High-Risk Morphological and Physiological Coronary Disease Attributes as Outcome Markers After Medical Treatment and Revascularization

Abstract

OBJECTIVES This study sought to evaluate the prognostic impact of plaque morphology and coronary physiology on outcomes after medical treatment or percutaneous coronary intervention (PCI). BACKGROUND Although fractional flow reserve (FFR) is currently best practice, morphological characteristics of coronary artery disease also contribute to outcomes. METHODS A total of 872 vessels in 538 patients were evaluated by invasive FFR and coronary computed tomography angiography. High-risk attributes (HRA) were defined as high-risk physiological attribute (invasive FFR <=.8) and high risk morphological attributes including: 1) local plaque burden (minimum lumen area <4 mm(2) and plaque burden >= 70%); 2) adverse plaque characteristics >= 2; and 3) global plaque burden (total plaque volume >= 306.5 mm(3) and percent atheroma volume >= 32.2%). The primary outcome was the composite of revascularization, myocardial infarction, or cardiac death at 5 years. RESULTS The mean FFR was 0.88 +/- 0.08, and PCI was performed in 239 vessels. The primary outcome occurred in 54 vessels (6.2%). All high-risk morphological attributes were associated with the increased risk of adverse outcomes after adjustment for FFR <= 0.8 and demonstrated direct prognostic effect not mediated by FFR <= 0.8. The 5-year event risk proportionally increased as the number of HRA increased (p for trend <0.001) with lower risk in the PCI group than the medical treatment group in vessels with 1 or 2 HRA (9.7% vs. 14.7%), but not in vessels with either 0 or >= 3 HRA. Of the vessels with pre-procedural FFR . 0.8, ischemia relief by PCI (pre-PCI FFR <= 0.8 and post-PCI FFR >0.8) significantly reduced vessel-oriented composite outcome risk compared with medical treatment alone in vessels with 0 or 1 high-risk morphological attributes (hazard ratio: 0.33; 95% confidence interval: 0.12 to 0.93; p = 0.035), but the risk reduction was attenuated in vessels with >= 2 high-risk morphological attributes. CONCLUSIONS High-risk morphological attributes offered additive prognostic value to coronary physiology and may optimize selection of treatment strategies by adding to FFR-based risk predictions.