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Gupta A, Taqueti VR, van de Hoef TP, Bajaj NS, Bravo PE, Murthy VL, Osborne MT, Seidelmann SB, Vita T, Bibbo CF, Harrington M, Hainer J, Rimoldi O, Dorbala S, Bhatt DL, Blankstein R, Camici PG, Di Carli MF. Integrated Noninvasive Physiological Assessment of Coronary Circulatory Function and Impact on Cardiovascular Mortality in Patients With Stable Coronary Artery Disease. Circulation 2017; 136:2325-2336. [PMID: 28864442 DOI: 10.1161/circulationaha.117.029992] [Citation(s) in RCA: 174] [Impact Index Per Article: 24.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 08/22/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND It is suggested that the integration of maximal myocardial blood flow (MBF) and coronary flow reserve (CFR), termed coronary flow capacity, allows for comprehensive evaluation of patients with known or suspected stable coronary artery disease. Because management decisions are predicated on clinical risk, we sought to determine the independent and integrated value of maximal MBF and CFR for predicting cardiovascular death. METHODS MBF and CFR were quantified in 4029 consecutive patients (median age 66 years, 50.5% women) referred for rest/stress myocardial perfusion positron emission tomography scans from January 2006 to December 2013. The primary outcome was cardiovascular mortality. Maximal MBF <1.8 mL·g-1·min-1 and CFR<2 were considered impaired. Four patient groups were identified based on the concordant or discordant impairment of maximal MBF or CFR. Association of maximal MBF and CFR with cardiovascular death was assessed using Cox and Poisson regression analyses. RESULTS A total of 392 (9.7%) cardiovascular deaths occurred over a median follow-up of 5.6 years. CFR was a stronger predictor of cardiovascular mortality than maximal MBF beyond traditional cardiovascular risk factors, left ventricular ejection fraction, myocardial scar and ischemia, rate-pressure product, type of radiotracer or stress agent used, and revascularization after scan (adjusted hazard ratio, 1.79; 95% confidence interval [CI], 1.38-2.31; P<0.001 per unit decrease in CFR after adjustment for maximal MBF and clinical covariates; and adjusted hazard ratio, 1.03; 95% CI, 0.84-1.27; P=0.8 per unit decrease in maximal MBF after adjustment for CFR and clinical covariates). In univariable analyses, patients with concordant impairment of CFR and maximal MBF had high cardiovascular mortality of 3.3% (95% CI, 2.9-3.7) per year. Patients with impaired CFR but preserved maximal MBF had an intermediate cardiovascular mortality of 1.7% (95% CI, 1.3-2.1) per year. These patients were predominantly women (70%). Patients with preserved CFR but impaired maximal MBF had low cardiovascular mortality of 0.9% (95% CI, 0.6-1.6) per year. Patients with concordantly preserved CFR and maximal MBF had the lowest cardiovascular mortality of 0.4% (95 CI, 0.3-0.6) per year. In multivariable analysis, the cardiovascular mortality risk gradient across the 4 concordant or discordant categories was independently driven by impaired CFR irrespective of impairment in maximal MBF. CONCLUSIONS CFR is a stronger predictor of cardiovascular mortality than maximal MBF. Concordant and discordant categories based on integrating CFR and maximal MBF identify unique prognostic phenotypes of patients with known or suspected coronary artery disease.
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Affiliation(s)
- Ankur Gupta
- Division of Cardiovascular Medicine, Department of Medicine, Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (A.G., V.R.T., N.S.B., P.E.B., S.B.S., T.V., C.F.B., M.H., J.H., S.D., R.B., M.F.D.C.)
| | - Viviany R Taqueti
- Division of Cardiovascular Medicine, Department of Medicine, Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (A.G., V.R.T., N.S.B., P.E.B., S.B.S., T.V., C.F.B., M.H., J.H., S.D., R.B., M.F.D.C.)
| | - Tim P van de Hoef
- AMC Heart Center, Academic Medical Center, University of Amsterdam, The Netherlands (T.P.v.d.H.)
