Author + information
- Received May 23, 2018
- Revision received September 24, 2018
- Accepted October 8, 2018
- Published online January 14, 2019.
- Roel S. Driessen, MDa,
- Ibrahim Danad, MDa,
- Wijnand J. Stuijfzand, MDa,
- Pieter G. Raijmakers, MD, PhDb,
- Stefan P. Schumacher, MDa,
- Pepijn A. van Diemen, MDa,
- Jonathon A. Leipsic, MDc,
- Juhani Knuuti, MD, PhDd,
- S. Richard Underwood, MD, PhDe,
- Peter M. van de Ven, PhDf,
- Albert C. van Rossum, MD, PhDa,
- Charles A. Taylor, PhDg,h and
- Paul Knaapen, MD, PhDa,∗ (, )@VumcAmsterdam
- aDepartment of Cardiology, VU University Medical Center, Amsterdam, the Netherlands
- bDepartment of Radiology, Nuclear Medicine & PET Research, VU University Medical Center, Amsterdam, the Netherlands
- cDepartment of Medicine and Radiology, University of British Columbia, Vancouver, British Columbia, Canada
- dTurku PET Centre, Turku University Hospital and University of Turku, Turku, Finland
- eDepartment of Nuclear Medicine, Royal Brompton Hospital, London, United Kingdom
- fDepartment of Epidemiology and Biostatistics, VU University Medical Center, Amsterdam, the Netherlands
- gHeartFlow, Inc., Redwood City, California
- hDepartment of Bioengineering, Stanford University, Stanford, California
- ↵∗Address for correspondence:
Dr. Paul Knaapen, Department of Cardiology, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, the Netherlands.
Background Fractional flow reserve (FFR) computation from coronary computed tomography angiography (CTA) datasets (FFRCT) has emerged as a promising noninvasive test to assess hemodynamic severity of coronary artery disease (CAD), but has not yet been compared with traditional functional imaging.
Objectives The purpose of this study was to evaluate the diagnostic performance of FFRCT and compare it with coronary CTA, single-photon emission computed tomography (SPECT), and positron emission tomography (PET) for ischemia diagnosis.
Methods This subanalysis involved 208 prospectively included patients with suspected stable CAD, who underwent 256-slice coronary CTA, 99mTc-tetrofosmin SPECT, [15O]H2O PET, and routine 3-vessel invasive FFR measurements. FFRCT values were retrospectively derived from the coronary CTA images. Images from each modality were interpreted by core laboratories, and their diagnostic performances were compared using invasively measured FFR ≤0.80 as the reference standard.
Results In total, 505 of 612 (83%) vessels could be evaluated with FFRCT. FFRCT showed a diagnostic accuracy, sensitivity, and specificity of 87%, 90%, and 86% on a per-vessel basis and 78%, 96%, and 63% on a per-patient basis, respectively. Area under the receiver-operating characteristic curve (AUC) for identification of ischemia-causing lesions was significantly greater for FFRCT (0.94 and 0.92) in comparison with coronary CTA (0.83 and 0.81; p < 0.01 for both) and SPECT (0.70 and 0.75; p < 0.01 for both), on a per-vessel and -patient level, respectively. FFRCT also outperformed PET on a per-vessel basis (AUC 0.87; p < 0.01), but not on a per-patient basis (AUC 0.91; p = 0.56). In the intention-to-diagnose analysis, PET showed the highest per-patient and -vessel AUC followed by FFRCT (0.86 vs. 0.83; p = 0.157; and 0.90 vs. 0.79; p = 0.005, respectively).
Conclusions In this study, FFRCT showed higher diagnostic performance than standard coronary CTA, SPECT, and PET for vessel-specific ischemia, provided coronary CTA images were evaluable by FFRCT, whereas PET had a favorable performance in per-patient and intention-to-diagnose analysis. Still, in patients in whom 3-vessel FFRCT could be analyzed, FFRCT holds clinical potential to provide anatomic and hemodynamic significance of coronary lesions.
- coronary artery disease
- coronary computed tomography angiography
- fractional flow reserve
- myocardial perfusion imaging
Dr. Leipsic has received research grants from GE Healthcare; and serves as a consultant and holds stock options in Circle CVI and HeartFlow. Dr. Knuuti has provided trial consultancy for GE Healthcare and AstraZeneca. Dr. Underwood provides occasional consultancy to GE Healthcare. Dr. Taylor has an equity interest in and is an employee of HeartFlow. Dr. Knaapen has received unrestricted research grants from HeartFlow. All other authors have reported that 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 May 23, 2018.
- Revision received September 24, 2018.
- Accepted October 8, 2018.
- 2019 American College of Cardiology Foundation
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