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European Radiology
Published in: European Radiology 6/2019

01-06-2019 | Computed Tomography | Cardiac

Additional diagnostic value of new CT imaging techniques for the functional assessment of coronary artery disease: a meta-analysis

Authors: Michèle Hamon, Damien Geindreau, Lydia Guittet, Christophe Bauters, Martial Hamon

Published in: European Radiology | Issue 6/2019

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Abstract

Objectives

To determine the diagnostic performance of cardiac computed tomography (CT)–based modalities including coronary CT angiography (CTA), stress myocardial CT perfusion (stress CTP), computer simulation of fractional flow reserve by CT (FFRCT), and transluminal attenuation gradients (TAG), for the diagnosis of hemodynamic significant coronary artery disease (CAD), using invasive fractional flow reserve as the reference standard.

Methods

PubMed and Cochrane databases were searched for original articles until July 2018. Diagnostic accuracy results were pooled at per-patient and per-vessel level using random effect models.

Results

Fifty articles were included in the meta-analysis (3024 subjects). The per-patient analysis per imaging modality demonstrated a pooled positive likelihood ratio (PLR) of 1.78 (95% confidence interval CI 1.49–2.11), 4.58 (95% CI 3.54–5.91), and 3.45 (95% CI 2.38–5.00) for CTA, stress CTP, and FFRCT respectively. Per-patient specificity of stress CTP (82%, 95% CI 76–86) and FFRCT (72%, 95% CI 68–76) were higher than for CTA (48%, 95% CI 44–51). At the vessel level, PLR was 2.42 (95% CI 1.93–3.02), 7.72 (95% CI 5.50–10.83), 3.50 (95% CI 2.73–4.78), 1.97 (95% CI 1.32–2.93) for CTA, stress CTP, FFRCT, and TAG respectively.

Conclusion

With improved PLR and specificity, stress CTP and FFRCT have incremental value over CTA for the detection of functionally significant CAD.

