Author + information
- Received December 31, 2018
- Revision received January 25, 2019
- Accepted February 18, 2019
- Published online May 13, 2019.
- Joo Myung Lee, MD, MPH, PhDa,
- Ki Hong Choi, MDa,
- Bon-Kwon Koo, MD, PhDb,c,∗ (, )@SNUnow,
- Jonghanne Park, MDb,
- Jihoon Kim, MDa,
- Doyeon Hwang, MDb,
- Tae-Min Rhee, MDb,
- Hyung Yoon Kim, MDd,
- Hae Won Jung, MDe,
- Kyung-Jin Kim, MDf,
- Kawase Yoshiaki, MDg,
- Eun-Seok Shin, MD, PhDh,i,
- Joon-Hyung Doh, MD, PhDj,
- Hyuk-Jae Chang, MD, PhDk,
- Yun-Kyeong Cho, MD, PhDl,
- Hyuck-Jun Yoon, MD, PhDl,
- Chang-Wook Nam, MD, PhDl,
- Seung-Ho Hur, MD, PhDl,
- Jianan Wang, MD, PhDm,
- Shaoliang Chen, MD, PhDn,
- Shoichi Kuramitsu, MDo,
- Nobuhiro Tanaka, MD, PhDp,
- Hitoshi Matsuo, MD, PhDg and
- Takashi Akasaka, MD, PhDq
- aDivision of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- bDepartment of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
- cInstitute on Aging, Seoul National University, Seoul, Korea
- dDepartment of Cardiovascular Medicine, Chonnam National University Hospital, Gwangju, Korea
- eDepartment of Cardiology, Daegu Catholic University Medical Center, Daegu, Korea
- fDepartment of Internal Medicine, Ewha Womans University Medical Center, Ewha Womans University School of Medicine, Seoul, Korea
- gDepartment of Cardiology, Gifu Heart Center, Gifu, Japan
- hDepartment of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
- iDivision of Cardiology, Ulsan Hospital, Ulsan, Korea
- jDepartment of Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
- kDivision of Cardiology, Severance Cardiovascular Hospital, Yonsei-Cedars-Sinai Integrative Cardiovascular Imaging Research Center, Yonsei University College of Medicine, Seoul, Korea
- lDepartment of Medicine, Keimyung University Dongsan Medical Center, Daegu, Korea
- mDepartment of Cardiology, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- nDepartment of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
- oDepartment of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
- pDepartment of Cardiology, Tokyo Medical University, Tokyo, Japan
- qWakayama Medical University, Wakayama, Japan
- ↵∗Address for correspondence:
Dr. Bon-Kwon Koo, Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, 101 Daehang-ro, Chongno-gu, Seoul 110-744, Korea.
Background Although the presence of ischemia is a key prognostic factor in patients with coronary artery disease, the presence of high-risk plaque characteristics (HRPC) is also associated with increased risk of cardiovascular events. Limited data exist regarding the prognostic implications of combined information on physiological stenosis severity assessed by fractional flow reserve (FFR) and plaque vulnerability by coronary computed tomography angiography (CTA)–defined HRPC.
Objectives The current study aimed to evaluate the: 1) association between physiological stenosis severity and coronary CTA-defined HRPC; and 2) prognostic implications of coronary CTA-defined HRPC according to physiological stenosis severity in patients with coronary artery disease.
Methods A total of 772 vessels (299 patients) evaluated by both coronary CTA and FFR were analyzed. The presence and number of HRPC (minimum lumen area <4 mm2, plaque burden ≥70%, low attenuating plaque, positive remodeling, napkin-ring sign, or spotty calcification) were assessed using coronary CTA images. The risk of vessel-oriented composite outcome (VOCO) (a composite of vessel-related ischemia-driven revascularization, vessel-related myocardial infarction, or cardiac death) at 5 years was compared according to the number of HRPC and FFR categories.
Results The proportion of lesions with ≥3 HRPC was significantly decreased according to the increase in FFR values (58.6%, 46.5%, 36.8%, 15.7%, and 3.5% for FFR ≤0.60, 0.61 to ≤0.70, 0.71 to ≤0.80, 0.81 to ≤0.90, and >0.90, respectively; overall p value <0.001). Both FFR and number of HRPC showed significant association with the estimated risk of VOCO (p = 0.008 and p = 0.023, respectively). In the FFR >0.80 group, lesions with ≥3 HRPC showed significantly higher risk of VOCO than those with <3 HRPC (15.0% vs. 4.3%; hazard ratio: 3.964; 95% confidence interval: 1.451 to 10.828; p = 0.007). However, there was no significant difference in the risk of VOCO according to HRPC in the FFR ≤0.80 group. By multivariable analysis, the presence of ≥3 HRPC was independently associated with the risk of VOCO in the FFR >0.80 group.
Conclusions Physiological stenosis severity and the number of HRPC were closely related, and both components had significant association with the risk of clinical events. However, the prognostic implication of HRPC was different according to FFR. Integration of both physiological stenosis severity and plaque vulnerability would provide better prognostic stratification of patients than either individual component alone, especially in patients with FFR >0.80. (Clinical Implication of 3-vessel Fractional Flow Reserve [3V FFR-FRIENDS study]; NCT01621438)
This study was supported by an unrestricted research grant from St. Jude Medical. The company had no role in study design, conduct, data analysis, or manuscript preparation. Dr. Joo Myung Lee has received a research grant from St. Jude Medical (Abbott Vascular) and Philips Volcano. Dr. Bon-Kwon Koo has received an institutional research grant from St. Jude Medical (Abbott Vascular) and Philips Volcano. All other authors have reported they have no relationships relevant to the contents of this paper to disclose.
Listen to this manuscript's audio summary by Editor-in-Chief Dr. Valentin Fuster on JACC.org.
- Received December 31, 2018.
- Revision received January 25, 2019.
- Accepted February 18, 2019.
- 2019 American College of Cardiology Foundation
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