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.

Pericoronary adipose tissue attenuation in low-risk asymptomatic individuals, sex-differences and association with markers of cardiovascular disease

Funding Acknowledgements

Type of funding sources: None.

Introduction

Pericoronary adipose tissue (PCAT) attenuation by coronary computed tomography angiography (CCTA) is a marker of coronary inflammation and predicts clinical outcomes in symptomatic patients undergoing CCTA. Sex-differences in PCAT CT attenuation among asymptomatic individuals are not previously described.

Purpose

To evaluate PCAT CT attenuation according to sex and markers of cardiovascular disease (CVD).

Methods

Cross-sectional cohort study including asymptomatic individuals, 50- or 60-year of age, not taking any medicine and without known CVD or type-2 diabetes. At baseline and 5-year follow-up smoking habits, blood pressures and biochemistry (lipids, CRP, fibrinogen, D-dimer, t-PA, PAI-1, vWF) were recorded and Agatston Score measured. At follow-up, CCTA was achieved. Quantitative coronary plaque analysis was performed and PCAT CT attenuation within a radial distance of 3 mm from the outer vessel wall 10–50 mm distal to the origin of the right coronary artery measured. A validated PCAT CT attenuation threshold (high vs low risk) of -70.1 Hounsfield units was applied.

Results

Included were 123 participants (60 women). Independent of co-variation, PCAT CT attenuation (median, [IQR]) was lower in women (-71.0, [-77.2- -67.0]) vs men (-64.5, [-69.9- -57.4]), p < 0.001. No associations between PCAT CT attenuation (high vs low) and risk factors of CVD, CAC or coronary plaque volumes were demonstrated (Table). Variations in blood pressures, biochemical markers and CAC over five years were not associated with PCAT CT attenuation.

Conclusion

In low-risk asymptomatic individuals, PCAT CT attenuation was lower in women compared to men, irrespective of markers of CVD.

Table. Patient characteristics stratified by PCAT CT attenuation PCAT CT attenuation ≤ -70.1 HU (n = 49) PCAT CT attenuation > -70.1 HU (n = 74) p-value Risk factors Age65-years55-years 2623 3143 0.32 SexMenWomen 1534 4826 <0.001 TobaccoNeverCurrent/previous 1732 3737 0.10 Systolic BP, mmHgDiastolic BP, mmHgTotal cholesterol, mmol/lLDL-cholesterol, mmol/lHDL-cholesterol, mmol/lTriglycerides, mmol/l 137 (17)76 (10)5.61 (0.92)3.50 (0.93)1.41 (0.30)1.65 (0.99 - 2.22) 136 (16)77 (10)5.42 (0.82)3.30 (0.82)1.45 (0.35)1.35 (1.03 - 2.11) 0.660.590.230.220.570.52 Biochemistry CRP, mg/lFibrinogen, μmol/lD-dimer, mg/lvWFt-PAPAI-1 1.16 (0.99 - 2.22)9.5 (8.5 - 10.7)0.40 (0.30 - 0.49)128 (102 - 154)7.1 (5.8 - 8.8)20.5 (16.2 - 31.8) 0.61 (0.30 - 1.14)9.0 (7.8 - 10.0)0.32 (0.24 - 0.47)116 (92 - 146)6.3 (5.1 - 8.8)20.3 (14.7 - 26.3) <0.010.10<0.050.110.200.34 Coronary plaque data Agatston ScoreTotal plaque volume, mm³NCP volume, mm³CP volume, mm³LD-NCP volume, mm³ 1 (0 - 36)15.7 (0 - 143.3)0 (0 - 128.1)0 (0 - 14.6)0.5 (0 - 18.7) 8 (0 - 115)15.6 (0 - 268.2)13.5 (0 - 220.5)1.7 (0 - 31.7)1.8 (0 - 21.8) 0.300.450.490.360.74 Values are n (%), mean (SD) or median (IQR).Abbreviations: HU =Hounsfield unit; LDL =low-density lipoprotein; HDL =high-density lipoprotein; BP =blood pressure; CRP = c-reactive protein: vWF =von-Willebrand Factor; t-PA =tissue plasminogen activator; PAI-1 =plasminogen activator inhibitor -1; NCP =non-calcified plaque; CP =calcified plaque; LD-NCP =low-density non-calcified plaque.

P6184Association of coronary plaque characteristics and the translesional gradient by FFRct in asymptomatic patients with newly diagnosed type-2 diabetes mellitus

Background

Coronary CT angiography (CCTA) derived fractional flow reserve (FFRct) is increasingly for decision-making in patients with stable chest pain. The relation between vessel specific plaque characteristics and the translesional gradient by FFRct in patients with type-2 diabetes mellitus (T2DM) is not fully explored.

Purpose

To examine the association between vessel specific plaque characteristics as determined by CCTA and the translesional gradient as assessed by FFRct in asymptomatic patients with newly diagnosed T2DM.

Methods

Total plaque volume and the volumes of calcified plaque (CP), low-density noncalcified plaque (LD-NCP) and non-LD-NCP were assessed on a per-vessel basis by quantitative plaque analysis using Autoplaque. Irregularities of the vessel wall giving a vessel-specific total plaque volume <50 mm3 were excluded from the analyses. Positive remodeling was defined by a remodeling index >1.1. Spotty calcification was defined as calcifications comprising <90° of the vessel circumference and <3 mm length. FFRct-analysis was performed from standard acquired CCTA data sets by HeartFlow. Any FFRct-value in the major coronary arteries >1.8 mm in diameter was registered. The translesional gradient, defined as the difference of FFRct-values immediately proximal and distal to lesion, was calculated in most severe lesion per-vessel. Lesions were categorized according to a ΔFFRct threshold of 0.06. Plaque analysis and comparison to ΔFFRct were performed by staff blinded to patient data.

