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Published on: January 28, 2020
High-Risk Morphological and Physiological Coronary Disease Attributes as Outcome Markers After Medical Treatment and
Seokhun Yang1, Bon-Kwon Koo2, Doyeon Hwang1
1Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea.
Insights
High-risk plaque morphology in coronary artery disease offers prognostic value beyond fractional flow reserve (FFR). Incorporating plaque characteristics can refine risk prediction and guide treatment decisions for better patient outcomes.
Area of Science:
- Cardiovascular Imaging and Intervention
- Interventional Cardiology
- Coronary Artery Disease
Background:
- Fractional flow reserve (FFR) is the standard for assessing coronary artery disease severity.
- Coronary computed tomography angiography (CCTA) provides detailed plaque morphology information.
- The combined prognostic impact of FFR and CCTA-derived plaque characteristics is not fully understood.
Purpose of the Study:
- To evaluate the prognostic significance of coronary plaque morphology and physiology.
- To assess outcomes after medical treatment versus percutaneous coronary intervention (PCI).
- To determine if plaque morphology adds value to FFR in risk stratification.
Main Methods:
- Invasive FFR and CCTA were performed on 872 vessels in 538 patients.
- High-risk attributes (HRA) included physiological (FFR ≤0.8) and morphological factors (plaque burden, adverse characteristics, global plaque burden).
- Primary outcome was a composite of revascularization, myocardial infarction, or cardiac death at 5 years.
Main Results:
- High-risk morphological attributes were associated with increased adverse outcomes, independent of FFR.
- Event risk increased proportionally with the number of HRA.
- PCI reduced risk in vessels with 1-2 HRA compared to medical treatment, but not in vessels with 0 or ≥3 HRA.
Conclusions:
- Coronary plaque morphology provides additive prognostic information to FFR.
- Integrating morphological data may optimize treatment selection for coronary artery disease.
- This approach can enhance FFR-based risk prediction models.
Objectives:
This study sought to evaluate the prognostic impact of plaque morphology and coronary physiology on outcomes after medical treatment or percutaneous coronary intervention (PCI).
Background:
Although fractional flow reserve (FFR) is currently best practice, morphological characteristics of coronary artery disease also contribute to outcomes.
Methods:
A total of 872 vessels in 538 patients were evaluated by invasive FFR and coronary computed tomography angiography. High-risk attributes (HRA) were defined as high-risk physiological attribute (invasive FFR ≤0.8) and high-risk morphological attributes including: 1) local plaque burden (minimum lumen area <4 mm2 and plaque burden ≥70%); 2) adverse plaque characteristics ≥2; and 3) global plaque burden (total plaque volume ≥306.5 mm3 and percent atheroma volume ≥32.2%). The primary outcome was the composite of revascularization, myocardial infarction, or cardiac death at 5 years.
Results:
The mean FFR was 0.88 ± 0.08, and PCI was performed in 239 vessels. The primary outcome occurred in 54 vessels (6.2%). All high-risk morphological attributes were associated with the increased risk of adverse outcomes after adjustment for FFR ≤0.8 and demonstrated direct prognostic effect not mediated by FFR ≤0.8. The 5-year event risk proportionally increased as the number of HRA increased (p for trend <0.001) with lower risk in the PCI group than the medical treatment group in vessels with 1 or 2 HRA (9.7% vs. 14.7%), but not in vessels with either 0 or ≥3 HRA. Of the vessels with pre-procedural FFR ≤0.8, ischemia relief by PCI (pre-PCI FFR ≤0.8 and post-PCI FFR >0.8) significantly reduced vessel-oriented composite outcome risk compared with medical treatment alone in vessels with 0 or 1 high-risk morphological attributes (hazard ratio: 0.33; 95% confidence interval: 0.12 to 0.93; p = 0.035), but the risk reduction was attenuated in vessels with ≥2 high-risk morphological attributes.
Conclusions:
High-risk morphological attributes offered additive prognostic value to coronary physiology and may optimize selection of treatment strategies by adding to FFR-based risk predictions (CCTA-FFR Registry for Development of Comprehensive Risk Prediction Model; NCT04037163).
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