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Yang S, Jung JW, Park SH, Zhang J, Lee K, Hwang D, Lee KS, Na SH, Doh JH, Nam CW, Kim TH, Shin ES, Chun EJ, Choi SY, Kim HK, Hong YJ, Park HJ, Kim SY, Husic M, Lambrechtsen J, Jensen JM, Nørgaard BL, Andreini D, Maurovich-Horvat P, Merkely B, Penicka M, de Bruyne B, Ihdayhid A, Ko B, Tzimas G, Leipsic J, Sanz J, Rabbat MG, Katchi F, Shah M, Tanaka N, Nakazato R, Asano T, Terashima M, Takashima H, Amano T, Sobue Y, Matsuo H, Otake H, Kubo T, Takahata M, Akasaka T, Kido T, Mochizuki T, Yokoi H, Okonogi T, Kawasaki T, Nakao K, Sakamoto T, Yonetsu T, Kakuta T, Yamauchi Y, Taylor CA, Bax JJ, Shaw LJ, Stone PH, Narula J, Koo BK. Prognostic Time Frame of Plaque and Hemodynamic Characteristics and Integrative Risk Prediction for Acute Coronary Syndrome. JACC Cardiovasc Imaging 2025:S1936-878X(25)00130-5. [PMID: 40272335 DOI: 10.1016/j.jcmg.2025.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2024] [Revised: 02/07/2025] [Accepted: 02/13/2025] [Indexed: 04/25/2025]
Abstract
BACKGROUND The relevant time frame for predicting future acute coronary syndrome (ACS) based on coronary lesion characteristics remains uncertain. OBJECTIVES The aim of this study was to investigate the association of lesion characteristics with test-to-event time and their prognostic impact on ACS. METHODS The EMERALD II (Exploring the Mechanism of Plaque Rupture in Acute Coronary Syndrome Using Coronary CT Angiography and Computational Fluid Dynamics II) study analyzed 351 patients who underwent coronary computed tomography angiography (CTA) and experienced ACS between 1 month and 3 years of follow-up. Lesions identified on coronary CTA were classified as culprit (n = 363) or nonculprit (n = 2,088) on the basis of invasive coronary angiography findings at the time of ACS. Core laboratory coronary CTA analyses assessed 4 domains: degree of stenosis, plaque burden, number of adverse plaque characteristics (APC) (low-attenuation plaque, positive remodeling, spotty calcification, and napkin-ring sign), and changes in coronary CTA-derived fractional flow reserve across the lesion (ΔFFRCT). Patients were categorized into short (<1 year), mid (1-2 years), and long (2-3 years) test-to-event time groups. RESULTS Patient characteristics, including cardiovascular risk factors, did not differ across short, mid, and long test-to-event groups (P > 0.05 for all), and the proportion of ACS culprit lesions was similar (P = 0.552). Among culprit lesions, shorter test-to-event time was associated with higher luminal stenosis, plaque burden, and ΔFFRCT (P for trend < 0.001 for all). The predictability for ACS culprit lesions based on the combined 4 characteristics tended to decrease over time and significantly reduced beyond 2 years (AUC: 0.851 vs 0.741; P = 0.006). In predicting ACS risk within test-to-event time <2 years using obstructive lesions (stenosis ≥ 50%), APC ≥2, plaque burden ≥70%, and ΔFFRCT ≥0.10, the risk was elevated compared to the average proportion of lesions becoming ACS culprit (12.1%) in the following subsets: lesions with 4 characteristics (proportion of lesions becoming ACS culprit: 49.3%; P < 0.001), lesions with 3 characteristics (obstructive lesions with plaque burden ≥70% and either ΔFFRCT ≥0.10 [proportion of lesions becoming ACS culprit: 33.0%; P < 0.001] or APC ≥2 [proportion of lesions becoming ACS culprit: 31.2%; P < 0.001]), and lesions with 2 characteristics (plaque burden ≥70% and ΔFFRCT ≥0.10; proportion of lesions becoming ACS culprit: 21.5%; P = 0.016). CONCLUSIONS Increased luminal stenosis, plaque burden, and ΔFFRCT were associated with shorter test-to-ACS event time. The prognostic impact of lumen, plaque, and local hemodynamic characteristics was most relevant to ACS risk within a 2-year period, with higher risk observed when specific combinations of them were present. (Exploring the Mechanism of Plaque Rupture in Acute Coronary Syndrome Using Coronary CT Angiography and Computational Fluid Dynamics II [EMERALD II] Study; NCT03591328).
