Stress Myocardial Blood Flow Ratio by Dynamic CT Perfusion Identifies Hemodynamically Significant CAD

Yang, Junjie; Dou, Guanhua; He, Bo; Jin, Qinhua; Chen, Zhiye; Jing, Jing; Carli, Marcelo F. Di; Chen, Yundai; Blankstein, Ron

doi:10.1016/j.jcmg.2019.06.016

Cited by 37 publications

(29 citation statements)

References 23 publications

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“…In this setting, the reported stress subendocardial RMPI [12] provides a simpli ed and more useful semi-quantitative parameter for clinical practice, with a high diagnostic accuracy to determine FFR≤0.80 intermediate-grade stenoses, in line with those of previous meta-analyses, including mainly semi-quantitative and quantitative MRI analyses [10]. This approach has also been reported in stress dynamic computed tomography perfusion showing better accuracy to identify ow-limiting stenoses than the myocardial blood ow in the area-at-risk [24]. Nevertheless, using RMPI three false-negative and three false-positive cases remained for the FFR≤0.8 cutoff, owing to image artifacts and the existence of the so-called gray-zone of FFR values (0.75-0.80) [25].…”

Section: Patient and Intermediate-grade Coronary Stenoses Characterissupporting

confidence: 70%

Semi-quantitative Analysis of Adenosine Perfusion Magnetic Resonance Imaging Outperforms Visual Analysis in Identifying Fractional Flow Reserve-Altered Intermediate-grade Coronary Artery Stenosis: A Pilot Study

Ghekiere

Dacher

Dewilde

et al. 2021

Preprint

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PurposeTo evaluate the diagnostic accuracy of semi-quantitative adenosine perfusion magnetic resonance imaging(MRI) to determine fractional flow reserve(FFR)≤0.80 intermediate-grade coronary stenoses as compared to visual analysis.Methods Forty-six patients (mean age 61±9 years;33 males) with 49 intermediate-grade stenoses underwent adenosine perfusion MRI and FFR measurement within 4 months between 2010 and 2013. Retrospective interpretation of all prospectively acquired data was performed. MRI was visually assessed by 2 experienced readers twice with one-year interval, the second time with the knowledge of the diseased artery. All myocardial enhancement maximal upslopes were evaluated distal to the coronary stenosis (=RISK) and in remote myocardium supplied by normal arteries (=REMOTE); stress subendocardial relative myocardial perfusion index (RMPI; RISK/REMOTE upslopes) was assessed in predicting FFR≤0.80 stenoses. Deep learning boosting models including all RISK and REMOTE upslopes were fitted to confirm the added value of accounting for perfusion changes in remote myocardium for FFR prediction. Results The average FFR value was 0.84±0.09 and 15/49 (31%) stenoses were FFR≤0.80. Both readers had moderate accuracy (range: 36/49(73%)-38/49(78%)) in predicting FFR≤0.80 stenoses, even with the knowledge of the stenosis location. At a cutoff value of 0.84, stress subendocardial RMPI had higher accuracy (43/49(88%)) than individual visual readings to predict FFR≤0.80 stenoses. The best FFR prediction using the boosting model occurred when accounting for REMOTE myocardial perfusion parameters, leading to diagnostic accuracy of 44/49(90%) for FFR≤0.80. Conclusion Semi-quantitative adenosine perfusion MRI accounting for stress perfusion in remote myocardium predicts FFR≤0.80 intermediate-grade coronary stenoses with a higher accuracy than individual visual analysis.

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Section: Patient and Intermediate-grade Coronary Stenoses Characterissupporting

confidence: 70%

Semi-quantitative Analysis of Adenosine Perfusion Magnetic Resonance Imaging Outperforms Visual Analysis in Identifying Fractional Flow Reserve-Altered Intermediate-grade Coronary Artery Stenosis: A Pilot Study

Ghekiere

Dacher

Dewilde

et al. 2021

Preprint

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“…125 Calculation of stress myocardial blood flow ratio (SFR) might improve specificity and diagnostic accuracy of CTA. 126 Head-to-head comparisons of varying combinations of perfusion imaging and CT-FFR techniques as well as meta-analyses of independent cohorts, suggest comparable performance and potentially complementary value of both functional CT applications when added to coronary CTA. 62,127,128 Studies in patients with stable angina referred to invasive coronary angiography based on coronary CTA, FFR CT and CMR yielded similar overall diagnostic accuracy.…”

Section: Ct Myocardial Perfusionmentioning

confidence: 96%

SCCT 2021 Expert Consensus Document on Coronary Computed Tomographic Angiography: A Report of the Society of Cardiovascular Computed Tomography

