Division of Cardiology, Gifu Heart Center, Japan (S.I., T.K., Y.K., H.M.).
Division of Cardiology, Cardiovascular Research Foundation, New York, NY (G.W.S.).
Circ Cardiovasc Interv. 2019 Feb;12(2):e006961. doi: 10.1161/CIRCINTERVENTIONS.118.006961.
Background The basis of discordance between invasive coronary angiographic (ICA) anatomic stenosis and fractional flow reserve (FFR) is not fully understood. We analyzed coronary computed tomography angiography (CTA) characteristics of ICA-verified nonobstructive lesions in the proximal or midleft anterior descending artery with FFR ≤0.8, that is, anatomy-physiology mismatch. Methods and Results CTA and ICA were performed in 108 patients. FFR was measured during intravenous ATP (180 μg/[kg·min]) infusion. CTA-verified plaque characteristics between 53 consecutive ICA-FFR mismatch (ICA-quantitative coronary angiography <50%, FFR≤0.8) and 55 ICA-FFR match (ICA-quantitative coronary angiography<50%, FFR>0.8) vessels were compared. CTA-verified vessel area (20.7±6.7 versus 16.9±4.8 mm; P=0.0007), positive area remodeling index (ARI; 1.38±0.23 versus 1.06±0.11; P<0.0001), %plaque area (64.7±12.7 versus 57.4±8.5%; P<0.0007), jeopardized myocardial mass (46.2±18.5 versus 37.1±14.3 g; P= 0.006), and the prevalence of low attenuation plaque (45.3% versus 9.1%; P<0.0001) at the minimum lumen area were significantly higher in the ICA-FFR mismatch than the match group. By receiver operation curve analysis, the areas under the curve for positive area remodeling index, %plaque area and jeopardized myocardial mass were 0.921, 0.681, and 0.641, respectively, for the diagnosis of mismatch (cutoff values 1.13, 66% and 58.7 g, respectively). The sensitivity and specificity of area remodeling index >1.13 for predicting ICA-FFR mismatch were 88.7% and 78.2%, respectively. Conclusions In the absence of anatomically significant stenosis, abnormal FFR is more frequently encountered in patients with CTA-derived positive remodeling, larger plaque burden, and low attenuation plaque. These findings contribute to a better understanding of how FFR-based decision-making might translate into demonstrated superior clinical outcomes.
在有创冠状动脉造影（ICA）解剖学狭窄和血流储备分数（FFR）之间存在差异的基础尚不完全清楚。我们分析了在左前降支近段或中段 FFR≤0.8 时，通过冠状动脉计算机断层扫描血管造影（CTA）证实的非阻塞性病变的特征，即解剖-生理学不匹配。
对 108 例患者进行 CTA 和 ICA 检查。在静脉注射 ATP（180μg/[kg·min]）时测量 FFR。比较了 53 例连续 ICA-FFR 不匹配（ICA-定量冠状动脉造影<50%，FFR≤0.8）和 55 例 ICA-FFR 匹配（ICA-定量冠状动脉造影<50%，FFR>0.8）血管的 CTA 证实的斑块特征。比较了 CTA 证实的血管面积（20.7±6.7 与 16.9±4.8mm；P=0.0007）、阳性面积重构指数（ARI；1.38±0.23 与 1.06±0.11；P<0.0001）、%斑块面积（64.7±12.7 与 57.4±8.5%；P<0.0007）、危险心肌质量（46.2±18.5 与 37.1±14.3g；P=0.006）和最小管腔面积的低衰减斑块（45.3%与 9.1%；P<0.0001）在 ICA-FFR 不匹配组中明显更高。通过接收者操作特征曲线分析，阳性面积重构指数、%斑块面积和危险心肌质量的曲线下面积分别为 0.921、0.681 和 0.641，用于诊断不匹配（截断值分别为 1.13、66%和 58.7g）。ARI>1.13 预测 ICA-FFR 不匹配的灵敏度和特异性分别为 88.7%和 78.2%。
在没有明显解剖学狭窄的情况下，在 CTA 得出的阳性重构、更大的斑块负担和低衰减斑块的患者中，更常出现异常的 FFR。这些发现有助于更好地理解基于 FFR 的决策如何转化为显示出的优越临床结果。
