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Plaque Characteristics and Stenosis Severity in Coronary Artery Disease
Study Questions:
What is the association between physiological stenosis severity and coronary CTA-defined high-risk plaque characteristics (HRPC) and the prognostic implications of coronary computed tomography angiography (CTA)–defined HRPC in patients with coronary artery disease?
Methods:
The investigators analyzed a total of 772 vessels (299 patients) evaluated by both coronary CTA and fractional flow reserve (FFR). 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. A multivariable marginal Cox model was used to identify independent predictors of VOCO among deferred vessels.
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, 1.451-10.828; 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:
The authors concluded that physiological stenosis severity and the number of HRPC were closely related, and both components had significant association with the risk of clinical events.
Perspective:
This study reports that both FFR and number of HRPC showed a significant association with the cumulative incidence of VOCO at 5 years and both were independent predictors for the risk of VOCO among deferred vessels. Furthermore, the lesions with ≥3 HRPC showed significantly higher risk of VOCO compared with those with <3 HRPC in the FFR >0.80 group. These data suggest that combined use of both physiological stenosis severity and plaque vulnerability may provide better prognostic stratification of patients than either component alone, particularly in patients with FFR >0.80. Additional prospective studies are indicated to assess the usefulness of combined FFR and HRPC data for prognosis.
Clinical Topics: Cardiac Surgery, Cardiovascular Care Team, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Atherosclerotic Disease (CAD/PAD), Cardiac Surgery and Arrhythmias, Interventions and Coronary Artery Disease, Interventions and Imaging, Angiography, Computed Tomography, Nuclear Imaging
Keywords: Calcinosis, Coronary Angiography, Constriction, Pathologic, Coronary Artery Disease, Diagnostic Imaging, Fractional Flow Reserve, Myocardial, Ischemia, Myocardial Infarction, Myocardial Revascularization, Plaque, Atherosclerotic, Primary Prevention, Prognosis, Tomography, X-Ray Computed
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