Key Points

• New functional CT imaging techniques, such as stress CTP and FFRCT, improve diagnostic accuracy of coronary CTA to predict hemodynamically relevant stenosis.
• TAG yields poor diagnostic performance.
• Combination of CTA and some functional CT techniques (stress CTP and FFRCT) might become a “must” to improve diagnostic accuracy of CAD and to reduce unnecessary invasive coronary angiography.
Appendix
Available only for authorised users
Literature
1.
Hamon M, Biondi-Zoccai GG, Malagutti P et al (2006) Diagnostic performance of multislice spiral computed tomography of coronary arteries as compared with conventional invasive coronary angiography: a meta-analysis. J Am Coll Cardiol 48:1896–1910CrossRefPubMed
2.
Montalescot G, Sechtem U, Achenbach S et al (2013) ESC guidelines on the management of stable coronary artery disease: the task force on the management of stable coronary artery disease of the European Society of Cardiology. Eur Heart J 34:2949–3003CrossRefPubMed
3.
Gonçalves Pde A, Rodríguez-Granillo GA, Spitzer E et al (2015) Functional evaluation of coronary disease by CT angiography. JACC Cardiovasc Imaging 11:1322–1335
4.
Tonino PA, De Bruyne B, Pijls NH et al (2009) Fractional flow reserve versus angiography for guiding percutaneous coronary intervention. N Engl J Med 360:213–224CrossRefPubMed
5.
De Bruyne B, Pijls NH, Kalesan B et al (2012) Fractional flow reserve-guided PCI versus medical therapy in stable coronary disease. N Engl J Med 367:991–1001CrossRefPubMed
6.
Boden WE, O'Rourke RA, Teo KK et al (2007) Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med 356(15):1503–1516CrossRefPubMed
7.
Liberati A, Altman DG, Tetzlaff J et al (2009) The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ 339:b2700CrossRefPubMedPubMedCentral
8.
Whiting PF, Rutjes AW, Westwood ME et al (2011) QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies. Ann Intern Med 8:529–536CrossRef
9.
10.
Meijboom WB, Van Mieghem CA, van Pelt N et al (2008) Comprehensive assessment of coronary artery stenoses: computed tomography coronary angiography versus conventional coronary angiography and correlation with fractional flow reserve in patients with stable angina. J Am Coll Cardiol 52:636–643CrossRefPubMed
11.
van Werkhoven JM, Schuijf JD, Jukema JW et al (2009) Comparison of non-invasive multi-slice computed tomography coronary angiography versus invasive coronary angiography and fractional flow reserve for the evaluation of men with known coronary artery disease. Am J Cardiol 104:653–656CrossRefPubMed
12.
Sarno G, Decraemer I, Vanhoenacker PK et al (2009) On the inappropriateness of noninvasive multidetector computed tomography coronary angiography to trigger coronary revascularization: a comparison with invasive angiography. JACC Cardiovasc Interv 2:550–557CrossRefPubMed
13.
Kristensen TS, Engstrøm T, Kelbæk H, von der Recke P, Nielsen MB, Kofoed KF (2010) Correlation between coronary computed tomographic angiography and fractional flow reserve. Int J Cardiol 144:200–205CrossRefPubMed
14.
Opolski MP, Kepka C, Achenbach S et al (2014) Advanced computed tomographic anatomical and morphometric plaque analysis for prediction of fractional flow reserve in intermediate coronary lesions. Eur J Radiol 83:135–141CrossRefPubMed
15.
Rossi A, Papadopoulou SL, Pugliese F et al (2014) Quantitative computed tomographic coronary angiography: does it predict functionally significant coronary stenoses? Circ Cardiovasc Imaging 1:43–51CrossRef
16.
Voros S, Rinehart S, Vazquez-Figueroa JG et al (2014) Prospective, head-to-head comparison of quantitative coronary angiography, quantitative computed tomography angiography, and intravascular ultrasound for the prediction of hemodynamic significance in intermediate and severe lesions, using fractional flow reserve as reference standard (from the ATLANTA I and II Study). Am J Cardiol 113:23–29CrossRefPubMed
17.
Ko BS, Wong DT, Cameron JD et al (2014) 320-row CT coronary angiography predicts freedom from revascularisation and acts as a gatekeeper to defer invasive angiography in stable coronary artery disease: a fractional flow reserve-correlated study. Eur Radiol 24:738–747CrossRefPubMed
18.
Ghekiere O, Dewilde W, Bellekens M et al (2015) Diagnostic performance of quantitative coronary computed tomography angiography and quantitative coronary angiography to predict hemodynamic significance of intermediate-grade stenoses. Int J Cardiovasc Imaging 31:1651–1661CrossRefPubMed
19.
Danad I, Rajmakers PG, Driessen R et al (2017) Comparison of coronary angiography, SPECT, PET, and hybrid imaging for diagnosis of ischemic heart disease determined by fractional flow reserve. JAMA Cardiol 2(10):1100–1107CrossRefPubMedPubMedCentral