| | - Navkaranbir S Bajaj
- Division of Cardiovascular Medicine, Department of Medicine, Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (A.G., V.R.T., N.S.B., P.E.B., S.B.S., T.V., C.F.B., M.H., J.H., S.D., R.B., M.F.D.C.)
| | - Paco E Bravo
- Division of Cardiovascular Medicine, Department of Medicine, Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (A.G., V.R.T., N.S.B., P.E.B., S.B.S., T.V., C.F.B., M.H., J.H., S.D., R.B., M.F.D.C.)
| | - Venkatesh L Murthy
- Frankel Cardiovascular Center, University of Michigan, Ann Arbor (V.L.M.)
| | - Michael T Osborne
- Cardiac MR/PET/CT Program, Department of Radiology, Cardiology Division, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston (M.T.O.)
| | - Sara B Seidelmann
- Division of Cardiovascular Medicine, Department of Medicine, Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (A.G., V.R.T., N.S.B., P.E.B., S.B.S., T.V., C.F.B., M.H., J.H., S.D., R.B., M.F.D.C.)
| | - Tomas Vita
- Division of Cardiovascular Medicine, Department of Medicine, Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (A.G., V.R.T., N.S.B., P.E.B., S.B.S., T.V., C.F.B., M.H., J.H., S.D., R.B., M.F.D.C.)
| | - Courtney F Bibbo
- Division of Cardiovascular Medicine, Department of Medicine, Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (A.G., V.R.T., N.S.B., P.E.B., S.B.S., T.V., C.F.B., M.H., J.H., S.D., R.B., M.F.D.C.)
| | - Meagan Harrington
- Division of Cardiovascular Medicine, Department of Medicine, Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (A.G., V.R.T., N.S.B., P.E.B., S.B.S., T.V., C.F.B., M.H., J.H., S.D., R.B., M.F.D.C.)
| | - Jon Hainer
- Division of Cardiovascular Medicine, Department of Medicine, Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (A.G., V.R.T., N.S.B., P.E.B., S.B.S., T.V., C.F.B., M.H., J.H., S.D., R.B., M.F.D.C.)
| | | | - Sharmila Dorbala
- Division of Cardiovascular Medicine, Department of Medicine, Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (A.G., V.R.T., N.S.B., P.E.B., S.B.S., T.V., C.F.B., M.H., J.H., S.D., R.B., M.F.D.C.)
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA (D.L.B.)
| | - Ron Blankstein
- Division of Cardiovascular Medicine, Department of Medicine, Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (A.G., V.R.T., N.S.B., P.E.B., S.B.S., T.V., C.F.B., M.H., J.H., S.D., R.B., M.F.D.C.)
| | - Paolo G Camici
- Vita-Salute University and San Raffaele Hospital, Milan, Italy (P.G.C.)
| | - Marcelo F Di Carli
- Division of Cardiovascular Medicine, Department of Medicine, Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (A.G., V.R.T., N.S.B., P.E.B., S.B.S., T.V., C.F.B., M.H., J.H., S.D., R.B., M.F.D.C.)
