This project will study subjects with an indication to undergo ICA, and aims to replace ICA. This pushes the indication of non-invasive imaging from the intermediate risk subjects (to reclassify to low/high risk) to the high-risk group. According to the guidelines, non-invasive imaging is not performed in this patient category, due to the high likelihood of coronary stenosis on CT and/or myocardial ischemia on myocardial perfusion imaging. However, at ICA, even in this category, up to 70% does not need revascularization (European Society of Cardiology data). We expect that identification of patients in need of revascularization can be derived from non-invasive imaging, by including innovative non-invasive measures of FFR and / or myocardial perfusion. If the hypothesis is confirmed, this project will have great impact on clinical practice, by obviating the need for diagnostic ICA, decreasing costs of diagnosis and therapy, increasing patient comfort, and potentially improving patient outcome.

Recently, a new quantitative approach has been proposed based on common coronary CTA data, allowing FFR estimation without invasive procedure. This calculation, called CT FFR, is based on computational fluid dynamics. Initial reports show good correlations between CT FFR and invasively measured FFR on group level. CT FFR as measure of hemodynamic significance may allow CT to become a comprehensive non-invasive test of flow-limiting CAD and replace diagnostic ICA, guiding the indication for revascularization. Furthermore, based on computational fluid dynamics, the effect of PCI and/or CABG on downstream blood flow may be possible to calculate, then allowing for prediction of treatment effect and selection of treatment modality. The very long computation time of the original CT FFR approach, performed off-site, limits clinical implementation. In this study, we will investigate an innovative quick on-site technique, based on software in late stages of development by an industry partner.


The Future

The quantification of myocardial perfusion based on MRI data should be further developed because this will likely improve the accuracy of treatment guidance. This also allows evaluation and validation of the effect of PCI on myocardial perfusion, by examination before and after the procedure. Previous research found good correlation between MRI-derived MPR and PET measurements, but only limited comparability of absolute perfusion measures. Recently, MRI-derived MPR was reported to be lower in women with MVD, but a diagnostic cut-off is still lacking. In this project we will validate new approaches for quantitative evaluation of myocardial perfusion parameters.


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