20.
Bamberg F, Becker A, Schwarz F et al (2011) Detection of hemodynamically significant coronary artery stenosis: incremental diagnostic value of dynamic CT-based myocardial perfusion imaging. Radiology 260:689–698CrossRefPubMed
21.
Ko BS, Cameron JD, Meredith IT et al (2012) Computed tomography stress myocardial perfusion imaging in patients considered for revascularization: a comparison with fractional flow reserve. Eur Heart J 33:67–77CrossRefPubMed
22.
Ko BS, Cameron JD, Leung M et al (2012) Combined CT coronary angiography and stress myocardial perfusion imaging for hemodynamically significant stenoses in patients with suspected coronary artery disease: a comparison with fractional flow reserve. JACC Cardiovasc Imaging 5:1097–1111CrossRefPubMed
23.
Bettencourt N, Chiribiri A, Schuster A et al (2013) Direct comparison of cardiac magnetic resonance and multidetector computed tomography stress-rest perfusion imaging for detection of coronary artery disease. J Am Coll Cardiol 61:1099–1107CrossRefPubMed
24.
Choo KS, Hwangbo L, Kim JH et al (2013) Adenosine-stress low-dose single-scan CT myocardial perfusion imaging using a 128-slice dual-source CT: a comparison with fractional flow reserve. Acta Radiol 54:389–395CrossRefPubMed
25.
Greif M, von Ziegler F, Bamberg F et al (2013) CT stress perfusion imaging for detection of haemodynamically relevant coronary stenosis as defined by FFR. Heart 99:1004–1111CrossRefPubMed
26.
Huber AM, Leber V, Gramer BM et al (2013) Myocardium: dynamic versus single-shot CT perfusion imaging. Radiology 269:378–386CrossRefPubMed
27.
Rossi A, Dharampal A, Wragg A et al (2014) Diagnostic performance of hyperaemic myocardial blood flow index obtained by dynamic computed tomography: does it predict functionally significant coronary lesions? Eur Heart J Cardiovasc Imaging 15:85–94CrossRefPubMed
28.
Wong DT, Ko BS, Cameron JD et al (2014) Comparison of diagnostic accuracy of combined assessment using adenosine stress computed tomography perfusion + computed tomography angiography with transluminal attenuation gradient + computed tomography angiography against invasive fractional flow reserve. J Am Coll Cardiol 63:1904–1912CrossRefPubMed
29.
Kono AK, Coenen A, Lubbers MM et al (2014) Relative myocardial blood flow by dynamic computed tomographic perfusion imaging predicts hemodynamic significance of coronary stenosis better than absolute blood flow. Invest Radiol 49:801–807
30.
Yang DH, Kim YH, Roh JH et al (2015) Stress myocardial perfusion CT in patients suspected of having coronary artery disease: visual and quantitative analysis-validation by using fractional flow reserve. Radiology 276:715–723CrossRefPubMed
31.
Coenen A, Rossi A, Lubbers MM et al (2017) Integrating CT myocardial perfusion and CT-FFR in the work-up of coronary artery disease. JACC Cardiovasc Imaging 10:760–770
32.
Yang DH, Kim YH, Roh JH et al (2017) Diagnostic performance of on-site CT-derived fractional flow reserve versus CT perfusion. Eur Heart J Cardiovasc Imaging 18:432–440CrossRefPubMed
33.
Williams MC, Mirsadraee S, Dweck MR et al (2017) Computed tomography myocardial perfusion vs 15O-water positron emission tomography and fractional flow reserve. Eur Radiol 27:1114–1124CrossRefPubMed
34.
Coenen A, Lubbers MM, Kurata A et al (2017) Diagnostic value of transmural perfusion ratio derived from dynamic CT-based myocardial perfusion imaging for the detection of haemodynamically relevant coronary artery stenosis. Eur Radiol 27:2309–2316
35.
Pontone G, Andreini D, Guaricci AI et al (2018) Incremental diagnostic value of stress computed tomography myocardial perfusion with whole-heart coverage CT scanner in intermediate –to high risk symptomatic patients suspected of coronary artery disease. JACC Cardiovasc Imaging. Available online 14 February 2018. https://​doi.​org/​10.​1016/​j.​jcmg.​2017.​10.​025
36.
Koo BK, Erglis A, Doh JH et al (2011) Diagnosis of ischemia-causing coronary stenoses by noninvasive fractional flow reserve computed from coronary computed tomographic angiograms. Results from the prospective multicenter DISCOVER-FLOW (Diagnosis of Ischemia-Causing Stenoses Obtained Via Noninvasive Fractional Flow Reserve) study. J Am Coll Cardiol 58:1989–1897CrossRefPubMed
37.
38.
Nørgaard BL, Leipsic J, Gaur S et al (2014) Diagnostic performance of noninvasive fractional flow reserve derived from coronary computed tomography angiography in suspected coronary artery disease: the NXT trial (Analysis of Coronary Blood Flow Using CT Angiography: Next Steps). J Am Coll Cardiol 63:1145–1155CrossRefPubMed
39.
Kim KH, Doh JH, Koo BK et al (2014) A novel noninvasive technology for treatment planning using virtual coronary stenting and computed tomography-derived computed fractional flow reserve. JACC Cardiovasc Interv 7:72–78CrossRefPubMed