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Park SH, Jeon KH, Lee JM, Nam CW, Doh JH, Lee BK, Rha SW, Yoo KD, Jung KT, Cho YS, Lee HY, Youn TJ, Chung WY, Koo BK. Long-Term Clinical Outcomes of Fractional Flow Reserve-Guided Versus Routine Drug-Eluting Stent Implantation in Patients With Intermediate Coronary Stenosis: Five-Year Clinical Outcomes of DEFER-DES Trial. Circ Cardiovasc Interv 2016; 8:e002442. [PMID: 26643736 DOI: 10.1161/circinterventions.115.002442] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND We aimed to compare the long-term clinical outcomes between fractional flow reserve (FFR)-guided and routine drug-eluting stent (DES) implantation in patients with an intermediate coronary stenosis. METHODS AND RESULTS A total of 229 patients with an angiographically intermediate coronary stenosis were randomly assigned to FFR-guided or Routine-DES implantation group. For FFR-guided group (n=114), treatment strategy was determined according to the target vessel FFR (FFR<0.75: DES implantation [FFR-DES group]; FFR≥0.75: deferral of stenting [FFR-Defer group]). Routine-DES group underwent DES implantation without FFR measurement (n=115). The primary end point was the incidence of major adverse cardiac events, a composite of cardiac death, myocardial infarction, and target lesion revascularization. Of lesions assigned to FFR-guided strategy, only one quarter had functional significance (FFR<0.75). At 2-year follow-up, the cumulative incidence of major adverse cardiac events was 7.9±2.5% in the FFR-guided group and 8.8±2.7% in Routine-DES group (P=0.80). At 5-year follow-up, the cumulative incidence of major adverse cardiac events was 11.6±3.0% and 14.2±3.3% for the FFR-guided group and the Routine-DES group (P=0.55). There was no difference in major adverse cardiac events rates between the 2 groups ≤5-year follow-up (hazard ratio, 1.25; 95% confidence interval, 0.60-2.60). CONCLUSIONS In lesions with angiographically intermediate stenosis, FFR guidance provides a tailored approach, which is at least as good as an angiography-guided routine-DES implantation strategy and avoids unnecessary DES-stenting in a considerable part of the patients. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00592228.
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Affiliation(s)
- Sang Hyun Park
- From the Department of Internal Medicine, Eulji University Hospital, Daejeon, Korea (S.H.P., K.T.J.); Department of Internal Medicine, Sejong General Hospital, Bucheon, Korea (K.-H.J.); Department of Internal Medicine (J.M.L., H.-Y.L., B.-K.K.) and Institute of Aging (B.-K.K.), Seoul National University Hospital, Seoul, Korea; Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu, Korea (C.-W.N.); Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea (J.-H.D.); Department of Internal Medicine, Kangwon National University Hospital, Chuncheon, Korea (B.-K.L.); Department of Internal Medicine, Korea University Guro Hospital, Seoul, Korea (S.-W.R.); Department of Internal Medicine, St Vincent's Hospital, The Catholic University of Korea College of Medicine, Suwon, Korea (K.-d.Y.); Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea (Y.-S.C., T.-J.Y.); and Department of Internal Medicine, Seoul National University Boramae Medical Center, Korea, Seoul, Korea (W.-Y.C.)
| | - Ki-Hyun Jeon
- From the Department of Internal Medicine, Eulji University Hospital, Daejeon, Korea (S.H.P., K.T.J.); Department of Internal Medicine, Sejong General Hospital, Bucheon, Korea (K.-H.J.); Department of Internal Medicine (J.M.L., H.-Y.L., B.-K.K.) and Institute of Aging (B.-K.K.), Seoul National University Hospital, Seoul, Korea; Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu, Korea (C.-W.N.); Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea (J.-H.D.); Department of Internal Medicine, Kangwon National University Hospital, Chuncheon, Korea (B.-K.L.); Department of Internal Medicine, Korea University Guro Hospital, Seoul, Korea (S.-W.R.); Department of Internal Medicine, St Vincent's Hospital, The Catholic University of Korea College of Medicine, Suwon, Korea (K.-d.Y.); Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea (Y.-S.C., T.-J.Y.); and Department of Internal Medicine, Seoul National University Boramae Medical Center, Korea, Seoul, Korea (W.-Y.C.)
| | - Joo Myung Lee
- From the Department of Internal Medicine, Eulji University Hospital, Daejeon, Korea (S.H.P., K.T.J.); Department of Internal Medicine, Sejong General Hospital, Bucheon, Korea (K.-H.J.); Department of Internal Medicine (J.M.L., H.-Y.L., B.-K.K.) and Institute of Aging (B.-K.K.), Seoul National University Hospital, Seoul, Korea; Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu, Korea (C.-W.N.); Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea (J.-H.D.); Department of Internal Medicine, Kangwon National University Hospital, Chuncheon, Korea (B.-K.L.); Department of Internal Medicine, Korea University Guro Hospital, Seoul, Korea (S.-W.R.); Department of Internal Medicine, St Vincent's Hospital, The Catholic University of Korea College of Medicine, Suwon, Korea (K.-d.Y.); Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea (Y.-S.C., T.-J.Y.); and Department of Internal Medicine, Seoul National University Boramae Medical Center, Korea, Seoul, Korea (W.-Y.C.)
