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Coronary Plaque Burden And CT-FFR Are Predictors Of 5-year Mortality In PAD Patients With No Known Coronary Artery Disease
Dainis Krievins, MD, PhD
1, Sanda Jegere, MD, PhD
1,
Frank Arko, MD2, Edgars Zellans, MD
1, Andrejs Erglis, MD, PhD
1, Christopher Zarins, MD
3.
1Pauls Stradins clinical university hospital, Riga, Latvia,
2Sanger Heart and Vascular Institute, Charlotte, NC, USA,
3Stanford University Medical Center, Stanford, CA, USA.
OBJECTIVES: Coronary plaque burden quantified by CT-derived quantitative plaque analysis (CT-QPA) is a known predictor of cardiovascular death in patients with coronary artery disease (CAD). This study evaluated the prognostic value of CT-QPA in combination with CT-derived fractional flow reserve (CT-FFR) for predicting 5-year mortality in vascular surgery patients without cardiac symptoms or known CAD.
METHODS: Patients with peripheral artery disease (PAD) undergoing elective vascular surgery (lower-extremity revascularization or abdominal aortic aneurysm repair) were prospectively enrolled in an IRB-approved study of preoperative coronary CT angiography (CTA) for cardiac risk assessment. A total of 124 patients underwent CT-QPA and CT-FFR analysis. Lesion-specific ischemia was defined as CT-FFR ≤0.80. All patients received guideline-directed medical therapy; none underwent elective coronary revascularization. The primary endpoint was all-cause mortality at 5 years, assessed by univariate Cox regression.
RESULTS: Among 124 PAD patients with no history of CAD (mean age 67±8 years, 76% men), coronary plaque burden was high (median total plaque volume [TPV] 550 mm³; IQR 299-1156), and silent coronary ischemia was present in 53%. All patients successfully underwent planned surgery with no perioperative deaths. During 5-year follow-up, 32 patients (26%) died. Non-survivors had nearly twofold higher TPV compared with survivors (975 mm³ vs 458 mm³, p<.001), with significant increases across calcified (p<.001), noncalcified (p<.001), and low-attenuation plaque (p=.038). Both TPV >550 mm³ and CT-FFR ≤0.80 were associated with higher mortality (p<.001). Patients with both high TPV and CT-FFR ≤0.80 had a 5-year mortality of 42%, compared with 10% for patients with TPV ≤550 mm³ and CT-FFR >0.80 (HR 5.0, 95% CI 1.7-14.9; p=.004).
CONCLUSIONS: In asymptomatic PAD patients with no known CAD, coronary plaque burden and silent ischemia detected by CT-QPA and CT-FFR are strong predictors of 5-year mortality. Preoperative coronary CTA with quantitative plaque and FFR analysis should be considered for comprehensive cardiac risk stratification in vascular surgery patients, regardless of symptoms.
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