Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea; Institute on Aging, Seoul National University, Seoul, Korea.
J Am Coll Cardiol. 2019 May 21;73(19):2413-2424. doi: 10.1016/j.jacc.2019.02.060.
Although the presence of ischemia is a key prognostic factor in patients with coronary artery disease, the presence of high-risk plaque characteristics (HRPC) is also associated with increased risk of cardiovascular events. Limited data exist regarding the prognostic implications of combined information on physiological stenosis severity assessed by fractional flow reserve (FFR) and plaque vulnerability by coronary computed tomography angiography (CTA)-defined HRPC.
The current study aimed to evaluate the: 1) association between physiological stenosis severity and coronary CTA-defined HRPC; and 2) prognostic implications of coronary CTA-defined HRPC according to physiological stenosis severity in patients with coronary artery disease.
A total of 772 vessels (299 patients) evaluated by both coronary CTA and FFR were analyzed. The presence and number of HRPC (minimum lumen area <4 mm, plaque burden ≥70%, low attenuating plaque, positive remodeling, napkin-ring sign, or spotty calcification) were assessed using coronary CTA images. The risk of vessel-oriented composite outcome (VOCO) (a composite of vessel-related ischemia-driven revascularization, vessel-related myocardial infarction, or cardiac death) at 5 years was compared according to the number of HRPC and FFR categories.
The proportion of lesions with ≥3 HRPC was significantly decreased according to the increase in FFR values (58.6%, 46.5%, 36.8%, 15.7%, and 3.5% for FFR ≤0.60, 0.61 to ≤0.70, 0.71 to ≤0.80, 0.81 to ≤0.90, and >0.90, respectively; overall p value <0.001). Both FFR and number of HRPC showed significant association with the estimated risk of VOCO (p = 0.008 and p = 0.023, respectively). In the FFR >0.80 group, lesions with ≥3 HRPC showed significantly higher risk of VOCO than those with <3 HRPC (15.0% vs. 4.3%; hazard ratio: 3.964; 95% confidence interval: 1.451 to 10.828; p = 0.007). However, there was no significant difference in the risk of VOCO according to HRPC in the FFR ≤0.80 group. By multivariable analysis, the presence of ≥3 HRPC was independently associated with the risk of VOCO in the FFR >0.80 group.
Physiological stenosis severity and the number of HRPC were closely related, and both components had significant association with the risk of clinical events. However, the prognostic implication of HRPC was different according to FFR. Integration of both physiological stenosis severity and plaque vulnerability would provide better prognostic stratification of patients than either individual component alone, especially in patients with FFR >0.80. (Clinical Implication of 3-vessel Fractional Flow Reserve [3V FFR-FRIENDS study]; NCT01621438).
尽管存在缺血是冠心病患者的一个关键预后因素，但存在高危斑块特征（HRPC）也与心血管事件风险增加相关。关于通过血流储备分数（FFR）评估的生理狭窄严重程度和通过冠状动脉计算机断层扫描血管造影（CTA）定义的 HRPC 的斑块脆弱性的综合信息的预后意义的数据有限。
本研究旨在评估：1）生理狭窄严重程度与冠状动脉 CTA 定义的 HRPC 之间的关系；以及 2）在冠心病患者中，根据生理狭窄严重程度，冠状动脉 CTA 定义的 HRPC 的预后意义。
对同时接受冠状动脉 CTA 和 FFR 检查的 772 支血管（299 例患者）进行了分析。使用冠状动脉 CTA 图像评估 HRPC 的存在和数量（最小管腔面积 <4mm、斑块负荷≥70%、低衰减斑块、正性重构、餐巾环征或点状钙化）。根据 HRPC 和 FFR 类别，比较 5 年内血管定向复合结局（VOCO）（血管相关缺血驱动血运重建、血管相关心肌梗死或心脏死亡的复合）的风险。
随着 FFR 值的增加，存在≥3 个 HRPC 的病变比例显著降低（FFR≤0.60、0.61 至≤0.70、0.71 至≤0.80、0.81 至≤0.90 和>0.90 分别为 58.6%、46.5%、36.8%、15.7%和 3.5%；总体 p 值<0.001）。FFR 和 HRPC 数量均与 VOCO 的估计风险显著相关（p=0.008 和 p=0.023）。在 FFR>0.80 组中，存在≥3 个 HRPC 的病变发生 VOCO 的风险显著高于存在<3 个 HRPC 的病变（15.0% vs. 4.3%；危险比：3.964；95%置信区间：1.451 至 10.828；p=0.007）。然而，在 FFR≤0.80 组中，HRPC 数量与 VOCO 的风险无显著差异。多变量分析显示，存在≥3 个 HRPC 与 FFR>0.80 组 VOCO 的风险独立相关。
生理狭窄严重程度和 HRPC 的数量密切相关，两者均与临床事件风险有显著关联。然而，HRPC 的预后意义因 FFR 而异。生理狭窄严重程度和斑块脆弱性的综合评估比单独使用任何一个指标都能提供更好的患者预后分层，尤其是在 FFR>0.80 的患者中。
