.9{\%}; 95{\%} CI: 2.0{\%} to 6.9{\%}) (p = 0.58) but was higher (when compared with group 1) in groups 3 (9.4{\%}; p = 0.04) and 4 (6.6{\%}; p = 0.08). Risk of myocardial infarction was lower in group 4 (1.3{\%}) than in group 3 (8{\%}; p < 0.001). Conclusions: In patients with intermediate-range coronary stenosis, FFR CT is effective in differentiating patients who do not require further diagnostic testing or intervention (FFR CT >0.80) from higher-risk patients (FFR CT ≤0.80) in whom further testing with invasive coronary angiography and possibly intervention may be needed. Further studies assessing the risk and optimal management strategy in patients undergoing first-line CTA with selective FFR CT testing are needed.",
keywords = "computed tomography angiography, coronary angiography, coronary artery disease, fractional flow reserve",
author = "N{\o}rgaard, {Bjarne L.} and Terkelsen, {Christian J.} and Mathiassen, {Ole N.} and Grove, {Erik L.} and B{\o}tker, {Hans Erik} and Erik Parner and Jonathon Leipsic and Steffensen, {Flemming H.} and Riis, {Anders H.} and Kamilla Pedersen and Christiansen, {Evald H.} and Michael M{\ae}ng and Krusell, {Lars R.} and Kristensen, {Steen D.} and Ashkan Eftekhari and Lars Jakobsen and Jensen, {Jesper M.}",
year = "2018",
doi = "10.1016/j.jacc.2018.07.043",
language = "English",
volume = "72",
pages = "2123--2134",
journal = "Journal of the American College of Cardiology",
issn = "0735-1097",
publisher = "Heinemann",
number = "18",

}

Nørgaard, BL, Terkelsen, CJ, Mathiassen, ON, Grove, EL, Bøtker, HE, Parner, E, Leipsic, J, Steffensen, FH, Riis, AH, Pedersen, K, Christiansen, EH, Mæng, M, Krusell, LR, Kristensen, SD, Eftekhari, A, Jakobsen, L & Jensen, JM 2018, 'Coronary CT Angiographic and Flow Reserve-Guided Management of Patients With Stable Ischemic Heart Disease', Journal of the American College of Cardiology, bind 72, nr. 18, s. 2123-2134. https://doi.org/10.1016/j.jacc.2018.07.043

Coronary CT Angiographic and Flow Reserve-Guided Management of Patients With Stable Ischemic Heart Disease. / Nørgaard, Bjarne L.; Terkelsen, Christian J.; Mathiassen, Ole N.; Grove, Erik L.; Bøtker, Hans Erik; Parner, Erik; Leipsic, Jonathon; Steffensen, Flemming H.; Riis, Anders H.; Pedersen, Kamilla; Christiansen, Evald H.; Mæng, Michael; Krusell, Lars R.; Kristensen, Steen D.; Eftekhari, Ashkan; Jakobsen, Lars; Jensen, Jesper M.

I: Journal of the American College of Cardiology, Bind 72, Nr. 18, 2018, s. 2123-2134.

Publikation: Bidrag til tidsskriftTidsskriftartikelForskningpeer review

TY - JOUR

T1 - Coronary CT Angiographic and Flow Reserve-Guided Management of Patients With Stable Ischemic Heart Disease

AU - Nørgaard, Bjarne L.

AU - Terkelsen, Christian J.

AU - Mathiassen, Ole N.

AU - Grove, Erik L.

AU - Bøtker, Hans Erik

AU - Parner, Erik

AU - Leipsic, Jonathon

AU - Steffensen, Flemming H.

AU - Riis, Anders H.

AU - Pedersen, Kamilla

AU - Christiansen, Evald H.

AU - Mæng, Michael

AU - Krusell, Lars R.

AU - Kristensen, Steen D.

AU - Eftekhari, Ashkan

AU - Jakobsen, Lars

AU - Jensen, Jesper M.

