title: Automated Quantitative Plaque Burden from Coronary CT Angiography Noninvasively Predicts Hemodynamic Significance by using Fractional Flow Reserve in Intermediate Coronary Lesions.
abstract: OBJECTIVE
  To evaluate the utility of multiple automated plaque measurements from coronary computed tomographic (CT) angiography in determining hemodynamic significance by using invasive fractional flow reserve (FFR) in patients with intermediate coronary stenosis.
  
  
  METHODS
  The study was approved by the institutional review board. All patients provided written informed consent. Fifty-six intermediate lesions (with 30%-69% diameter stenosis) in 56 consecutive patients (mean age, 62 years; range, 46-88 years), who subsequently underwent invasive coronary angiography with assessment of FFR (values ≤0.80 were considered hemodynamically significant) were analyzed at coronary CT angiography. Coronary CT angiography images were quantitatively analyzed with automated software to obtain the following measurements: volume and burden (plaque volume × 100 per vessel volume) of total, calcified, and noncalcified plaque; low-attenuation (<30 HU) noncalcified plaque; diameter stenosis; remodeling index; contrast attenuation difference (maximum percent difference in attenuation per unit area with respect to the proximal reference cross section); and lesion length. Logistic regression adjusted for potential confounding factors, receiver operating characteristics, and integrated discrimination improvement were used for statistical analysis.
  
  
  RESULTS
  FFR was 0.80 or less in 21 (38%) of the 56 lesions. Compared with nonischemic lesions, ischemic lesions had greater diameter stenosis (65% vs 52%, P = .02) and total (49% vs 37%, P = .0003), noncalcified (44% vs 33%, P = .0004), and low-attenuation noncalcified (9% vs 4%, P < .0001) plaque burden. Calcified plaque and remodeling index were not significantly different. In multivariable analysis, only total, noncalcified, and low-attenuation noncalcified plaque burden were significant predictors of ischemia (P < .015). For predicting ischemia, the area under the receiver operating characteristics curve was 0.83 for total plaque burden versus 0.68 for stenosis (P = .04).
  
  
  CONCLUSIONS
  Compared with stenosis grading, automatic quantification of total, noncalcified, and low-attenuation noncalcified plaque burden substantially improves determination of lesion-specific hemodynamic significance by FFR in patients with intermediate coronary lesions.
authors.affiliation: From the Department of Imaging and Medicine, Division of Nuclear Medicine (M.D.Z., R.N., H.G., P.J.S., D.S.B.), and Biomedical Imaging Research Institute (D.D.), Cedars-Sinai Medical Center, 8700 Beverly Blvd, S. Mark Taper Building A238, Los Angeles, CA 90048; Department of Internal Medicine 2, University of Erlangen, Erlangen, Germany (A.S., S.A.); Cardiovascular Institute, Mount Sinai Medical Center, New York, NY (J.N.); Department of Radiology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY (J.K.M.); Department of Medicine, Inje University Ilsan-Paik Hospital, Goyang, South Korea (J.H.D.); and Department of Medicine, Seoul National University Hospital, Seoul, South Korea (B.K.K.).
authors.forename: Mariana
authors.initials: M
authors.lastname: Diaz-Zamudio
authors.affiliation: From the Department of Imaging and Medicine, Division of Nuclear Medicine (M.D.Z., R.N., H.G., P.J.S., D.S.B.), and Biomedical Imaging Research Institute (D.D.), Cedars-Sinai Medical Center, 8700 Beverly Blvd, S. Mark Taper Building A238, Los Angeles, CA 90048; Department of Internal Medicine 2, University of Erlangen, Erlangen, Germany (A.S., S.A.); Cardiovascular Institute, Mount Sinai Medical Center, New York, NY (J.N.); Department of Radiology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY (J.K.M.); Department of Medicine, Inje University Ilsan-Paik Hospital, Goyang, South Korea (J.H.D.); and Department of Medicine, Seoul National University Hospital, Seoul, South Korea (B.K.K.).
authors.forename: Damini
authors.initials: D
authors.lastname: Dey
authors.affiliation: From the Department of Imaging and Medicine, Division of Nuclear Medicine (M.D.Z., R.N., H.G., P.J.S., D.S.B.), and Biomedical Imaging Research Institute (D.D.), Cedars-Sinai Medical Center, 8700 Beverly Blvd, S. Mark Taper Building A238, Los Angeles, CA 90048; Department of Internal Medicine 2, University of Erlangen, Erlangen, Germany (A.S., S.A.); Cardiovascular Institute, Mount Sinai Medical Center, New York, NY (J.N.); Department of Radiology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY (J.K.M.); Department of Medicine, Inje University Ilsan-Paik Hospital, Goyang, South Korea (J.H.D.); and Department of Medicine, Seoul National University Hospital, Seoul, South Korea (B.K.K.).
