Algorithmic Versus Expert Human Interpretation of Instantaneous Wave-Free Ratio Coronary Pressure-Wire Pull Back Data

Q: What are the key findings of this study?

Algorithmic interpretation of iFR pressure-wire pull back data was noninferior to median expert human interpretation for determining hemodynamic appropriateness for PCI.

Q: What is the clinical evidence from this study?

Study design: Cross-Sectional. Population: Stable coronary artery disease (n=640). Intervention: Algorithmic interpretation of instantaneous wave-free ratio (iFR) pressure-wire pull back data vs. Median expert human interpretation. Primary outcome: Agreement with Heart Team consensus on the hemodynamic appropriateness for PCI (p=<0.01).

Q: What does this research mean for the field?

Algorithmic interpretation of iFR pressure-wire pull back data is noninferior to median expert human interpretation in determining hemodynamic appropriateness and physiological strategy for percutaneous coronary intervention. Novelty: ClaimNovelty.METHODOLOGICAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Christopher Cook; Takayuki Warisawa; James P. Howard; Thomas Keeble; Juan F. Iglesias; Érick Schampaert; Ravinay Bhindi; Alphonse Ambrosia; Hitoshi Matsuo; Hidetaka Nishina; Yuetsu Kikuta; Yasutsugu Shiono; Masafumi Nakayama; Shunichi Doi; Manabu Takai; Sonoka Goto; Yohei Yakuta; Kenichi Karube; Yoshihiro J. Akashi; Gerald Clesham; Paul A. Kelly; John R. Davies; Grigoris V. Karamasis; Yoshiaki Kawase; Nicholas Robinson; Andrew Sharp; Javier Escaned; Justin E. Davies

doi:10.1016/j.jcin.2019.05.025

Key result

Algorithmic iFR pullback analysis matches expert human interpretation with ~89% agreement for PCI appropriateness.

P<0.01
n=640

Figures

Graphical abstract published by JACC: Cardiovascular Interventions — Graphical abstract · Published by JACC: Cardiovascular Interventions · CC BY

Why the study?

Interpretation of instantaneous wave-free ratio pressure-wire pull back data can be complex and subjective.

Does algorithmic interpretation of iFR pressure-wire pull back data provide noninferior assessment of appropriateness and strategy for PCI compared to expert human interpretation in patients with stable coronary artery disease?

Study Design

Type

Cross-Sectional (n=640)

Blinding

Single-blind

Multicenter

Yes

Structured PICO

Does algorithmic interpretation of iFR pressure-wire pull back data provide noninferior assessment of appropriateness and strategy for PCI compared to expert human interpretation in patients with stable coronary artery disease?

P

Population

640 patients (691 unique vessels) with stable coronary artery disease, mean age 65.4, 26.1% female, who contributed retrospectively acquired iFR coronary pressure-wire pull back traces.

I

Intervention

Algorithmic interpretation of instantaneous wave-free ratio (iFR) coronary pressure-wire pull back traces

C

Comparator

Expert human interpretation (median expert human and Heart Team consensus)

O

Outcome

Agreement with Heart Team consensus on the hemodynamic appropriateness for percutaneous coronary intervention (PCI)surrogate

Main Result

Absolute Event Rate: 89.4% vs 89.3%

p-value: p=<0.01

Algorithmic interpretation of iFR pull back traces offers a standardized, reproducible alternative that is noninferior to expert human assessment and automatically corrects for pressure-wire drift.

Limitations

Did not capture additional data that may have influenced decisions, such as diffuseness of disease or integration with angiograms and clinical characteristics.
High prevalence of left anterior descending vessels (79.5%).
Did not replicate barriers to iFR interpretation in real-world physical environments.
Retrospective dataset, so actual clinical decisions were not recorded.
Lack of integration with coronary angiogram and individual patient characteristics
High prevalence of left anterior descending vessels
Retrospective nature means actual clinical decisions made at the time of iFR measurement were not recorded
Real-world physical environment barriers and multitasking distractions were not replicated

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Implication

Supports algorithmic iFR interpretation as reproducible alternative to experts; leaves open prospective outcome validation before clinical adoption.

Abstract

OBJECTIVES: The aim of this study was to investigate whether algorithmic interpretation (AI) of instantaneous wave-free ratio (iFR) pressure-wire pull back data would be noninferior to expert human interpretation. BACKGROUND: Interpretation of iFR pressure-wire pull back data can be complex and is subjective. METHODS: Fifteen human experts interpreted 1,008 iFR pull back traces (691 unique, 317 duplicate). For each trace, experts determined the hemodynamic appropriateness for percutaneous coronary intervention (PCI) and, in such cases, the optimal physiological strategy for PCI. The heart team (HT) interpretation was determined by consensus of the individual expert opinions. The same 1,008 pull back traces were also interpreted algorithmically. The coprimary hypotheses of this study were that AI would be noninferior to the interpretation of the median expert human in determining: 1) the hemodynamic appropriateness for PCI; and 2) the physiological strategy for PCI. RESULTS: Regarding the hemodynamic appropriateness for PCI, the median expert human demonstrated 89.3% agreement with the HT in comparison with 89.4% for AI (p < 0.01 for noninferiority). Across the 372 cases judged as hemodynamically appropriate for PCI according to the HT, the median expert human demonstrated 88.8% agreement with the HT in comparison with 89.7% for AI (p < 0.0001 for noninferiority). On reproducibility testing, the HT opinion itself changed 1 in 10 times for both the appropriateness for PCI and the physiological PCI strategy. In contrast, AI showed no change. CONCLUSIONS: AI of iFR pressure-wire pull back data was noninferior to expert human interpretation in determining both the hemodynamic appropriateness for PCI and the optimal physiological strategy for PCI.

Discussion

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Cite This Study

Cook et al. (2019) conducted a cross-sectional in Stable coronary artery disease (n=640). Algorithmic interpretation of instantaneous wave-free ratio (iFR) pressure-wire pull back data vs. Median expert human interpretation was evaluated on Agreement with Heart Team consensus on the hemodynamic appropriateness for PCI (p=<0.01). Algorithmic interpretation of iFR pressure-wire pull back data was noninferior to median expert human interpretation for determining hemodynamic appropriateness for PCI.

synapsesocial.com/papers/6a20195c1e0e2546e9a1a5d5 https://doi.org/10.1016/j.jcin.2019.05.025

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Algorithmic Versus Expert Human Interpretation of Instantaneous Wave-Free Ratio Coronary Pressure-Wire Pull Back Data

Figures

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Algorithmic Versus Expert Human Interpretation of Instantaneous Wave-Free Ratio Coronary Pressure-Wire Pull Back Data

Figures

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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