| | - Chang-Wook Nam
- From the Department of Internal Medicine, Eulji University Hospital, Daejeon, Korea (S.H.P., K.T.J.); Department of Internal Medicine, Sejong General Hospital, Bucheon, Korea (K.-H.J.); Department of Internal Medicine (J.M.L., H.-Y.L., B.-K.K.) and Institute of Aging (B.-K.K.), Seoul National University Hospital, Seoul, Korea; Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu, Korea (C.-W.N.); Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea (J.-H.D.); Department of Internal Medicine, Kangwon National University Hospital, Chuncheon, Korea (B.-K.L.); Department of Internal Medicine, Korea University Guro Hospital, Seoul, Korea (S.-W.R.); Department of Internal Medicine, St Vincent's Hospital, The Catholic University of Korea College of Medicine, Suwon, Korea (K.-d.Y.); Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea (Y.-S.C., T.-J.Y.); and Department of Internal Medicine, Seoul National University Boramae Medical Center, Korea, Seoul, Korea (W.-Y.C.)
| | - Joon-Hyung Doh
- From the Department of Internal Medicine, Eulji University Hospital, Daejeon, Korea (S.H.P., K.T.J.); Department of Internal Medicine, Sejong General Hospital, Bucheon, Korea (K.-H.J.); Department of Internal Medicine (J.M.L., H.-Y.L., B.-K.K.) and Institute of Aging (B.-K.K.), Seoul National University Hospital, Seoul, Korea; Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu, Korea (C.-W.N.); Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea (J.-H.D.); Department of Internal Medicine, Kangwon National University Hospital, Chuncheon, Korea (B.-K.L.); Department of Internal Medicine, Korea University Guro Hospital, Seoul, Korea (S.-W.R.); Department of Internal Medicine, St Vincent's Hospital, The Catholic University of Korea College of Medicine, Suwon, Korea (K.-d.Y.); Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea (Y.-S.C., T.-J.Y.); and Department of Internal Medicine, Seoul National University Boramae Medical Center, Korea, Seoul, Korea (W.-Y.C.)
| | - Bong-Ki Lee
- From the Department of Internal Medicine, Eulji University Hospital, Daejeon, Korea (S.H.P., K.T.J.); Department of Internal Medicine, Sejong General Hospital, Bucheon, Korea (K.-H.J.); Department of Internal Medicine (J.M.L., H.-Y.L., B.-K.K.) and Institute of Aging (B.-K.K.), Seoul National University Hospital, Seoul, Korea; Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu, Korea (C.-W.N.); Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea (J.-H.D.); Department of Internal Medicine, Kangwon National University Hospital, Chuncheon, Korea (B.-K.L.); Department of Internal Medicine, Korea University Guro Hospital, Seoul, Korea (S.-W.R.); Department of Internal Medicine, St Vincent's Hospital, The Catholic University of Korea College of Medicine, Suwon, Korea (K.-d.Y.); Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea (Y.-S.C., T.-J.Y.); and Department of Internal Medicine, Seoul National University Boramae Medical Center, Korea, Seoul, Korea (W.-Y.C.)
| | - Seung-Woon Rha
- From the Department of Internal Medicine, Eulji University Hospital, Daejeon, Korea (S.H.P., K.T.J.); Department of Internal Medicine, Sejong General Hospital, Bucheon, Korea (K.-H.J.); Department of Internal Medicine (J.M.L., H.-Y.L., B.-K.K.) and Institute of Aging (B.-K.K.), Seoul National University Hospital, Seoul, Korea; Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu, Korea (C.-W.N.); Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea (J.-H.D.); Department of Internal Medicine, Kangwon National University Hospital, Chuncheon, Korea (B.-K.L.); Department of Internal Medicine, Korea University Guro Hospital, Seoul, Korea (S.-W.R.); Department of Internal Medicine, St Vincent's Hospital, The Catholic University of Korea College of Medicine, Suwon, Korea (K.-d.Y.); Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea (Y.-S.C., T.-J.Y.); and Department of Internal Medicine, Seoul National University Boramae Medical Center, Korea, Seoul, Korea (W.-Y.C.)
