Prognostic value of FFRCT in patients with stable chest pain – a 3-year follow-up of the ADVANCE-DK registry

Introduction

The short-term safety of using coronary CT angiography (CTA) derived fractional flow reserve (FFRCT) to guide downstream testing after CTA is well documented. Whether the prognostic information provided by FFRCT can be extended to sustained follow-up and to patients with a high degree of coronary artery calcification (CAC) is unknown.

Purpose

To evaluate the association between FFRCT and clinical outcomes in new onset stable symptomatic patients with coronary stenosis up to 3 years after CTA index testing.

Methods

Multicenter 3-year follow-up study of 900 patients from the Assessing Diagnostic Value of Non-invasive FFRCT in Coronary Care (ADVANCE) registry at three Danish sites, the “ADVANCE-DK Registry”. All patients had at least one ≥30% coronary stenosis by CTA and underwent subsequent core laboratory FFRCT analysis by HeartFlow. The criterium for an abnormal FFRCT test result was an FFRCT value ≤0.80 (2 cm distal to stenosis). High CAC was defined as a CAC score ≥400. The primary endpoint (PE) was a composite of all-cause death and spontaneous myocardial infarction (MI). The secondary endpoint (SE) was a composite of cardiovascular (CV) death and spontaneous MI. Events were adjudicated by an independent clinical committee.

Results

Patient characteristics are given in Table 1. Coronary stenosis ≥50% was present in 750 (83%) patients. In total 36 patients suffered a PE (all-cause death, n=24; MI, n=12) and 22 an SE (CV death, n=10; MI, n=12). An abnormal vs a normal FFRCT test result was associated with an increased risk of the PE and of the SE both overall and in patients with high CAC; PE (all), 6.6% vs 2.1%, relative risk (RR): 3.1; 95% CI: 1.6–6.3, p<0.001, SE (all), 5.0% vs 0.6%, RR: 8.7; 95% CI: non assessable, p<0.001, PE (high CAC), 9.0% vs 2.2%, RR: 4.1; 85% CI: 1.4–11.8, p=0.001, and SE (high CAC), 6.6% vs 0.5%, RR: 12.0; 95% CI: non assessable, p=0.01, respectively, Figure 1. The observed increased risk in patients with an abnormal vs a normal FFRCT test result persisted after adjustment for degree of stenosis by CCTA (< / ≥50%) and amount of CAC (< / ≥400): PE, adjusted RR: 2.5; 95% CI: 1.2–5.2, p=0.02, and SE, adjusted RR: 8.0; 95% CI: 2.1–30.2, p=0.002.

Conclusion

Patients with stable chest pain, stenosis by CTA and a normal FFRCT test result have a low risk of adverse outcomes during 3 years of follow-up. An abnormal FFRCT identifies patients at increased risk of death or spontaneous MI. These associations are consistent in patients with high levels of CAC.

Funding Acknowledgement

Type of funding sources: None.

FFRCT and recurrent symptoms in patients with stable chest pain

Introduction

The major benefit of coronary revascularization when compared with optimal medical treatment (OMT) in patients with stable chest pain (CP) relates to improvement of symptoms and reduction of reinterventions. Non-invasive methods are warranted to discriminate between patients at low and high risk of recurrent CP for subsequent guidance of antianginal treatment (invasive or OMT).

Purpose

To evaluate the association between coronary CT angiography (CTA) derived fractional flow reserve (FFRCT), recurrent CP and quality of life (QOL) in patients with new onset stable CP and stenosis by CTA.

Methods

Multicenter cohort 3-year follow-up sub-study of 769 patients from the Assessing Diagnostic Value of Non-invasive FFRCT in Coronary Care (ADVANCE) registry at three Danish sites, the “ADVANCE-DK Registry”. All patients had at least one ≥30% coronary stenosis by CTA and underwent subsequent core laboratory FFRCT analysis by HeartFlow. An abnormal FFRCT was defined as the lowest in vessel FFRCT value ≤0.80. Patients were classified according to completeness of revascularization by FFRCT: 1) completely revascularized (CR-FFRCT), all coronary arteries with an abnormal FFRCT test result revascularized; 2) incompletely revascularized (IR-FFRCT), ≥1 coronary artery with an abnormal FFRCT test result not revascularized. All patients completed the Seattle Angina Questionnaire (SAQ-7), the EuroQol questionnaire (EQ-5D-5L) and graded (0–100) overall health using the EQ VAS scale at 3-year follow-up. Recurrent CP was defined as CP within the last 4 weeks prior to this follow-up.

