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      Non-invasive CT-derived fractional flow reserve and static rest and stress CT myocardial perfusion imaging for detection of haemodynamically significant coronary stenosis

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          Abstract

          Computed tomography derived fractional flow reserve (FFR CT) and computed tomography stress myocardial perfusion imaging (CTP) are techniques to assess haemodynamic significance of coronary stenosis. To compare the diagnostic performance of FFR CT and static rest/stress CTP in detecting fractional flow reserve (FFR) defined haemodynamically-significant stenosis (FFR ≤ 0.8). Fifty-one patients (96 vessels) with suspected coronary artery disease from a single institution planned for elective invasive-angiography prospectively underwent research indicated 320-detector-CT-coronary-angiography (CTA) and adenosine-stress CTP and invasive FFR. Analyses were performed in separate core-laboratories for FFR CT and CTP blinded to FFR results. Myocardial perfusion was assessed visually and semi-quantitatively by transmural perfusion ratio (TPR). Invasive FFR ≤ 0.8 was present in 33% of vessels and 49% of patients. FFR CT, visual CTP and TPR analysis was feasible in 96%, 92% and 92% of patients respectively. Overall per-vessel sensitivity, specificity and diagnostic accuracy for FFR CT were 81%, 85%, 84%, for visual CTP were 50%, 89%, 75% and for TPR were 69%, 48%, 56% respectively. Receiver-operating-characteristics curve analysis demonstrated larger per vessel area-under-curve (AUC) for FFR CT (0.89) compared with visual CTP (0.70; p < 0.001), TPR (0.58; p < 0.001) and CTA (0.70; p = 0.0007); AUC for CTA + FFR CT (0.91) was higher than CTA + visual CTP (0.77, p = 0.008) and CTA + TPR (0.74, p < 0.001). Per-patient AUC for FFR CT (0.90) was higher than visual CTP (0.69; p = 0.0016), TPR (0.56; p < 0.0001) and CTA (0.68; p = 0.001). Based on this selected cohort of patients FFR CT is superior to visually and semi-quantitatively assessed static rest/stress CTP in detecting haemodynamically-significant coronary stenosis as determined on invasive FFR.

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          Comparison of Coronary CT Angiography, SPECT, PET, and Hybrid Imaging for Diagnosis of Ischemic Heart Disease Determined by Fractional Flow Reserve

          Ibrahim Danad, Pieter G. Raijmakers, Roel S. Driessen … (2017)
          Importance At present, the choice of noninvasive testing for a diagnosis of significant coronary artery disease (CAD) is ambiguous, but nuclear myocardial perfusion imaging with single-photon emission tomography (SPECT) or positron emission tomography (PET) and coronary computed tomography angiography (CCTA) is predominantly used for this purpose. However, to date, prospective head-to-head studies are lacking regarding the diagnostic accuracy of these imaging modalities. Furthermore, the combination of anatomical and functional assessments configuring a hybrid approach may yield improved accuracy. Objectives To establish the diagnostic accuracy of CCTA, SPECT, and PET and explore the incremental value of hybrid imaging compared with fractional flow reserve. Design, Setting, and Participants A prospective clinical study involving 208 patients with suspected CAD who underwent CCTA, technetium 99m/tetrofosmin–labeled SPECT, and [ 15 O]H 2 O PET with examination of all coronary arteries by fractional flow reserve was performed from January 23, 2012, to October 25, 2014. Scans were interpreted by core laboratories on an intention-to-diagnose basis. Hybrid images were generated in case of abnormal noninvasive anatomical or functional test results. Main Outcomes and Measures Hemodynamically significant stenosis in at least 1 coronary artery as indicated by a fractional flow reserve of 0.80 or less and relative diagnostic accuracy of SPECT, PET, and CCTA in detecting hemodynamically significant CAD. Results Of the 208 patients in the study (76 women and 132 men; mean [SD] age, 58 [9] years), 92 (44.2%) had significant CAD (fractional flow reserve ≤0.80). Sensitivity was 90% (95% CI, 82%-95%) for CCTA, 57% (95% CI, 46%-67%) for SPECT, and 87% (95% CI, 78%-93%) for PET, whereas specificity was 60% (95% CI, 51%-69%) for CCTA, 94% (95% CI, 88%-98%) for SPECT, and 84% (95% CI, 75%-89%) for PET. Single-photon emission tomography was found to be noninferior to PET in terms of specificity ( P  < .001) but not in terms of sensitivity ( P  > .99) using the predefined absolute margin of 10%. Diagnostic accuracy was highest for PET (85%; 95% CI, 80%-90%) compared with that of CCTA (74%; 95% CI, 67%-79%; P  = .003) and SPECT (77%; 95% CI, 71%-83%; P  = .02). Diagnostic accuracy was not enhanced by either hybrid SPECT and CCTA (76%; 95% CI, 70%-82%; P  = .75) or by PET and CCTA (84%; 95% CI, 79%-89%; P  = .82), but resulted in an increase in specificity ( P  = .004) at the cost of a decrease in sensitivity ( P  = .001). Conclusions and Relevance This controlled clinical head-to-head comparative study revealed PET to exhibit the highest accuracy for diagnosis of myocardial ischemia. Furthermore, a combined anatomical and functional assessment does not add incremental diagnostic value but guides clinical decision-making in an unsalutary fashion. This head-to-head comparative study evaluates the diagnostic accuracy of coronary computed tomography angiography, single-photon emission tomography, and positron emission tomography and explores the incremental value of hybrid imaging compared with fractional flow reserve. Question What are the diagnostic performances of coronary computed tomography angiography, single-photon emission tomography, [ 15 O]H 2 O positron emission tomography, and hybrid imaging for the diagnosis of myocardial ischemia using fractional flow reserve as a reference standard? Findings In this head-to-head comparative study of 208 adults, sensitivity was 90% for coronary computed tomography angiography, 57% for single-photon emission tomography, and 87% for positron emission tomography, whereas specificity was 60% for coronary computed tomography angiography, 94% for single-photon emission tomography, and 84% for positron emission tomography. Positron emission tomography exhibited the highest diagnostic accuracy compared with single-photon emission tomography and coronary computed tomography angiography. Meaning Coronary computed tomography angiography and [ 15 O]H 2 O positron emission tomography are both useful in the diagnosis of myocardial ischemia, while single-photon emission tomography and hybrid imaging guide clinical decision making in an unsalutary fashion.
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            Standardized myocardial segmentation and nomenclature for tomographic imaging of the heart. A statement for healthcare professionals from the Cardiac Imaging Committee of the Council on Clinical Cardiology of the American Heart Association.