| | - Ki-dong Yoo
- From the Department of Internal Medicine, Eulji University Hospital, Daejeon, Korea (S.H.P., K.T.J.); Department of Internal Medicine, Sejong General Hospital, Bucheon, Korea (K.-H.J.); Department of Internal Medicine (J.M.L., H.-Y.L., B.-K.K.) and Institute of Aging (B.-K.K.), Seoul National University Hospital, Seoul, Korea; Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu, Korea (C.-W.N.); Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea (J.-H.D.); Department of Internal Medicine, Kangwon National University Hospital, Chuncheon, Korea (B.-K.L.); Department of Internal Medicine, Korea University Guro Hospital, Seoul, Korea (S.-W.R.); Department of Internal Medicine, St Vincent's Hospital, The Catholic University of Korea College of Medicine, Suwon, Korea (K.-d.Y.); Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea (Y.-S.C., T.-J.Y.); and Department of Internal Medicine, Seoul National University Boramae Medical Center, Korea, Seoul, Korea (W.-Y.C.)
| | - Kyung Tae Jung
- From the Department of Internal Medicine, Eulji University Hospital, Daejeon, Korea (S.H.P., K.T.J.); Department of Internal Medicine, Sejong General Hospital, Bucheon, Korea (K.-H.J.); Department of Internal Medicine (J.M.L., H.-Y.L., B.-K.K.) and Institute of Aging (B.-K.K.), Seoul National University Hospital, Seoul, Korea; Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu, Korea (C.-W.N.); Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea (J.-H.D.); Department of Internal Medicine, Kangwon National University Hospital, Chuncheon, Korea (B.-K.L.); Department of Internal Medicine, Korea University Guro Hospital, Seoul, Korea (S.-W.R.); Department of Internal Medicine, St Vincent's Hospital, The Catholic University of Korea College of Medicine, Suwon, Korea (K.-d.Y.); Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea (Y.-S.C., T.-J.Y.); and Department of Internal Medicine, Seoul National University Boramae Medical Center, Korea, Seoul, Korea (W.-Y.C.)
| | - Young-Seok Cho
- From the Department of Internal Medicine, Eulji University Hospital, Daejeon, Korea (S.H.P., K.T.J.); Department of Internal Medicine, Sejong General Hospital, Bucheon, Korea (K.-H.J.); Department of Internal Medicine (J.M.L., H.-Y.L., B.-K.K.) and Institute of Aging (B.-K.K.), Seoul National University Hospital, Seoul, Korea; Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu, Korea (C.-W.N.); Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea (J.-H.D.); Department of Internal Medicine, Kangwon National University Hospital, Chuncheon, Korea (B.-K.L.); Department of Internal Medicine, Korea University Guro Hospital, Seoul, Korea (S.-W.R.); Department of Internal Medicine, St Vincent's Hospital, The Catholic University of Korea College of Medicine, Suwon, Korea (K.-d.Y.); Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea (Y.-S.C., T.-J.Y.); and Department of Internal Medicine, Seoul National University Boramae Medical Center, Korea, Seoul, Korea (W.-Y.C.)
| | - Hae-Young Lee
- From the Department of Internal Medicine, Eulji University Hospital, Daejeon, Korea (S.H.P., K.T.J.); Department of Internal Medicine, Sejong General Hospital, Bucheon, Korea (K.-H.J.); Department of Internal Medicine (J.M.L., H.-Y.L., B.-K.K.) and Institute of Aging (B.-K.K.), Seoul National University Hospital, Seoul, Korea; Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu, Korea (C.-W.N.); Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea (J.-H.D.); Department of Internal Medicine, Kangwon National University Hospital, Chuncheon, Korea (B.-K.L.); Department of Internal Medicine, Korea University Guro Hospital, Seoul, Korea (S.-W.R.); Department of Internal Medicine, St Vincent's Hospital, The Catholic University of Korea College of Medicine, Suwon, Korea (K.-d.Y.); Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea (Y.-S.C., T.-J.Y.); and Department of Internal Medicine, Seoul National University Boramae Medical Center, Korea, Seoul, Korea (W.-Y.C.)
