Arnav Kumar1, Elizabeth W Thompson2, Adrien Lefieux3, David S Molony2, Emily L Davis2, Nikita Chand2, Stephane Fournier4, Hee Su Lee2, Jon Suh2, Kimi Sato5, Yi-An Ko6, Daniel Molloy2, Karthic Chandran2, Hossein Hosseini2, Sonu Gupta2, Anastasios Milkas4, Bill Gogas2, Hyuk-Jae Chang7, James K Min7, William F Fearon8, Alessandro Veneziani9, Don P Giddens10, Spencer B King2, Bernard De Bruyne4, Habib Samady11. 1. Andreas Gruentzig Cardiovascular Center, Emory University School of Medicine, Atlanta, Georgia. Electronic address: https://twitter.com/arnavkumar. 2. Andreas Gruentzig Cardiovascular Center, Emory University School of Medicine, Atlanta, Georgia. 3. Andreas Gruentzig Cardiovascular Center, Emory University School of Medicine, Atlanta, Georgia; Department of Mathematics and Computer Science, Emory University, Atlanta, Georgia. 4. Cardiovascular Center, Aalst, Belgium. 5. Cardiovascular Division, University of Tsukuba, Tsukuba, Japan. 6. Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia. 7. Department of Radiology, Weill Cornell Medicine, New York, New York. 8. Stanford Cardiovascular Institute and Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California. 9. Department of Mathematics and Computer Science, Emory University, Atlanta, Georgia. 10. Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, Georgia. 11. Andreas Gruentzig Cardiovascular Center, Emory University School of Medicine, Atlanta, Georgia. Electronic address: hsamady@emory.edu.
Abstract
BACKGROUND: Coronary lesions with low fractional flow reserve (FFR) that are treated medically are associated with higher revascularization rates. High wall shear stress (WSS) has been linked with increased plaque vulnerability. OBJECTIVES: This study investigated the prognostic value of WSS measured in the proximal segments of lesions (WSSprox) to predict myocardial infarction (MI) in patients with stable coronary artery disease (CAD) and hemodynamically significant lesions. The authors hypothesized that in patients with low FFR and stable CAD, higher WSSprox would predict MI. METHODS: Among 441 patients in the FAME II (Fractional Flow Reserve Versus Angiography for Multivessel Evaluation II) trial with FFR ≤0.80 who were randomized to medical therapy alone, 34 (8%) had subsequent MI within 3 years. Patients with vessel-related MI and adequate angiograms for 3-dimensional reconstruction (n = 29) were propensity matched to a control group with no MI (n = 29) by using demographic and clinical variables. Coronary lesions were divided into proximal, middle, and distal, along with 5-mm upstream and downstream segments. WSS was calculated for each segment. RESULTS:Median age was 62 years, and 46 (79%) were male. In the marginal Cox model, whereas lower FFR showed a trend (hazard ratio: 0.084; p = 0.064), higher WSSprox (hazard ratio: 1.234; p = 0.002, C-index = 0.65) predicted MI. Adding WSSprox to FFR resulted in a significant increase in global chi-square for predicting MI (p = 0.045), a net reclassification improvement of 0.69 (p = 0.005), and an integrated discrimination index of 0.11 (p = 0.010). CONCLUSIONS: In patients with stable CAD and hemodynamically significant lesions, higher WSS in the proximal segments of atherosclerotic lesions is predictive of MI and has incremental prognostic value over FFR.
RCT Entities:
BACKGROUND: Coronary lesions with low fractional flow reserve (FFR) that are treated medically are associated with higher revascularization rates. High wall shear stress (WSS) has been linked with increased plaque vulnerability. OBJECTIVES: This study investigated the prognostic value of WSS measured in the proximal segments of lesions (WSSprox) to predict myocardial infarction (MI) in patients with stable coronary artery disease (CAD) and hemodynamically significant lesions. The authors hypothesized that in patients with low FFR and stable CAD, higher WSSprox would predict MI. METHODS: Among 441 patients in the FAME II (Fractional Flow Reserve Versus Angiography for Multivessel Evaluation II) trial with FFR ≤0.80 who were randomized to medical therapy alone, 34 (8%) had subsequent MI within 3 years. Patients with vessel-related MI and adequate angiograms for 3-dimensional reconstruction (n = 29) were propensity matched to a control group with no MI (n = 29) by using demographic and clinical variables. Coronary lesions were divided into proximal, middle, and distal, along with 5-mm upstream and downstream segments. WSS was calculated for each segment. RESULTS: Median age was 62 years, and 46 (79%) were male. In the marginal Cox model, whereas lower FFR showed a trend (hazard ratio: 0.084; p = 0.064), higher WSSprox (hazard ratio: 1.234; p = 0.002, C-index = 0.65) predicted MI. Adding WSSprox to FFR resulted in a significant increase in global chi-square for predicting MI (p = 0.045), a net reclassification improvement of 0.69 (p = 0.005), and an integrated discrimination index of 0.11 (p = 0.010). CONCLUSIONS: In patients with stable CAD and hemodynamically significant lesions, higher WSS in the proximal segments of atherosclerotic lesions is predictive of MI and has incremental prognostic value over FFR.
Authors: Habib Samady; David S Molony; Ahmet U Coskun; Anubodh S Varshney; Bernard De Bruyne; Peter H Stone Journal: J Cardiovasc Comput Tomogr Date: 2019-12-04
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