Coronary 18F-Sodium Fluoride Uptake Predicts Outcomes in Patients With Coronary Artery Disease
Key result
Elevated coronary 18F-NaF uptake is linked to ~7.1-fold higher risk of myocardial infarction.
- HR 7.1
- 95% CI 2.2 to 25.1
- P=0.003
- n=293
Why the study?
Reliable methods for predicting myocardial infarction in patients with established coronary artery disease are lacking.
Does coronary 18F-sodium fluoride (18F-NaF) uptake predict fatal or non-fatal myocardial infarction in patients with established coronary artery disease?
Study Design
Type
Observational (n=293)
Blinding
Single-blind (outcome assessors)
Multicenter
Yes
Structured PICO
Does coronary 18F-sodium fluoride (18F-NaF) uptake predict fatal or non-fatal myocardial infarction in patients with established coronary artery disease?
P
Population
293 predominantly male (84%) adults (mean age 65 years) with established coronary artery disease were followed for a median of 42 months.
E
Exposure
Coronary 18F-sodium fluoride (18F-NaF) positron emission tomography (PET) to assess atherosclerotic activity via coronary microcalcification activity (CMA) and maximum target to background (TBR).
C
Comparator
Patients with no or lower coronary 18F-NaF uptake (e.g., CMA=0).
O
Outcome
Fatal or non-fatal myocardial infarction over 42 [31-49] months median follow-up.hard clinical
Main Result
Hazard Ratio: 7.1 (95% CI 2.2–25.1)
p-value: p=0.003
Limitations
- Post-hoc analysis of data collected for prospective observational studies
- Cohort heterogeneity due to inclusion of both stable and unstable coronary artery disease patients
- Need for CT angiogram alongside PET incurs a modest additional dose of radiation
- PET imaging was performed 1 hour after tracer injection, leaving the potential benefits of delayed image acquisition unevaluated
- Included patients with both stable and unstable coronary artery disease, increasing heterogeneity
- PET imaging was performed 1 hour after tracer injection, whereas delayed imaging might improve quality
- Modest additional dose of radiation from CT angiogram alongside PET
Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“Calcium scoring has been shown in many publications to be a very powerful predictor of cardiac events, and yet in this population here—the patients with stable established coronary disease, so not people with suspected disease—calcium doesn't really predict events. It surprised me how well sodium fluoride separated considering we didn't have that many events here and this is a relatively small sample. For this kind of a prognostic study, we had a very clear separation from those CT-based measures, both the CT and CTA measures.”
“We are both really excited & honored to receive this prestigious award & we would like to thank our mentors: Prof David Newby & Marc Dweck from the University of Edinburgh, & Daniel Berman & Piotr Slomka from Cedars Sinai.”
VFValentin FusterJACC Editor-in-Chief, Icahn School of Medicine at Mount Sinai
“William Parmley was a pioneer for all cardiovascular researchers. I feel proud that JACC continues to honor his legacy by recognizing up-and-coming researchers, as well as their mentors and institutional research programs.”
Implication
Coronary 18F-sodium fluoride (18F-NaF) PET uptake provides powerful, independent prediction of fatal or non-fatal myocardial infarction in patients with established coronary artery disease, outperforming standard clinical risk scores and coronary calcium scoring.
Abstract
Background We lack reliable methods for predicting myocardial infarction in patients with established coronary artery disease. Coronary 18F-sodium fluoride (18F-NaF) positron emission tomography (PET) provides an assessment of atherosclerosis activity. Objectives We assessed whether 18F-NaF PET predicts myocardial infarction and provides additional prognostic information to current methods of risk stratification. Methods Patients with known coronary artery disease underwent 18F-NaF PET computed tomography and were followed-up for fatal or non-fatal myocardial infarction over 42 [31–49] months. Total coronary 18F-NaF uptake was determined using coronary microcalcification activity (CMA). Results In a post-hoc analysis of data collected for prospective observational studies we studied 293 study participants (65±9 years; 84% male), of whom 203 (69%) showed increased coronary 18F-NaF activity (CMA>0). Fatal or non-fatal myocardial infarction occurred only in patients with increased coronary 18F-NaF activity (20/203 CMA>0 versus 0/90 CMA=0; p<0.001). On receiver operator-curve analysis, fatal or non-fatal myocardial infarction prediction was highest for 18F-NaF CMA, outperforming coronary calcium scoring, modified Duke coronary artery disease index, REACH and SMART risk scores (areas under curve: 0.76 versus 0.54, 0.62, 0.52 and 0.54; p<0.001 for all). Patients with CMA>1.56 had >7-fold increase in fatal or non-fatal myocardial infarction (hazard ratio 7.1, 95% confidence interval 2.2 to 25.1; p=0.003) independent of age, gender, risk factors, segment involvement and coronary calcium scores, presence of coronary stents, coronary stenosis, REACH and SMART scores, the Duke coronary artery disease index and recent myocardial infarction. Conclusion In patients with established coronary artery disease, 18F-NaF PET provides powerful independent prediction of fatal or non-fatal myocardial infarction.
Discussion
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Cite This Study
Kwieciński et al. (2020) conducted an observational in Coronary artery disease (n=293). Coronary 18F-sodium fluoride (18F-NaF) uptake (CMA > 1.56) vs. Lower or no coronary 18F-NaF uptake (CMA ≤ 1.56) was evaluated on Fatal or non-fatal myocardial infarction (HR 7.1, 95% CI 2.2 to 25.1, p=0.003).