Results

A total of 76 patients; age, mean (SD): 56 (11) years; males, n (%): 49 (65), with newly diagnosed (<1 year) T2DM were studied. Haemoglobin A1c, median (IQR) was 45 mmol/L (42–50). Risk factors, mean (SD) were as follows: total-cholesterol, 4.4 mmol/L (1.0); LDL-cholesterol, 2.5 mmol/L (0.8); systolic blood pressure, 131 mmHg (12). In the analysis 57 vessels in 30 patients were included, while 24 vessels were classified as having irregularities. ΔFFRct ≥0.06 was registered in 22 (39%) plaques. Vessel specific plaque volumes (mm3), ΔFFRct ≥0.06 vs. ΔFFRct <0.06, were, median (IQR): LD-NCP, 28.1 (9.5–62.3) vs. 18.3 (10.2–27.5); non-LD-NCP, 129.5 (74.1–186.8) vs. 98.1 (65.7–142.1); total plaque volume, 209.4 (137.1–359.3) vs. 139.6 (108.3–220.0), all p>0.05. The vessel-specific CP volume, median (IQR), was higher in vessels with ΔFFRct ≥0.06 vs. ΔFFRct <0.06: 51.9 (20.5–85.4) vs. 13.5 (4.1–68.5), p=0.015. Adverse plaque characteristics ΔFFRct ≥0.06 vs. ΔFFRct <0.06, were, n (%): positive remodeling, 21 (95%) vs. 34 (97%) and spotty calcification, 9 (41%) vs. 14 (40%). The relative distribution of vessel specific plaque components according to ΔFFRct is illustrated in the Figure.

Conclusion

In asymptomatic patients with newly diagnosed and well-controlled T2DM, the occurrence of high-risk coronary plaque features was frequently observed. The applied translesional gradient by FFRct was not predictive of adverse coronary plaque characteristics.

Acknowledgement/Funding

The Danish Diabetes Academy supported by the Novo Nordisk Foundation; University of Southern DenmarkCenter Southwest, Denmark

Genome-wide analysis of genetic determinants of circulating factor VII-activating protease (FSAP) activity

Essentials Knowledge of genetic regulators of plasma factor VII activating protease (FSAP) levels is limited. We performed a genome-wide analysis of variants influencing FSAP activity in Scandinavian cohorts. We replicated an association for Marburg-1 and identified an association for a HABP2 stop variant. We identified a novel locus near ADCY2 as a potential additional regulator of FSAP activity.

SUMMARY

Background Factor VII-activating protease (FSAP) has roles in both coagulation and fibrinolysis. Recent data indicate its involvement in several other processes, such as vascular remodeling and inflammation. Plasma FSAP activity is highly variable among healthy individuals and, apart from the low-frequency missense variant Marburg-I (rs7080536) in the FSAP-encoding gene HABP2, determinants of this variation are unclear. Objectives To identify novel genetic variants within and outside of the HABP2 locus that influence circulating FSAP activity. Patients/Methods We performed an exploratory genome-wide association study (GWAS) on plasma FSAP activity amongst 3230 Swedish subjects. Directly genotyped rare variants were also analyzed with gene-based tests. Using GWAS, we confirmed the strong association between the Marburg-I variant and FSAP activity. HABP2 was also significant in the gene-based analysis, and remained significant after exclusion of Marburg-I carriers. This was attributable to a rare HABP2 stop variant (rs41292628). Carriers of this stop variant showed a similar reduction in FSAP activity as Marburg-I carriers, and this finding was replicated. A secondary genome-wide significant locus was identified at a 5p15 locus (rs35510613), and this finding requires future replication. This common variant is located upstream of ADCY2, which encodes a protein catalyzing the formation of cAMP. Results and Conclusions This study verified the Marburg-I variant to be a strong regulator of FSAP activity, and identified an HABP2 stop variant with a similar impact on FSAP activity. A novel locus near ADCY2 was identified as a potential additional regulator of FSAP activity.

Uncontrolled hypertension is associated with coronary artery calcification and electrocardiographic left ventricular hypertrophy: a case-control study

We conducted a 1:2 matched case-control study in order to evaluate whether the prevalence of coronary artery calcium (CAC) and electrocardiographic left ventricular hypertrophy (LVH) or strain was higher in patients with uncontrolled hypertension than in subjects from the general population, and evaluate the association between CAC and LVH in patients with uncontrolled hypertension. Cases were patients with uncontrolled hypertension, whereas the controls were random individuals from the general population without cardiovascular disease. CAC score was assessed using a non-contrast computed tomographic scan. LVH was evaluated using the Sokolow-Lyon voltage combination and Cornell voltage-duration product, respectively. Associations between CAC, LVH and traditional cardiovascular risk factors were tested by means of ordinal, conditional and classic binary logistic regression models. We found that uncontrolled hypertension was independently associated with both an ordinal CAC score category (odds ratio (OR) 3.9 (95% CI, 1.6-9.1), P = 0.002), the presence of CAC score>99 (OR 4.5 (95% CI, 1.4-14.7), P = 0.01) and electrocardiographic LVH (OR 10.1 (95% CI, 3.4-30.2), P < 0.001) on both univariate and multivariable analyses. There was, however, no correlation between CAC and LVH. The lack of an association between CAC and LVH suggests that they are markers of different complications of hypertension and may have independent predictive values. Patients with both CAC and LVH may be at higher risk than those in whom only one of these markers is present.