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Affiliation(s)
- Seokhun Yang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul National University of College of Medicine, Seoul, South Korea
| | - Jae Wook Jung
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul National University of College of Medicine, Seoul, South Korea
| | - Sang-Hyeon Park
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul National University of College of Medicine, Seoul, South Korea
| | - Jinlong Zhang
- Department of Cardiology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Keehwan Lee
- Division of Cardiology, Department of Medicine, Gangneung Asan Hospital, Gangneung, South Korea
| | - Doyeon Hwang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul National University of College of Medicine, Seoul, South Korea
| | - Kyu-Sun Lee
- Department of Cardiology, Eulji University Medical Center, Daejeon, South Korea
| | - Sang-Hoon Na
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul National University of College of Medicine, Seoul, South Korea
| | - Joon-Hyung Doh
- Department of Medicine, Inje University Ilsan Paik Hospital, Goyang, South Korea
| | - Chang-Wook Nam
- Department of Medicine, Keimyung University Dongsan Medical Center, Daegu, South Korea
| | - Tae Hyun Kim
- Department of Cardiology, Ulsan Medical Center, Ulsan, South Korea
| | - Eun-Seok Shin
- Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, South Korea
| | - Eun Ju Chun
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Su-Yeon Choi
- Department of Internal Medicine, Seoul National University Hospital Healthcare System Gangnam Center, Seoul, South Korea
| | - Hyun Kuk Kim
- Department of Internal Medicine and Cardiovascular Center, Chosun University Hospital, University of Chosun College of Medicine, Gwangju, South Korea
| | - Young Joon Hong
- Department of Cardiology, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, South Korea
| | - Hun-Jun Park
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - Song-Yi Kim
- Division of Cardiology, Department of Internal Medicine, Jeju National University Hospital, Jeju, South Korea
| | - Mirza Husic
- Department of Cardiology, Odense University Hospital, Svendborg, Denmark
| | - Jess Lambrechtsen
- Department of Cardiology, Odense University Hospital, Svendborg, Denmark
| | - Jesper M Jensen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Bjarne L Nørgaard
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Daniele Andreini
- Division of University Cardiology, IRCCS Ospedale Galeazzi Sant'Ambrogio, Milan, Italy
| | - Pal Maurovich-Horvat
- Department of Radiology, Medical Imaging Centre, Semmelweis University, Budapest, Hungary
| | - Bela Merkely
- The Heart and Vascular Center, Semmelweis University, Semmelweis University, Budapest, Hungary
| | | | | | - Abdul Ihdayhid
- Monash Cardiovascular Research Centre, Monash University and Monash Heart, Monash Health, Clayton, Victoria, Australia
| | - Brian Ko
- Monash Cardiovascular Research Centre, Monash University and Monash Heart, Monash Health, Clayton, Victoria, Australia
| | - Georgios Tzimas
- Department of Medicine and Radiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jonathon Leipsic
- Department of Medicine and Radiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Javier Sanz
- Blavatnik Family Research Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Mark G Rabbat
- Division of Cardiology, Loyola University Chicago, Chicago, Illinois, USA
| | - Farhan Katchi
- Department of Cardiology, Washington University School of Medicine in St. Louis, Missouri, USA
| | - Moneal Shah
- Department of Cardiology, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
| | - Nobuhiro Tanaka
- Department of Cardiology, Tokyo Medical University Hachioji Medical Center, Tokyo, Japan
| | - Ryo Nakazato
- Cardiovascular Center, St Luke's International Hospital, Tokyo, Japan
| | - Taku Asano
- Cardiovascular Center, St Luke's International Hospital, Tokyo, Japan
| | | | | | - Tetsuya Amano
- Department of Cardiology, Aichi Medical University, Nagakute, Japan
| | - Yoshihiro Sobue