authors.forename: Annika
authors.initials: A
authors.lastname: Schuhbaeck
authors.affiliation: From the Department of Imaging and Medicine, Division of Nuclear Medicine (M.D.Z., R.N., H.G., P.J.S., D.S.B.), and Biomedical Imaging Research Institute (D.D.), Cedars-Sinai Medical Center, 8700 Beverly Blvd, S. Mark Taper Building A238, Los Angeles, CA 90048; Department of Internal Medicine 2, University of Erlangen, Erlangen, Germany (A.S., S.A.); Cardiovascular Institute, Mount Sinai Medical Center, New York, NY (J.N.); Department of Radiology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY (J.K.M.); Department of Medicine, Inje University Ilsan-Paik Hospital, Goyang, South Korea (J.H.D.); and Department of Medicine, Seoul National University Hospital, Seoul, South Korea (B.K.K.).
authors.forename: Ryo
authors.initials: R
authors.lastname: Nakazato
authors.affiliation: From the Department of Imaging and Medicine, Division of Nuclear Medicine (M.D.Z., R.N., H.G., P.J.S., D.S.B.), and Biomedical Imaging Research Institute (D.D.), Cedars-Sinai Medical Center, 8700 Beverly Blvd, S. Mark Taper Building A238, Los Angeles, CA 90048; Department of Internal Medicine 2, University of Erlangen, Erlangen, Germany (A.S., S.A.); Cardiovascular Institute, Mount Sinai Medical Center, New York, NY (J.N.); Department of Radiology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY (J.K.M.); Department of Medicine, Inje University Ilsan-Paik Hospital, Goyang, South Korea (J.H.D.); and Department of Medicine, Seoul National University Hospital, Seoul, South Korea (B.K.K.).
authors.forename: Heidi
authors.initials: H
authors.lastname: Gransar
authors.affiliation: From the Department of Imaging and Medicine, Division of Nuclear Medicine (M.D.Z., R.N., H.G., P.J.S., D.S.B.), and Biomedical Imaging Research Institute (D.D.), Cedars-Sinai Medical Center, 8700 Beverly Blvd, S. Mark Taper Building A238, Los Angeles, CA 90048; Department of Internal Medicine 2, University of Erlangen, Erlangen, Germany (A.S., S.A.); Cardiovascular Institute, Mount Sinai Medical Center, New York, NY (J.N.); Department of Radiology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY (J.K.M.); Department of Medicine, Inje University Ilsan-Paik Hospital, Goyang, South Korea (J.H.D.); and Department of Medicine, Seoul National University Hospital, Seoul, South Korea (B.K.K.).
authors.forename: Piotr J
authors.initials: PJ
authors.lastname: Slomka
authors.affiliation: From the Department of Imaging and Medicine, Division of Nuclear Medicine (M.D.Z., R.N., H.G., P.J.S., D.S.B.), and Biomedical Imaging Research Institute (D.D.), Cedars-Sinai Medical Center, 8700 Beverly Blvd, S. Mark Taper Building A238, Los Angeles, CA 90048; Department of Internal Medicine 2, University of Erlangen, Erlangen, Germany (A.S., S.A.); Cardiovascular Institute, Mount Sinai Medical Center, New York, NY (J.N.); Department of Radiology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY (J.K.M.); Department of Medicine, Inje University Ilsan-Paik Hospital, Goyang, South Korea (J.H.D.); and Department of Medicine, Seoul National University Hospital, Seoul, South Korea (B.K.K.).
authors.forename: Jagat
authors.initials: J
authors.lastname: Narula
authors.affiliation: From the Department of Imaging and Medicine, Division of Nuclear Medicine (M.D.Z., R.N., H.G., P.J.S., D.S.B.), and Biomedical Imaging Research Institute (D.D.), Cedars-Sinai Medical Center, 8700 Beverly Blvd, S. Mark Taper Building A238, Los Angeles, CA 90048; Department of Internal Medicine 2, University of Erlangen, Erlangen, Germany (A.S., S.A.); Cardiovascular Institute, Mount Sinai Medical Center, New York, NY (J.N.); Department of Radiology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY (J.K.M.); Department of Medicine, Inje University Ilsan-Paik Hospital, Goyang, South Korea (J.H.D.); and Department of Medicine, Seoul National University Hospital, Seoul, South Korea (B.K.K.).
