Abstract
PURPOSE: In patients with reduced remote flow, dynamic stress CT perfusion imaging (CTP) has limited utility for detecting obstructive coronary artery disease (CAD). We compared fractal analysis, a descriptor of macro- and microvascular ischemia patterns, with relative myocardial blood flow (MBF) for detecting obstructive CAD stratified by remote flow. MATERIALS AND METHODS: This secondary analysis of the prospective multi-center AMPLIFiED trial included patients who underwent invasive coronary angiography (ICA) with fractional flow reserve (FFR) and dynamic stress CTP. Obstructive CAD was defined invasively (stenosis ≥ 90% or FFR < 0.8). We assessed diagnostic accuracy of fractal analysis and relative MBF in patient groups subdivided into high, intermediate, and low remote flow. RESULTS: In 148 patients (30% female; 416 vessels), obstructive CAD was present in 71/148 patients (48%), while signs of microvascular ischemia were found in 26/148 patients (prevalence in high, intermediate, low remote flow: 9%, 37%, 70%). Fractal analysis outperformed relative MBF in detecting obstructive CAD (patient-based sensitivity and specificity: 94% and 92% versus 80% and 64%, p < 0.005). In vessel-based subgroup analysis, both methods performed comparably in high remote flow (area under the receiver-operating curve [AUC]: 0.94 versus 0.88, p = 0.45), while fractal analysis outperformed relative MBF in intermediate and low remote flow (AUC: 0.93 versus 0.77, p = 0.004; 0.92 versus 0.6, p < 0.001). CONCLUSION: Fractal analysis eliminates reliance on remote flow for CTP imaging, which improves diagnostic accuracy for obstructive CAD particularly in patients with reduced remote flow or microvascular ischemia. TRIAL REGISTRATION: This study reports about data from the prospective, multi-center AMPLIFiED trial (UMIN000016353).