- Department of Cardiovascular Medicine, Gifu Heart Center, Gifu, Japan
| | - Hitoshi Matsuo
- Department of Cardiovascular Medicine, Gifu Heart Center, Gifu, Japan
| | - Hiromasa Otake
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Takashi Kubo
- Department of Cardiology, Tokyo Medical University Hachioji Medical Center, Tokyo, Japan
| | - Masahiro Takahata
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Takashi Akasaka
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Teruhito Kido
- Department of Radiology, Ehime University Graduate School of Medicine, Ehime, Japan
| | - Teruhito Mochizuki
- Department of Radiology, Ehime University Graduate School of Medicine, Ehime, Japan
| | - Hiroyoshi Yokoi
- Cardiovascular Center, Fukuoka Sanno Hospital, Fukuoka, Japan
| | - Taichi Okonogi
- Cardiovascular Center, Shin-Koga Hospital, Kurume, Japan
| | | | - Koichi Nakao
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, Kumamoto, Japan
| | | | - Taishi Yonetsu
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tsunekazu Kakuta
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Yohei Yamauchi
- Department of Cardiology, Osaka Medical and Pharmaceutical University, Takatsuki, Japan
| | - Charles A Taylor
- Department of Internal Medicine and Oden Institute for Computational Engineering and Sciences, University of Texas, Austin, Texas, USA
| | - Jeroen J Bax
- Department of Cardiology, Heart Lung Centre, Leiden University Medical Centre, Leiden, the Netherlands
| | - Leslee J Shaw
- Blavatnik Family Research Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Peter H Stone
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jagat Narula
- McGovern Medical School, University of Texas Health Sciences Center, Houston, Texas, USA
| | - Bon-Kwon Koo
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul National University of College of Medicine, Seoul, South Korea.
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Hwang D, Park SH, Nam CW, Doh JH, Kim HK, Kim Y, Chun EJ, Koo BK. Diagnostic Performance of On-Site Automatic Coronary Computed Tomography Angiography-Derived Fractional Flow Reserve. Korean Circ J 2024; 54:382-394. [PMID: 38767442 PMCID: PMC11252635 DOI: 10.4070/kcj.2023.0288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 02/05/2024] [Accepted: 03/05/2024] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Fractional flow reserve (FFR) is an invasive standard method to identify ischemia-causing coronary artery disease (CAD). With the advancement of technology, FFR can be noninvasively computed from coronary computed tomography angiography (CCTA). Recently, a novel simpler method has been developed to calculate on-site CCTA-derived FFR (CT-FFR) with a commercially available workstation. METHODS A total of 319 CAD patients who underwent CCTA, invasive coronary angiography, and FFR measurement were included. The primary outcome was the accuracy of CT-FFR for defining myocardial ischemia evaluated with an invasive FFR as a reference. The presence of ischemia was defined as FFR ≤0.80. Anatomical obstructive stenosis was defined as diameter stenosis on CCTA ≥50%, and the diagnostic performance of CT-FFR and CCTA stenosis for ischemia was compared. RESULTS Among participants (mean age 64.7±9.4 years, male 77.7%), mean FFR was 0.82±0.10, and 126 (39.5%) patients had an invasive FFR value of ≤0.80. The diagnostic accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of CT-FFR were 80.6% (95% confidence interval [CI], 80.5-80.7%), 88.1% (95% CI, 82.4-93.7%), 75.6% (95% CI, 69.6-81.7%), 70.3% (95% CI, 63.1-77.4%), and 90.7% (95% CI, 86.2-95.2%), respectively. CT-FFR had higher diagnostic accuracy (80.6% vs. 59.1%, p<0.001) and discriminant ability (area under the curve from receiver operating characteristic curve 0.86 vs. 0.64, p<0.001), compared with anatomical obstructive stenosis on CCTA. CONCLUSIONS This novel CT-FFR obtained from an on-site workstation demonstrated clinically acceptable diagnostic performance and provided better diagnostic accuracy and discriminant ability for identifying hemodynamically significant lesions than CCTA alone.