authors.forename: Daniel S
authors.initials: DS
authors.lastname: Berman
authors.affiliation: From the Department of Imaging and Medicine, Division of Nuclear Medicine (M.D.Z., R.N., H.G., P.J.S., D.S.B.), and Biomedical Imaging Research Institute (D.D.), Cedars-Sinai Medical Center, 8700 Beverly Blvd, S. Mark Taper Building A238, Los Angeles, CA 90048; Department of Internal Medicine 2, University of Erlangen, Erlangen, Germany (A.S., S.A.); Cardiovascular Institute, Mount Sinai Medical Center, New York, NY (J.N.); Department of Radiology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY (J.K.M.); Department of Medicine, Inje University Ilsan-Paik Hospital, Goyang, South Korea (J.H.D.); and Department of Medicine, Seoul National University Hospital, Seoul, South Korea (B.K.K.).
authors.forename: Stephan
authors.initials: S
authors.lastname: Achenbach
authors.affiliation: From the Department of Imaging and Medicine, Division of Nuclear Medicine (M.D.Z., R.N., H.G., P.J.S., D.S.B.), and Biomedical Imaging Research Institute (D.D.), Cedars-Sinai Medical Center, 8700 Beverly Blvd, S. Mark Taper Building A238, Los Angeles, CA 90048; Department of Internal Medicine 2, University of Erlangen, Erlangen, Germany (A.S., S.A.); Cardiovascular Institute, Mount Sinai Medical Center, New York, NY (J.N.); Department of Radiology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY (J.K.M.); Department of Medicine, Inje University Ilsan-Paik Hospital, Goyang, South Korea (J.H.D.); and Department of Medicine, Seoul National University Hospital, Seoul, South Korea (B.K.K.).
authors.forename: James K
authors.initials: JK
authors.lastname: Min
authors.affiliation: From the Department of Imaging and Medicine, Division of Nuclear Medicine (M.D.Z., R.N., H.G., P.J.S., D.S.B.), and Biomedical Imaging Research Institute (D.D.), Cedars-Sinai Medical Center, 8700 Beverly Blvd, S. Mark Taper Building A238, Los Angeles, CA 90048; Department of Internal Medicine 2, University of Erlangen, Erlangen, Germany (A.S., S.A.); Cardiovascular Institute, Mount Sinai Medical Center, New York, NY (J.N.); Department of Radiology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY (J.K.M.); Department of Medicine, Inje University Ilsan-Paik Hospital, Goyang, South Korea (J.H.D.); and Department of Medicine, Seoul National University Hospital, Seoul, South Korea (B.K.K.).
authors.forename: Joon-Hyung
authors.initials: JH
authors.lastname: Doh
authors.affiliation: From the Department of Imaging and Medicine, Division of Nuclear Medicine (M.D.Z., R.N., H.G., P.J.S., D.S.B.), and Biomedical Imaging Research Institute (D.D.), Cedars-Sinai Medical Center, 8700 Beverly Blvd, S. Mark Taper Building A238, Los Angeles, CA 90048; Department of Internal Medicine 2, University of Erlangen, Erlangen, Germany (A.S., S.A.); Cardiovascular Institute, Mount Sinai Medical Center, New York, NY (J.N.); Department of Radiology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY (J.K.M.); Department of Medicine, Inje University Ilsan-Paik Hospital, Goyang, South Korea (J.H.D.); and Department of Medicine, Seoul National University Hospital, Seoul, South Korea (B.K.K.).
authors.forename: Bon-Kwon
authors.initials: BK
authors.lastname: Koo
mesh_terms: D017023:Coronary Angiography; D003324:Coronary Artery Disease / Q000150:complications / Q000000981:diagnostic imaging* / Q000503:physiopathology*; D005260:Female; D053805:Fractional Flow Reserve, Myocardial; D006439:Hemodynamics; D006801:Humans; D008297:Male; D008875:Middle Aged; D064847:Multimodal Imaging; D058226:Plaque, Atherosclerotic / Q000150:complications / Q000000981:diagnostic imaging* / Q000503:physiopathology*; D011237:Predictive Value of Tests; D014057:Tomography, X-Ray Computed