| | - Tae-Jin Youn
- From the Department of Internal Medicine, Eulji University Hospital, Daejeon, Korea (S.H.P., K.T.J.); Department of Internal Medicine, Sejong General Hospital, Bucheon, Korea (K.-H.J.); Department of Internal Medicine (J.M.L., H.-Y.L., B.-K.K.) and Institute of Aging (B.-K.K.), Seoul National University Hospital, Seoul, Korea; Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu, Korea (C.-W.N.); Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea (J.-H.D.); Department of Internal Medicine, Kangwon National University Hospital, Chuncheon, Korea (B.-K.L.); Department of Internal Medicine, Korea University Guro Hospital, Seoul, Korea (S.-W.R.); Department of Internal Medicine, St Vincent's Hospital, The Catholic University of Korea College of Medicine, Suwon, Korea (K.-d.Y.); Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea (Y.-S.C., T.-J.Y.); and Department of Internal Medicine, Seoul National University Boramae Medical Center, Korea, Seoul, Korea (W.-Y.C.)
| | - Woo-Young Chung
- From the Department of Internal Medicine, Eulji University Hospital, Daejeon, Korea (S.H.P., K.T.J.); Department of Internal Medicine, Sejong General Hospital, Bucheon, Korea (K.-H.J.); Department of Internal Medicine (J.M.L., H.-Y.L., B.-K.K.) and Institute of Aging (B.-K.K.), Seoul National University Hospital, Seoul, Korea; Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu, Korea (C.-W.N.); Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea (J.-H.D.); Department of Internal Medicine, Kangwon National University Hospital, Chuncheon, Korea (B.-K.L.); Department of Internal Medicine, Korea University Guro Hospital, Seoul, Korea (S.-W.R.); Department of Internal Medicine, St Vincent's Hospital, The Catholic University of Korea College of Medicine, Suwon, Korea (K.-d.Y.); Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea (Y.-S.C., T.-J.Y.); and Department of Internal Medicine, Seoul National University Boramae Medical Center, Korea, Seoul, Korea (W.-Y.C.)
| | - Bon-Kwon Koo
- From the Department of Internal Medicine, Eulji University Hospital, Daejeon, Korea (S.H.P., K.T.J.); Department of Internal Medicine, Sejong General Hospital, Bucheon, Korea (K.-H.J.); Department of Internal Medicine (J.M.L., H.-Y.L., B.-K.K.) and Institute of Aging (B.-K.K.), Seoul National University Hospital, Seoul, Korea; Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu, Korea (C.-W.N.); Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea (J.-H.D.); Department of Internal Medicine, Kangwon National University Hospital, Chuncheon, Korea (B.-K.L.); Department of Internal Medicine, Korea University Guro Hospital, Seoul, Korea (S.-W.R.); Department of Internal Medicine, St Vincent's Hospital, The Catholic University of Korea College of Medicine, Suwon, Korea (K.-d.Y.); Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea (Y.-S.C., T.-J.Y.); and Department of Internal Medicine, Seoul National University Boramae Medical Center, Korea, Seoul, Korea (W.-Y.C.).