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Affiliation(s)
- Doyeon Hwang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Sang-Hyeon Park
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Chang-Wook Nam
- Department of Medicine, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Joon-Hyung Doh
- Department of Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Hyun Kuk Kim
- Chosun University Hospital, University of Chosun College of Medicine, Gwangju, Korea
| | - Yongcheol Kim
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine and Cardiovascular Center, Yongin Severance Hospital, Yongin, Korea
| | - Eun Ju Chun
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Bon-Kwon Koo
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea.
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Yang S, Chung J, Lesina K, Doh JH, Jegere S, Erglis A, Leipsic JA, Fearon WF, Narula J, Koo BK. Long-term prognostic implications of CT angiography-derived fractional flow reserve: Results from the DISCOVER-FLOW study. J Cardiovasc Comput Tomogr 2024; 18:251-258. [PMID: 38378313 DOI: 10.1016/j.jcct.2024.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 01/08/2024] [Accepted: 01/26/2024] [Indexed: 02/22/2024]
Abstract
BACKGROUND & OBJECTIVES The long-term prognostic implications of CT angiography-derived fractional flow reserve (FFRCT) remains unclear. We aimed to explore the long-term outcomes of FFRCT in the first-in-human study of it. MATERIALS & METHODS A total of 156 vessels from 102 patients with stable coronary artery disease, who underwent coronary CT angiography (CCTA) and invasive FFR measurement, were followed. The primary endpoint was target vessel failure (TVF), including cardiovascular death, target vessel myocardial infarction, and target vessel revascularization. Outcome analysis with FFRCT was performed on a per-vessel basis using a marginal Cox proportional hazard model. RESULTS During median 9.9 years of follow-up, TVF occurred in 20 (12.8%) vessels. FFRCT ≤0.80 discriminated TVF (hazard ratio [HR] 2.61, 95% confidence interval [CI] 1.06, 6.45). Among 94 vessels with deferral of percutaneous coronary intervention (PCI), TVF risk was inversely correlated with FFRCT (HR 0.62 per 0.1 increase, 95% CI 0.44, 0.86), with the cumulative incidence of TVF being 2.6%, 15.2%, and 28.6% for vessels with FFRCT >0.90, 0.81-0.90, and ≤0.80, respectively (p-for-trend 0.005). Predictive value for clinical outcomes of FFRCT was similar to that of invasive FFR (c-index 0.79 vs 0.71, P = 0.28). The estimated TVF risk was higher in the deferral of PCI group than the PCI group for vessels with FFRCT ≤0.81. CONCLUSION FFRCT showed improved long-term risk stratification and displayed a risk continuum similar to invasive FFR. CLINICAL TRIAL REGISTRATION NCT01189331.
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Affiliation(s)
- Seokhun Yang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, South Korea
| | - Jaewook Chung
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, South Korea
| | - Krista Lesina
- Department of Medicine, Pauls Stradins Clinical University Hospital, Riga, Latvia
| | - Joon-Hyung Doh
- Department of Medicine, Inje University Ilsan Paik Hospital, Goyang, South Korea
| | - Sanda Jegere
- Department of Medicine, Pauls Stradins Clinical University Hospital, Riga, Latvia
| | - Andrejs Erglis
- Department of Medicine, Pauls Stradins Clinical University Hospital, Riga, Latvia
| | - Jonathon A Leipsic
- Department of Medicine and Radiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - William F Fearon
- Division of Cardiology, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Jagat Narula
- The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Bon-Kwon Koo
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, South Korea.
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