Sequential Strategy Including FFRCT Plus Stress-CTP Impacts on Management of Patients with Stable Chest Pain: The Stress-CTP RIPCORD Study.

Andrea Baggiano,Franco Fabbiocchi,Elisabetta Tonet,Patrizia Vivona,Saima Mushtaq,Chiara Martini,Margherita Soldi,Alberto Formenti,Daniela Trabattoni,Enrico Fraschini,Antonella Loffreno,Edoardo Conte,Marco Guglielmo,Annachiara Cavaliere,Vitanio Palmisano,Piero Montorsi,Francesca Ricci,Mauro Pepi,Daniele Andreini,Nicola Gaibazzi,Giulia Rizzon,Francesca Baessato,Alberico Del Torto,Fabio Fazzari,Gloria Cicala,Alexia Rossi,Antonio L Bartorelli,Laura Fusini,Gianluca Pontone,Giuseppe Muscogiuri,Maria L Danza ,Giacomo Maria Viani ,Mark Rabbat ,Andrea Annoni ,Emilio Assanelli ,Maria Elisabetta Mancini ,Andrea Igoren Guaricci

doi:10.3390/jcm9072147

Abstract

Stress computed tomography perfusion (Stress-CTP) and computed tomography-derived fractional flow reserve (FFRCT) are functional techniques that can be added to coronary computed tomography angiography (cCTA) to improve the management of patients with suspected coronary artery disease (CAD). This retrospective analysis from the PERFECTION study aims to assess the impact of their availability on the management of patients with suspected CAD scheduled for invasive coronary angiography (ICA) and invasive FFR. The management plan was defined as optimal medical therapy (OMT) or revascularization and was recorded for the following strategies: cCTA alone, cCTA+FFRCT, cCTA+Stress-CTP and cCTA+FFRCT+Stress-CTP. In 291 prospectively enrolled patients, cCTA+FFRCT, cCTA+Stress-CTP and cCTA+FFRCT+Stress-CTP showed a similar rate of reclassification of cCTA findings when FFRCT and Stress-CTP were added to cCTA. cCTA, cCTA+FFRCT, cCTA+Stress-CTP and cCTA+FFRCT+Stress-CTP showed a rate of agreement versus the final therapeutic decision of 63%, 71%, 89%, 84% (cCTA+Stress-CTP and cCTA+FFRCT+Stress-CTP vs cCTA and cCTA+FFRCT: p < 0.01), respectively, and a rate of agreement in terms of the vessels to be revascularized of 57%, 64%, 74%, 71% (cCTA+Stress-CTP and cCTA+FFRCT+Stress-CTP vs cCTA and cCTA+FFRCT: p < 0.01), respectively, with an effective radiation dose (ED) of 2.9 ± 1.3 mSv, 2.9 ± 1.3 mSv, 5.9 ± 2.7 mSv, and 3.1 ± 2.1 mSv. The addition of FFRCT and Stress-CTP improved therapeutic decision-making compared to cCTA alone, and a sequential strategy with cCTA+FFRCT+Stress-CTP represents the best compromise in terms of clinical impact and radiation exposure.

Highlights

Coronary computed tomography angiography was introduced as an anatomic imaging method to rule out the presence of coronary artery disease (CAD) [1] and for improving prognostic assessment beyond baseline risk factor evaluation and functional stress test findings [2,3,4]
The main findings of this study are (a) the addition of both FFRCT and Stress-CTP on top of coronary computed tomography angiography (cCTA) led to the reclassification of approximately one third of patients with intermediate to high risk for CAD; (b) compared to the cCTA+FFRCT strategy, cCTA+Stress-CTP showed a better performance in terms of final therapeutic decision-making and target vessels to be revascularized, it is
The main findings of this study are (a) the addition of both FFRCT and Stress-CTP on top of cCTA led to the reclassification of approximately one third of patients with intermediate to high risk for CAD; (b) compared to the cCTA+FFRCT strategy, cCTA+Stress-CTP showed a better performance in terms of final therapeutic decision-making and target vessels to be revascularized, it is associated with higher radiation exposure; and (c) a sequential strategy including cCTA+FFRCT+Stress-CTP where FFRCT is the gatekeeper for the decision to perform a Stress-CTP, seems to provide the best balance between performance and radiation exposure

Summary

Introduction

Coronary computed tomography angiography (cCTA) was introduced as an anatomic imaging method to rule out the presence of coronary artery disease (CAD) [1] and for improving prognostic assessment beyond baseline risk factor evaluation and functional stress test findings [2,3,4]. Several factors limit its specificity and positive predictive value [5,6] In this regard, there is an emerging body of literature on the added value of stress myocardial perfusion utilizing computed tomography (Stress-CTP) [7,8,9,10,11,12] and computed tomography-derived fractional flow reserve (FFRCT) on top of cCTA [9,13,14]. The aim of the study is to evaluate the allocation of patients to optimal medical treatment (OMT) or revascularization using cCTA, cCTA+FFRCT and cCTA+Stress-CTP, and the rate of agreement in terms of the vessels to be revascularized in relation to invasive coronary angiography (ICA) and FFR-defined significance

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Discussion

Conclusion