Sequential Strategy Including FFRCT Plus Stress-CTP Impacts on Management of Patients with Stable Chest Pain: The Stress-CTP RIPCORD Study

Figures

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  Figure A1. Study flow diagram. Consecutive symptomatic patients referred for suspected CAD and scheduled for clinically indicated ICA were screened. After the application of inclusion and exclusion criteria, 291 patients were enrolled, 147 in the first arm, in which Static Stress-CTP was performed, and 144 in the second arm, in which Dynamic Stress-CTP was performed. CAD: coronary artery disease; ICA: invasive coronary angiography; Stress-CTP: stress computed tomography perfusion.

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  Figure A2. Study protocol. Patients were asked to refrain from smoking and caffeine for 24 h and to maintain fasting for 6 h before the scan. All patients were treated with sublingual nitrates to ensure vasodilatation. In patients with a resting HR > 65 beats/min, metoprolol was intravenously administered, with a titration dose up to 15 mg to achieve a target HR ≤ 65 beats/min. However, all patients were studied even if the target HR was not reached. cCTA and FFRCT were evaluated with the acquisition of the first dataset; then, after a period of fifteen minutes, perfusion evaluation was performed during adenosine administration with the acquisition of the second dataset (Static or Dynamic protocols were used according to the specific arm of the study). HR: heart rate; cCTA: coronary computed tomography angiography; FFRCT: computed tomography-derived fractional flow reserve.

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  Figure 1. Clinical management algorithm. The clinical management algorithms to OMT, revascularization, or further information for cCTA alone (A), for the combined approach of cCTA+FFRCT (B), for the combined approach of cCTA+Stress-CTP (C) and for the sequential approach of cCTA+FFRCT+Stress-CTP (D) are illustrated. OMT: optimal medical treatment; cCTA: coronary computed tomography angiography; OMT: optimal medical treatment; ICA: invasive coronary angiography; FFRCT: computed tomography-derived fractional flow reserve; Stress-CTP: stress computed tomography perfusion.

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  Figure 2. Management according to cCTA alone. Nearly one third of the population needed further assessment to be allocated to OMT or revascularization. cCTA: coronary computed tomography angiography; OMT: optimal medical treatment; ICA: invasive coronary angiography; iFFR: invasive fractional flow reserve.

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  Figure 3. Management according to the addition of FFRCT to cCTA. If FFRCT is added to cCTA, there is a substantial equal redistribution of patients previously without a clear management indication to OMT or to revascularization. cCTA: coronary computed tomography angiography; OMT: optimal medical treatment; ICA: invasive coronary angiography; FFRCT: computed tomography-derived fractional flow reserve; iFFR: invasive fractional flow reserve.

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  Figure 4. Management according to the addition of Stress-CTP to cCTA. If Stress-CTP is added to cCTA, more than two-thirds of patients who were previously without a clear management indication were allocated to OMT. cCTA: coronary computed tomography angiography; OMT: optimal medical treatment; ICA: invasive coronary angiography; Stress-CTP: stress computed tomography perfusion; iFFR: invasive fractional flow reserve.

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  Figure 5. Management according to the sequential addition of FFRCT and Stress-CTP to cCTA. If a sequential approach is used, patients without a clear management indication after FFRCT analysis can be allocated to OMT or revascularization after Stress-CTP assessment. cCTA: coronary computed tomography angiography; OMT: optimal medical treatment; ICA: invasive coronary angiography; FFRCT: computed tomography-derived fractional flow reserve; Stress-CTP: stress computed tomography perfusion; iFFR: invasive fractional flow reserve.

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  Figure 6. Primary endpoint of the study between different diagnostic strategies. Both the cCTA+Stress-CTP and cCTA+FFRCT+Stress-CTP strategies showed a higher rate of agreement with the final decision as compared to cCTA alone and the cCTA+FFRCT strategy. cCTA: coronary computed tomography angiography; Stress-CTP: stress computed tomography perfusion; FFRCT: computed tomography-derived fractional flow reserve.

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  Figure 7. Secondary endpoints of the study between different diagnostic strategies. No differences were found in terms of evaluability between the different strategies. Both the cCTA+Stress-CTP and cCTA+FFRCT+Stress-CTP strategies showed a higher rate of patient reclassification and rate of agreement for the target vessel to be revascularized as compared to cCTA alone and the cCTA+FFRCT strategy. cCTA: coronary computed tomography angiography; Stress-CTP: stress computed tomography perfusion; FFRCT: computed tomography-derived fractional flow reserve.

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  Figure 8. Radiation exposure. In terms of radiation exposure, the cCTA+Stress-CTP strategy was associated with the highest ED with a progressive reduction in the ED for cCTA+FFRCT+Stress-CTP and cCTA+FFRCT. cCTA: coronary computed tomography angiography; Stress-CTP: stress computed tomography perfusion, ED: effective dose; FFRCT: computed tomography-derived fractional flow reserve.

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  Figure 9. Clinical Case. A 54 y/o male with hypertension, dyslipidaemia and recent onset of atypical chest pain. Panels (A–C): cCTA showing significant stenosis in the proximal LAD (A), moderate stenosis in the proximal LCx (B), and moderate stenosis in the mid RCA (C). Panels (D,E): FFRCT showing grey-zone values in the apical LAD, negative values in the RCA and LCx. Panels (F–H): Static Stress-CTP with short axis views (F,G) and 2-chamber long axis view (H) showing absence of perfusion defects. Panels (I–K): ICA showing moderate stenoses in the proximal LAD (I) and LCx (J), and mild stenosis in the mid RCA (K), all with negative FFR values. cCTA: coronary computed tomography angiography; LAD: left anterior descending; LCx: left circumflex; RCA: right coronary artery; FFRCT: computed tomography-derived fractional flow reserve; Stress-CTP: stress computed tomography perfusion; ICA: invasive coronary angiography; FFR: fractional flow reserve.