Results

Patient characteristics are given in Table 1. At follow-up 23% patients reported recurrent CP. An abnormal vs a normal FFRCT increased the risk of recurrent CP, 27% vs 15%, RR: 1.82; 95% CI: 1.31–2.52, p<0.001. Amongst patients with abnormal FFRCT, revascularization (+/−) was associated to a numerical, but not statistical significantly, reduced risk of recurrent CP, 23% vs 30%, RR: 0.76; 95% CI: 0.56–1.03, p=0.07. IR-FFRCT vs CR-FFRCT had a higher risk for recurrent CP, 31% vs 13%, RR: 2.34; 95% CI: 1.48–3.68, p<0.001, whilst no difference was observed for CR-FFRCT vs normal FFRCT, 13% vs 15%, RR: 0.92; 95% CI: 0.54–1.54, p=0.74. IR-FFRCT vs CR-FFRCT or normal FFRCT, had lower SAQ-7, EQ-5D-5L and EQ-VAS scores, Table 1, all p<0.005. Scores for three selected SAQ-7 domains are shown in Figure 1. Use of antianginal medicine was higher in IR-FFRCT compared to CR-FFRCT and normal FFRCT, mean ± SD: 1.2±0.05 vs 1.0±0.04, p=0.02.

Conclusion

An abnormal FFRCT identifies patients with an increased risk of recurrent CP up to 3 years after index testing. Completeness of revascularization by FFRCT reclassifies patients with abnormal FFRCT into groups with low and high risk for recurrent CP and impaired QOL.

Funding Acknowledgement

Type of funding sources: None.

Completeness of revascularization by FFRCT and prognosis in stable chest pain

Introduction

Major randomized trials of patients with stable chest pain (CP) demonstrated no prognostic benefits of coronary revascularization over optimal medical treatment (OMT). However, in a recent large-scale study, completeness of revascularization was associated with a reduced risk of all-cause death and non-fatal myocardial infarction (MI).

Purpose

To evaluate the association between completeness of revascularization relative to the result of coronary CT angiography (CTA) derived fractional flow reserve (FFRCT) and 3-year prognosis in patients with new onset stable CP and coronary stenosis.

Methods

Multicenter cohort 3-year follow-up sub-study of 900 patients from the Assessing Diagnostic Value of Non-invasive FFRCT in Coronary Care (ADVANCE) registry at three Danish sites, the “ADVANCE-DK Registry”. All patients had at least one ≥30% coronary stenosis by CTA and underwent subsequent core laboratory FFRCT analysis by HeartFlow. The FFRCT result was abnormal when ≤0.80 (2 cm distal to stenosis). Patients were classified according to completeness of revascularization by FFRCT: 1) completely revascularized (CR-FFRCT), all coronary arteries with an abnormal FFRCT test result revascularized; 2) incompletely revascularized (IR-FFRCT), ≥1 coronary artery with an abnormal FFRCT test result not revascularized. The primary endpoint (PE) was a composite of all-cause death and spontaneous MI. The secondary endpoint (SE) was a composite of cardiovascular (CV) death and spontaneous MI.

Results

Patient characteristics are given in Table 1. In total 36 (4.0%) patients suffered a PE (all-cause death, n=24; MI, n=12) and 22 (2.4%) an SE (CV death, n=10; MI, n=12). Overall, an abnormal vs a normal FFRCT test result was associated with an increased risk of both the PE, 6.6% vs 2.1%, relative risk (RR): 3.1; 95% CI: 1.6–6.3, p<0.001 and of the SE, 5.0% vs 0.6%, RR: 8.7; 95% CI: non assessable, p<0.001. In patients with abnormal FFRCT, revascularization vs no revascularization did not reduce the risk of the PE or the SE (data not shown). Patients with IR-FFRCT vs CR-FFRCT had a numerical, but not statistical significantly, increased risk of the PE, 8.6% vs 4.2%, RR: 2.14; 95% CI: 0.87–5.26, p=0.10), and an increased risk of the SE, 7.1% vs 2.4%, RR: 3.13; 95% CI: 1.02–9.63, p=0.04, Figure 1. In CR-FFRCT versus normal FFRCT no difference in the risk of the PE or the SE was observed, Figure 1. Univariate sensitivity analyses performed in the IR-FFRCT group did not reveal any differences in the risk of the PE or the SE after adjustment for neither statin therapy at follow-up (−/+), baseline risk variables (< / ≥3), amount of CAC (< / ≥400), degree of stenosis by CTA (< / ≥50%) nor referral to ICA (−/+).

Conclusion

In symptomatic patients with coronary stenosis by CTA, incomplete revascularization determined by FFRCT is associated with an increased risk of adverse cardiovascular outcomes compared to complete revascularization.

Funding Acknowledgement

Type of funding sources: None.