40.
Renker M, Schoepf UJ, Wang R et al (2014) Comparison of diagnostic value of a novel noninvasive coronary computed tomography angiography method versus standard coronary angiography for assessing fractional flow reserve. Am J Cardiol 114:1303–1308CrossRefPubMed
41.
Coenen A, Lubbers MM, Kurata A et al (2015) Fractional flow reserve computed from noninvasive CT angiography data: diagnostic performance of an on-site clinician-operated computational fluid dynamics algorithm. Radiology 274:674–683CrossRefPubMed
42.
Wang R, Renker M, Schoepf UJ et al (2015) Diagnostic value of quantitative stenosis predictors with coronary CT angiography compared to invasive fractional flow reserve. Eur J Radiol 84:1509–1515CrossRefPubMed
43.
44.
De Geer J, Sandstedt M, Björkholm A et al (2016) Software-based on-site estimation of fractional flow reserve using standard coronary CT angiography data. Acta Radiol 57:1186–1192CrossRefPubMed
45.
Kruk M, Wardziak L, Demkov M et al (2016) Workstation-based calculation of CTA-based FFR for intermediate stenosis. JACC Cardiovasc Imaging 9:690–699CrossRefPubMed
46.
Kawaji T, Shiomi H, Morishita H et al (2017) Feasibility and diagnostic performance of fractional flow reserve measurement derived from coronary computed tomography angiography in real clinical practice. Int J Cardiovasc Imaging 33:271–281CrossRefPubMed
47.
Tesche C, De Cecco CN, Caruso D et al (2017) Coronary CT angiography derived morphological and functional quantitative plaque markers correlated with invasive fractional flow reserve for detecting hemodynamically significant stenosis. J Cardiovasc Comput Tomogr 10:199–206CrossRef
48.
Kurata A, Coenen A, Lubbers MM et al (2017) The effect of blood pressure on non-invasive fractional flow reserve derived from coronary computed tomography angiography. Eur Radiol 27:1416–1423
49.
Osawa K, Miyoshi T, Miki T et al (2017) Coronary lesion characteristics with mismatch between fractional flow reserve derived from CT and invasive catheterization in clinical practice. Heart Vessels 32:390–398CrossRefPubMed
50.
51.
Ko BS, Cameron JD, Munnur RK et al (2017) Noninvasive CT-derived FFR based on structural and fluid analysis. A comparison with invasive FFR for detection of functionally significant stenosis. JACC Cardiovasc Imaging 10:663–673CrossRefPubMed
52.
Yoon YE, Choi JH, Kim JH et al (2012) Noninvasive diagnosis of ischaemia-causing coronary stenosis using CT angiography: diagnostic value of transluminal attenuation gradient and fractional flow reserve computed from coronary CT angiography compared to invasively measured fractional flow reserve. JACC Cardiovasc Imaging 5:1088–1016CrossRefPubMed
53.
Choi JH, Koo BK, Yoon YE et al (2012) Diagnostic performance of intracoronary gradient-based methods by coronary computed tomography angiography for the evaluation of physiologically significant coronary artery stenoses: a validation study with fractional flow reserve. Eur Heart J Cardiovasc Imaging 13:1001–1007CrossRefPubMed
54.
Wong DT, Ko BS, Cameron JD et al (2013) Transluminal attenuation gradient in coronary computed tomography angiography is a novel noninvasive approach to the identification of functionally significant coronary artery stenosis: a comparison with fractional flow reserve. J Am Coll Cardiol 61:1271–1279CrossRefPubMed
55.
Stuijfzand WJ, Danad I, Raijmakers PG et al (2014) Additional value of transluminal attenuation gradient in CT angiography to predict hemodynamic significance of coronary artery stenosis. JACC Cardiovasc Imaging 7:374–386CrossRefPubMedPubMedCentral
56.
Hell MM, Dey D, Marwan M, Achenbach S, Schmid J, Schuhbaeck A (2015) Non-invasive prediction of hemodynamically significant coronary artery stenoses by contrast density difference in coronary CT angiography. Eur J Radiol 84:1502–1508CrossRefPubMed
57.
Nakanishi R, Matsumoto S, Alani A et al (2015) Diagnostic performance of transluminal attenuation gradient and fractional flow reserve by coronary computed tomographic angiography (FFR(CT)) compared to invasive FFR: a sub-group analysis from the DISCOVER-FLOW and DeFACTO studies. Int J Cardiovasc Imaging 31:1251–1259CrossRefPubMed
58.
Ko BS, Wong DT, Nørgaard BL et al (2016) Diagnostic performance of transluminal attenuation gradient and noninvasive fractional flow reserve derived from 320-detector row CT angiography to diagnose hemodynamically significant coronary stenosis: an NXT substudy. Radiology 279:75–83CrossRefPubMed
59.
Ko BS, Seneviratne S, Cameron J et al (2016) Rest and stress transluminal attenuation gradient and contrast opacification difference for detection of hemodynamically significant stenosis in patients with suspected coronary artery disease. Int J Cardiovasc Imaging 32:1131–1141CrossRefPubMed