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Hlatky MA, De Bruyne B, Pontone G, Patel MR, Norgaard BL, Byrne RA, Curzen N, Purcell I, Gutberlet M, Rioufol G, Hink U, Schuchlenz HW, Feuchtner G, Gilard M, Andreini D, Jensen JM, Hadamitzky M, Wilk A, Wang F, Rogers C, Douglas PS. Quality-of-Life and Economic Outcomes of Assessing Fractional Flow Reserve With Computed Tomography Angiography: PLATFORM. J Am Coll Cardiol 2015; 66:2315-2323. [PMID: 26475205 DOI: 10.1016/j.jacc.2015.09.051] [Citation(s) in RCA: 137] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Revised: 09/25/2015] [Accepted: 09/25/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND Fractional flow reserve estimated using computed tomography (FFRCT) might improve evaluation of patients with chest pain. OBJECTIVES The authors sought to determine the effect on cost and quality of life (QOL) of using FFRCT instead of usual care to evaluate stable patients with symptoms suspicious for coronary disease. METHODS Symptomatic patients without known coronary disease were enrolled into 2 strata based on whether invasive or noninvasive diagnostic testing was planned. In each stratum, consecutive observational cohorts were evaluated with either usual care or FFRCT. The number of diagnostic tests, invasive procedures, hospitalizations, and medications during 90-day follow-up were multiplied by U.S. cost weights and summed to derive total medical costs. Changes in QOL from baseline to 90 days were assessed using the Seattle Angina Questionnaire, the EuroQOL, and a visual analog scale. RESULTS In the 584 patients, 74% had atypical angina, and the pre-test probability of coronary disease was 49%. In the planned invasive stratum, mean costs were 32% lower among the FFRCT patients than among the usual care patients ($7,343 vs. $10,734 p < 0.0001). In the noninvasive stratum, mean costs were not significantly different between the FFRCT patients and the usual care patients ($2,679 vs. $2,137; p = 0.26). In a sensitivity analysis, when the cost weight of FFRCT was set to 7 times that of computed tomography angiography, the FFRCT group still had lower costs than the usual care group in the invasive testing stratum ($8,619 vs. $ 10,734; p < 0.0001), whereas in the noninvasive testing stratum, when the cost weight of FFRCT was set to one-half that of computed tomography angiography, the FFRCT group had higher costs than the usual care group ($2,766 vs. $2,137; p = 0.02). Each QOL score improved in the overall study population (p < 0.0001). In the noninvasive stratum, QOL scores improved more in FFRCT patients than in usual care patients: Seattle Angina Questionnaire 19.5 versus 11.4, p = 0.003; EuroQOL 0.08 versus 0.03, p = 0.002; and visual analog scale 4.1 versus 2.3, p = 0.82. In the invasive cohort, the improvements in QOL were similar in the FFRCT and usual care patients. CONCLUSIONS An evaluation strategy based on FFRCT was associated with less resource use and lower costs within 90 days than evaluation with invasive coronary angiography. Evaluation with FFRCT was associated with greater improvement in quality of life than evaluation with usual noninvasive testing. (Prospective Longitudinal Trial of FFRCT: Outcomes and Resource Impacts [PLATFORM]; NCT01943903).
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Affiliation(s)
- Mark A Hlatky
- Department of Health Research and Policy and Department of Medicine, Stanford University School of Medicine, Stanford, California.
| | | | - Gianluca Pontone
- Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | - Manesh R Patel
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Bjarne L Norgaard
- Department of Cardiology, Aarhus University Hospital, Aarhus Skejby, Denmark
| | - Robert A Byrne
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Nick Curzen
- University Hospital Southampton NHS Trust, Southampton, United Kingdom
| | - Ian Purcell
- Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | | | - Gilles Rioufol
- Hospices Civils de Lyon and Laboratoire de Recherche en Cardiovasculaire, Métabolisme, Diabétologie et Nutrition, Institut National de la Santé et de la Recherche Médicale, Lyon, France
| | - Ulrich Hink
- Cardiology Department, Johannes Gutenberg University Hospital, Mainz, Germany
| | | | - Gudrun Feuchtner
- Department of Radiology, Innsbruck Medical University, Innsbruck, Austria
| | - Martine Gilard
- Department of Cardiology, Cavale Blanche Hospital, Brest, France
| | - Daniele Andreini
- Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | - Jesper M Jensen
- Department of Cardiology, Aarhus University Hospital, Aarhus Skejby, Denmark
| | - Martin Hadamitzky
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Alan Wilk
- HeartFlow, Inc., Redwood City, California
| | | | | | - Pamela S Douglas
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
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