Narula

Chandrashekhar

Ahmadi

et al. 2021

Journal of Cardiovascular Computed Tomography

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192

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2.1.2. Diagnostic performance of functional imaging and CTA compared to >50% diameter stenosis by ICA The National Cardiovascular Data Registry 9 suggested that functional testing is suboptimal for detecting significant coronary stenoses. Of the 661,063 patients undergoing elective catheterization, 64% had testing before the invasive coronary angiogram (ICA); of those, only 51.9% were abnormal. The percentages of patients with <50% DS on subsequent ICA ranged from 55 to 56% after an abnormal exercise treadmill test (ETT), stress echocardiography (SE), single photon emission computed tomography (SPECT) and magnetic resonance imaging (MRI); for resting CTA, the percentage was 30%. In the oldest report, Fleischmann et al. evaluated 5874 patients in 41 studies from 1990 to 1997, and reported sensitivity and specificity of 85% and 77% for SE and 87% and 64% for SPECT, with 52% and 71% for exercise ECG. 10 DeJong et al. (Table 2A), in a meta-analysis of 5088 patients in 51 studies from 2000 to 2011 evaluated MRI, SE and SPECT with >50%DS by ICA as reference. 11 MRI was the most sensitive and specific (91% and 80%), with SE (87% and 72%) and SPECT (83% and 77%) roughly similar. Jaarsma et al. (Table 2B), reported on SPECT, MRI and positron emission tomography (PET) in 141 per-patient studies and 70 per-vessel studies. 12 Per-patient diagnostic odds ratio (DOR) was highest for PET (36.47) followed by MRI (26.42) and SPECT (16.31). In pervessel analysis, PET and MRI were equal (24.74 and 24.11), while SPECT was lowest (11.75). In a meta-analysis limited to 26 studies in which CTA was compared to either ETT or SPECT in the same group of patients, Nielsen et al. 13 (Table 2C) reported CTA sensitivities of 95e99%, specificities of 68e93% and DOR of 128e728. Corresponding ranges for ETT were 65e70%, 24e60% and 0.7e4 and for SPECT were 67e73%, 48e52% and 2e4. It is important to understand that available meta-analyses are also challenged by the small numbers of patients in some of the individual reports, potential referral bias, and often include a mixture of newer and older technology (e.g., planar and SPECT imaging). Finally, in a paper published too recently for meta-analysis inclusion, 391 symptomatic patients, 52% with intermediate and 46% with high risk pre-test probability, who were scheduled for ICA, underwent both CTA and SPECT with >50%DS by ICA as reference. 14 Sensitivity, specificity, positive and negative predictive values were 0.92, 0.75, 0.84 and 0.87 for CTA and 0.62, 0.68, 0.74 and 0.55 for SPECT. AUC was significantly higher for CTA (0.91 versus 0.69, p < 0.001.

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“…However, the optimal quantification method remains controversial and the cut-off value on dynamic CTP imaging is still not standardized. Recently, relative flow reserve has been shown to be a better alternative to absolute MBF [40,65,66]. CFR is calculated as a quantitative ratio of stress MBF to rest MBF in stress and rest dynamic CTP protocol [36].…”

Section: Interpretation Of Ctp Imagesmentioning

confidence: 99%

Computed tomographic evaluation of myocardial ischemia

et al. 2020

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Myocardial ischemia is caused by a mismatch between myocardial oxygen consumption and oxygen delivery in coronary artery disease (CAD). Stratification and decision-making based on ischemia improves the prognosis in patients with CAD. Non-invasive tests used to evaluate myocardial ischemia include stress electrocardiography, echocardiography, single-photon emission computed tomography, and magnetic resonance imaging. Invasive fractional flow reserve is considered the reference standard for assessment of the hemodynamic significance of CAD. Computed tomography (CT) angiography has emerged as a first-line imaging modality for evaluation of CAD, particularly in the population at low to intermediate risk, because of its high negative predictive value; however, CT angiography does not provide information on the hemodynamic significance of stenosis, which lowers its specificity. Emerging techniques, e.g., CT perfusion and CT-fractional flow reserve, help to address this limitation of CT, by determining the hemodynamic significance of coronary artery stenosis. CT perfusion involves acquisition during the first pass of contrast medium through the myocardium following pharmacological stress. CTfractional flow reserve uses computational fluid dynamics to model coronary flow, pressure, and resistance. In this article, we review these two functional CT techniques in the evaluation of myocardial ischemia, including their principles, technology, advantages, limitations, pitfalls, and the current evidence.

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Stress Myocardial Blood Flow Ratio by Dynamic CT Perfusion Identifies Hemodynamically Significant CAD

Cited by 37 publications

References 23 publications

Semi-quantitative Analysis of Adenosine Perfusion Magnetic Resonance Imaging Outperforms Visual Analysis in Identifying Fractional Flow Reserve-Altered Intermediate-grade Coronary Artery Stenosis: A Pilot Study

Semi-quantitative Analysis of Adenosine Perfusion Magnetic Resonance Imaging Outperforms Visual Analysis in Identifying Fractional Flow Reserve-Altered Intermediate-grade Coronary Artery Stenosis: A Pilot Study

SCCT 2021 Expert Consensus Document on Coronary Computed Tomographic Angiography: A Report of the Society of Cardiovascular Computed Tomography

Computed tomographic evaluation of myocardial ischemia

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