PY - 2018

Y1 - 2018

N2 - Background: Clinical outcomes following coronary computed tomography–derived fractional flow reserve (FFR CT) testing in clinical practice are unknown. Objectives: This study sought to assess real-world clinical outcomes following a diagnostic strategy including first-line coronary computed tomography angiography (CTA) with selective FFR CT testing. Methods: The study reviewed the results of 3,674 consecutive patients with stable chest pain evaluated with CTA and FFR CT testing to guide downstream management in patients with intermediate stenosis (30% to 70%). The composite endpoint (all-cause death, myocardial infarction, hospitalization for unstable angina, and unplanned revascularization) was determined in 4 patient groups: 1) CTA stenosis <30%, optimal medical treatment (OMT), and no additional testing; 2) FFR CT >0.80, OMT, no additional testing; 3) FFR CT ≤0.80, OMT, no additional testing; and 4) FFR CT ≤0.80, OMT, and referral to invasive coronary angiography. Patients were followed for a median of 24 (range 8 to 41) months. Results: FFR CT was available in 677 patients, and the test result was negative (>0.80) in 410 (61%) patients. In 75% of the patients with FFR CT >0.80, maximum coronary stenosis was ≥50%. The cumulative incidence proportion (95% confidence interval [CI]) of the composite endpoint at the end of follow-up was comparable in groups 1 (2.8%; 95% CI: 1.4% to 4.9%) and 2 (3.9%; 95% CI: 2.0% to 6.9%) (p = 0.58) but was higher (when compared with group 1) in groups 3 (9.4%; p = 0.04) and 4 (6.6%; p = 0.08). Risk of myocardial infarction was lower in group 4 (1.3%) than in group 3 (8%; p < 0.001). Conclusions: In patients with intermediate-range coronary stenosis, FFR CT is effective in differentiating patients who do not require further diagnostic testing or intervention (FFR CT >0.80) from higher-risk patients (FFR CT ≤0.80) in whom further testing with invasive coronary angiography and possibly intervention may be needed. Further studies assessing the risk and optimal management strategy in patients undergoing first-line CTA with selective FFR CT testing are needed.

AB - Background: Clinical outcomes following coronary computed tomography–derived fractional flow reserve (FFR CT) testing in clinical practice are unknown. Objectives: This study sought to assess real-world clinical outcomes following a diagnostic strategy including first-line coronary computed tomography angiography (CTA) with selective FFR CT testing. Methods: The study reviewed the results of 3,674 consecutive patients with stable chest pain evaluated with CTA and FFR CT testing to guide downstream management in patients with intermediate stenosis (30% to 70%). The composite endpoint (all-cause death, myocardial infarction, hospitalization for unstable angina, and unplanned revascularization) was determined in 4 patient groups: 1) CTA stenosis <30%, optimal medical treatment (OMT), and no additional testing; 2) FFR CT >0.80, OMT, no additional testing; 3) FFR CT ≤0.80, OMT, no additional testing; and 4) FFR CT ≤0.80, OMT, and referral to invasive coronary angiography. Patients were followed for a median of 24 (range 8 to 41) months. Results: FFR CT was available in 677 patients, and the test result was negative (>0.80) in 410 (61%) patients. In 75% of the patients with FFR CT >0.80, maximum coronary stenosis was ≥50%. The cumulative incidence proportion (95% confidence interval [CI]) of the composite endpoint at the end of follow-up was comparable in groups 1 (2.8%; 95% CI: 1.4% to 4.9%) and 2 (3.9%; 95% CI: 2.0% to 6.9%) (p = 0.58) but was higher (when compared with group 1) in groups 3 (9.4%; p = 0.04) and 4 (6.6%; p = 0.08). Risk of myocardial infarction was lower in group 4 (1.3%) than in group 3 (8%; p < 0.001). Conclusions: In patients with intermediate-range coronary stenosis, FFR CT is effective in differentiating patients who do not require further diagnostic testing or intervention (FFR CT >0.80) from higher-risk patients (FFR CT ≤0.80) in whom further testing with invasive coronary angiography and possibly intervention may be needed. Further studies assessing the risk and optimal management strategy in patients undergoing first-line CTA with selective FFR CT testing are needed.

KW - computed tomography angiography

KW - coronary angiography

KW - coronary artery disease

KW - fractional flow reserve

U2 - 10.1016/j.jacc.2018.07.043

DO - 10.1016/j.jacc.2018.07.043

M3 - Journal article

VL - 72

SP - 2123

EP - 2134

JO - Journal of the American College of Cardiology

JF - Journal of the American College of Cardiology

SN - 0735-1097

IS - 18

ER -