60.
Gonzalez JA, Lipinski MJ, Flors L, Shaw PW, Kramer CM, Salerno M (2015) Meta-analysis of diagnostic performance of computed tomography, computed tomography perfusion and computed-tomography- fractional flow reserve in functional myocardial ischemia assessment versus invasive fractional flow reserve. Am J Cardiol 116:1469–1478CrossRefPubMedPubMedCentral
61.
Xu R, Li C, Qian J, Ge J (2015) Computed tomography-derived fractional flow reserve in the detection of lesion-specific ischemia. Medicine (Baltimore) 94(46):e1963CrossRef
62.
Deng S, Jing XD, Wang J et al (2015) Diagnostic performance of noninvasive fractional flow reserve derived from coronary computed tomography angiography in coronary artery disease: a systematic review and meta-analysis. Int J Cardiol 184:703–709CrossRefPubMed
63.
Li S, Tang X, Peng L, Luo Y, Dong R, Liu J (2015) The diagnostic performance of CT-derived fractional flow reserve for evaluation of myocardial ischemia confirmed by invasive fractional flow reserve: a meta-analysis. Clin Radiol 70:476–486CrossRefPubMed
64.
Ding A, Qiu G, Lin W et al (2016) Diagnostic performance of noninvasive fractional flow reserve derived from coronary computed tomography angiography in ischaemia-causing coronary stenosis: a meta-analysis. Jpn J Radiol 34:795808CrossRef
65.
Wu W, Pan DR, Foin N et al (2016) Noninvasive fractional flow reserve derived from coronary computed tomography angiography for identification of ischemic lesions: a systematic review and meta-analysis. Sci Rep 6:29409CrossRefPubMedPubMedCentral
66.
Cook CM, Petraco R, Shun-Shin M et al (2017) Diagnostic accuracy of computed tomography-derived fractional flow reserve. A systematic review. JAMA Cardiol 2:803–810CrossRefPubMed
67.
Baumann S, Renker M, Hetjens S et al (2016) Comparison of coronary computed tomography angiography-derived vs invasive fractional flow reserve assessment: meta-analysis with subgroup of intermediate stenosis. Acad Radiol 23:1402–1411
68.
Takx RA, Blomberg BA, El Aidi H et al (2015) Diagnostic accuracy of stress myocardial perfusion imaging compared to invasive coronary angiography with fractional flow reserve meta-analysis. Circ Cardiovasc Imaging 8:e002666CrossRefPubMed
69.
Danad I, Szymonifka J, Twisk JW et al (2017) Diagnostic performance of cardiac imaging methods to diagnose ischaemia-causing coronary artery disease when directly compared with fractional flow reserve as a reference standard: a meta-analysis. Eur Heart J 38:991–998PubMed
70.
Xu L, Sun Z, Fan Z (2015) Noninvasive physiologic assessment of coronary stenoses using cardiac CT. Biomed Res Int 2015:435737PubMedPubMedCentral
71.
Cademartiri F, Seitun S, Clemente A et al (2017) Myocardial blood flow quantification for evaluation of coronary artery disease by computed tomography. Cardiovasc Diagn Ther 7:129–150CrossRefPubMedPubMedCentral
72.
Pontone G, Muscogiuri G, Andreini D et al (2016) The new frontier of cardiac computed tomography angiography: fractional flow reserve and stress myocardial perfusion. Curr Treat Options Cardiovasc Med 18:74CrossRefPubMed
73.
Rossi A, Merkus D, Klotz E, Mollet N, de Feyter PJ, Krestin GP (2014) Stress myocardial perfusion: imaging with multidetector CT. Radiology 270:25–46CrossRefPubMed
74.
Techasith T, Cury RC (2011) Stress Myocardial CT perfusion: an update and future perspective. JACC Cardiovasc Imaging 4:905–916CrossRefPubMed
75.
Truong QA, Knaapen P, Pontone G et al (2015) Rationale and design of the dual-energy computed tomography for ischemia determination compared to “gold standard” non-invasive and invasive techniques (DECIDE-gold): a multicenter international efficacy diagnostic study of rest-stress dual-energy computed tomography angiography with perfusion. J Nucl Cardiol 22:1031–1040CrossRefPubMed
76.
Pontone G, Andreini D, Guaricci AI et al (2016) Rationale and design of the PERFECTION (comparison between stress cardiac computed tomography PERfusion versus fractional flow rEserve measured by computed tomography angiography in the evaluation of suspected cOroNary artery disease) prospective study. J Cardiovasc Comput Tomogr 10:330–334CrossRefPubMed
Metadata
Title
Additional diagnostic value of new CT imaging techniques for the functional assessment of coronary artery disease: a meta-analysis
Authors
Michèle Hamon
Damien Geindreau
Lydia Guittet
Christophe Bauters
Martial Hamon
Publication date
01-06-2019
Publisher
Springer Berlin Heidelberg
Published in
European Radiology / Issue 6/2019
Print ISSN: 0938-7994
Electronic ISSN: 1432-1084
DOI
https://doi.org/10.1007/s00330-018-5919-8

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