            Joseph Ryan, Vasken Dilsizian, Mario S Verani … (2002)
            Article 0 comments Cited 114 times – based on 0 reviews     Review now
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              Incremental prognostic value of myocardial perfusion single photon emission computed tomography for the prediction of cardiac death: differential stratification for risk of cardiac death and myocardial infarction.

              Rory Hachamovitch, Daniel Berman, Leslee J Shaw … (1998)
              The incremental prognostic value of stress single photon emission computed tomography (SPECT) for the prediction of cardiac death as an individual end point and the implications for risk stratification are undefined. We identified 5183 consecutive patients who underwent stress/rest SPECT and were followed up for the occurrence of cardiac death or myocardial infarction. Over a mean follow up of 642+/-226 days, 119 cardiac deaths and 158 myocardial infarctions occurred (3.0% cardiac death rate, 2.3% myocardial infarction rate). Patients with normal scans were at low risk (< or =0.5%/y), and rates of both outcomes increased significantly with worsening scan abnormalities. Patients who underwent exercise stress and had mildly abnormal scans had low rates of cardiac death but higher rates of myocardial infarction (0.7%/y versus 2.6%/y; P<.05). After adjustment for prescan information, scan results provided incremental prognostic value toward the prediction of cardiac death. The identification of patients at intermediate risk of nonfatal myocardial infarction and low risk for cardiac death by SPECT may result in significant cost savings when applied to a clinical testing strategy. Myocardial perfusion SPECT yields incremental prognostic information toward the identification of cardiac death. Patients with mildly abnormal scans after exercise stress are at low risk for cardiac death but intermediate risk for nonfatal myocardial infarction and thus may benefit from a noninvasive strategy and may not require invasive management.
              Article 0 comments Cited 105 times – based on 0 reviews     Review now
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                Author and article information

                Contributors
                Brian S. Ko: 61 3 95946666 , brian.ko@monashhealth.org
                Journal
                Journal ID (nlm-ta): Int J Cardiovasc Imaging
                Journal ID (iso-abbrev): Int J Cardiovasc Imaging
                Title: The International Journal of Cardiovascular Imaging
                Publisher: Springer Netherlands (Dordrecht )
                ISSN (Print): 1569-5794
                ISSN (Electronic): 1875-8312
                Publication date (Electronic): 4 July 2019
                Publication date PMC-release: 4 July 2019
                Publication date (Print): 2019
                Volume: 35
                Issue: 11
                Pages: 2103-2112
                Affiliations
                [1 ]GRID grid.419789.a, ISNI 0000 0000 9295 3933, Monash Cardiovascular Research Centre, , Monash University and MonashHeart, Monash Health, ; Clayton, VIC Australia
                [2 ]GRID grid.5254.6, ISNI 0000 0001 0674 042X, Department of Cardiology, The Heart Centre, Rigshospitalet, , University of Copenhagen, ; Copenhagen, Denmark
                [3 ]GRID grid.154185.c, ISNI 0000 0004 0512 597X, Department of Cardiology, , Aarhus University Hospital, ; Skejby, Aarhus, Denmark
                Article
                Publisher ID: 1658
                DOI: 10.1007/s10554-019-01658-x
                PMC ID: 6805817
                PubMed ID: 31273632
                SO-VID: 10861394-6687-4c77-adca-767a6ce0c9d4
                Copyright © © The Author(s) 2019
                License:

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

                History
                Date received : 12 February 2019
                Date accepted : 24 June 2019
                Categories
                Subject: Original Paper
                Custom metadata
                issue-copyright-statement © Springer Nature B.V. 2019

                ScienceOpen disciplines: Cardiovascular Medicine
                Keywords: imaging,coronary disease,ischemia,computed tomography,fractional flow reserve,myocardial perfusion imaging
                Data availability:
                ScienceOpen disciplines: Cardiovascular Medicine
                Keywords: imaging, coronary disease, ischemia, computed tomography, fractional flow reserve, myocardial perfusion imaging

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