Incremental Prognostic Value of Myocardial Blood Flow Quantified With Stress Dynamic Computed Tomography Perfusion Imaging

OBJECTIVES This study aimed to evaluate whether myocardial blood flow (MBF) quantified with dynamic computed tomography perfusion imaging (CTP) has an incremental prognostic value over coronary CT angiography (CTA) for major adverse cardiac events (MACEs) in patients with suspected coronary artery disease (CAD). BACKGROUND The incremental prognostic value of CTP over CTA is unclear. The quantification of MBF with dynamic CTP may potentially enhance risk stratification. METHODS A total of 332 patients (67% men; age: 67 +/- 10 years) with suspected CAD who underwent CTA and dynamic CTP was analyzed. A MACE was defined as cardiac death, nonfatal myocardial infarction (MI), unstable angina, or hospitalization for congestive heart failure. A summed stress score (SSS) was calculated by adding scores of all myocardial segments according to normalized MBF values. Abnormal perfusion was defined as SSS >= 4. Obstructive CAD was defined as >= 50% stenosis in >= 1 vessel on CTA. RESULTS During a median follow-up of 2.5 years, 19 patients had a MACE. Multivariate analysis showed that, when adjusted for obstructive CAD on CTA, abnormal perfusion was significantly associated with hazards for MACEs (hazard ratio [HR]: 5.7; 95% confidence interval [CI]: 1.9 to 16.9; p = 0.002), with a significant improvement in the prognostic value. Abnormal perfusion was an independent predictor even when adjusted for >= 70% stenosis in >= 1 vessel (HR: 5.4; 95% CI: 1.7 to 16.7; p = 0.003) or adjusted for >= 50% stenosis in >= 2 vessels (HR: 6.5; 95% CI: 2.2 to 18.9; p = 0.001). In the setting of obstructive CAD, annualized event rates showed a significant difference between the patients with and without abnormal perfusion for all events (12.2% vs. 1.5%; p = 0.002) and for cardiac death and nonfatal MI (4.2% vs. 0%; p = 0.015). CONCLUSIONS MBF quantified with dynamic CTP has an incremental prognostic value over CTA. The addition of dynamic CTP to CTA allows improved risk stratification of patients with CTA-detected stenosis. (C) 2019 by the American College of Cardiology Foundation.