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Quantitative Flow Ratio Identifies Nonculprit Coronary Lesions Requiring Revascularization in Patients With
Giosafat Spitaleri1, Matteo Tebaldi1, Simone Biscaglia1
1From the Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Cona (FE), Italy (G.S., M.T., S.B., A.E., G.P., A.B., R.F., G.C.); Department of Cardiology, Aarhus University Hospital, Skejby, Denmark (J.W.); University Hospital Clínic, Cardiovascular Clinic Institute, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (S.B., M.S.); Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy (A.M.L., C.T.); Division of Cardiology, Misericordia Hospital, Grosseto, Italy (A.P.); Bolognini Hospital, Seriate (BG), Italy (A.I.); Cardiologia Interventistica, A.O. Sant'Anna e San Sebastiano, Caserta, Italy (D.D.G.); Maria Cecilia Hospital, GVM Care and Research, E.S: Health Science Foundation, Cotignola, Italy (R.F., G.C.); Department of Radiology, Leiden University Medical Center, the Netherlands (J.H.C.R.); and University Hospital of Bern, Inselspital, Switzerland (M.V.).
Insights
Quantitative flow ratio (QFR) is a reliable tool for managing nonculprit lesions (NCLs) in ST-elevation myocardial infarction patients. QFR accurately identifies flow-limiting NCLs, guiding revascularization and improving patient outcomes.
Area of Science:
- Cardiology
- Interventional Cardiology
- Medical Imaging
Background:
- Management of nonculprit lesions (NCLs) in ST-segment-elevation myocardial infarction (STEMI) patients with multivessel disease remains a clinical challenge.
- Quantitative flow ratio (QFR) is an emerging noninvasive imaging tool to assess lesion severity.
Purpose of the Study:
- To evaluate the reliability and diagnostic accuracy of QFR in identifying flow-limiting NCLs in STEMI patients.
- To assess the long-term clinical outcomes associated with NCLs stratified by QFR values.
Main Methods:
- A 3-step study involving QFR reproducibility assessment (Cohort A), prospective validation against fractional flow reserve (FFR) (Cohort B), and long-term clinical outcome analysis (Cohort C).
- QFR values were computed by a blinded core laboratory for all NCLs.
Main Results:
- QFR demonstrated good reproducibility and agreement with acute and staged assessments (r=0.98).
- QFR showed high diagnostic accuracy compared to FFR (sensitivity 88%, specificity 97%, AUC 0.96).
- NCLs with QFR ≤0.80 were associated with a significantly higher risk of adverse events (HR 2.3, P=0.01).
Conclusions:
- QFR is a safe and reliable tool for guiding coronary revascularization of NCLs in STEMI patients.
- QFR can effectively stratify risk in NCLs, aiding clinical decision-making.
Background:
The nonculprit lesion (NCL) management in ST-segment-elevation myocardial infarction patients with multivessel disease is debated. We sought to assess whether quantitative flow ratio (QFR), a noninvasive tool to identify potentially flow-limiting lesions, may be reliable in this scenario.
Methods And Results:
The present proof-of-concept study is based on a 3-step process: (1) identification of the QFR reproducibility in NCLs assessment (cohort A, n=31); (2) prospective validation of QFR diagnostic accuracy in respect to fractional flow reserve (cohort B, n=45); and (3) investigation of long-term clinical outcomes of NCLs stratified according to QFR (cohort C, n=110). A blinded core laboratory computed QFR values for all NCLs. Cohort A showed a good correlation and agreement between QFR values at index (acute) and at staged (subacute, 3-4 days later) procedures (r=0.98; 95% confidence interval, 0.96-0.99; mean difference, 0.004 [-0.027 to 0.34]). The inter-rater agreement was κ=0.9. In cohort B, fractional flow reserve and QFR identified 16 (33%) and 17 (35%) NCLs potentially flow limiting. Sensitivity, specificity, negative, and positive predictive values were 88%, 97%, 94%, and 94%. The area under the receiver operating characteristics curve was 0.96 (95% confidence interval, 0.89-0.99). Finally, in cohort C, we identified 110 ST-segment-elevation myocardial infarction patients where at least 1 NCL was left untreated. Patients with NCLs showing a QFR value ≤0.80 were at higher risk of adverse events (hazard ratio, 2.3; 95% confidence interval, 1.2-4.5; P=0.01).
Conclusions:
In a limited and selected study population, our study showed that QFR computation may be a safe and reliable tool to guide coronary revascularization of NCLs in ST-segment-elevation myocardial infarction patients.
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