Determining Hemodynamically Significant Coronary Artery Disease: Patient-Specific Cutoffs in Quantitative Myocardial Blood Flow Using [15O]H2O PET Imaging

Roel Hoek; Pepijn A van Diemen; Pieter G Raijmakers; Roel S Driessen; Yvemarie B O Somsen; Ruben W de Winter; Ruurt A Jukema; Jos W R Twisk; Lourens F H J Robbers; Pim van der Harst; Antti Saraste; Mark Lubberink; Jens Sörensen; Paul Knaapen; Juhani Knuuti; Ibrahim Danad

doi:10.2967/jnumed.123.267195

Determining Hemodynamically Significant Coronary Artery Disease: Patient-Specific Cutoffs in Quantitative Myocardial Blood Flow Using [¹⁵O]H₂O PET Imaging

J Nucl Med. 2024 May 9:jnumed.123.267195. doi: 10.2967/jnumed.123.267195. Online ahead of print.

Authors

Roel Hoek¹, Pepijn A van Diemen², Pieter G Raijmakers³, Roel S Driessen², Yvemarie B O Somsen², Ruben W de Winter², Ruurt A Jukema², Jos W R Twisk⁴, Lourens F H J Robbers², Pim van der Harst⁵, Antti Saraste^{6

7}, Mark Lubberink⁸, Jens Sörensen⁸, Paul Knaapen², Juhani Knuuti⁶, Ibrahim Danad^{1

5}

Affiliations

¹ Department of Cardiology, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands; i.danad@umcutrecht.nl roel.hoek@amsterdamumc.nl.
² Department of Cardiology, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.
³ Department of Radiology and Nuclear Medicine, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.
⁴ Department of Epidemiology and Data Science, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.
⁵ Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands.
⁶ Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland.
⁷ Heart Center, Turku University Hospital and University of Turku, Turku, Finland; and.
⁸ Nuclear Medicine and PET, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.

PMID: 38724275
DOI: 10.2967/jnumed.123.267195

Abstract

Currently, cutoffs of quantitative [¹⁵O]H₂O PET to detect fractional flow reserve (FFR)-defined coronary artery disease (CAD) were derived from a single cohort that included patients without prior CAD. However, prior CAD, sex, and age can influence myocardial blood flow (MBF). Therefore, the present study determined the influence of prior CAD, sex, and age on optimal cutoffs of hyperemic MBF (hMBF) and coronary flow reserve (CFR) and evaluated whether cutoff optimization enhanced diagnostic performance of quantitative [¹⁵O]H₂O PET against an FFR reference standard. Methods: Patients with chronic coronary symptoms underwent [¹⁵O]H₂O PET and invasive coronary angiography with FFR. Optimal cutoffs for patients with and without prior CAD and subpopulations based on sex and age were determined. Results: This multicenter study included 560 patients. Optimal cutoffs were similar for patients with (n = 186) and without prior CAD (hMBF, 2.3 vs. 2.3 mL·min^-1·g^-1; CFR, 2.7 vs. 2.6). Females (n = 190) had higher hMBF cutoffs than males (2.8 vs. 2.3 mL·min^-1·g^-1), whereas CFRs were comparable (2.6 vs. 2.7). However, female sex-specific hMBF cutoff implementation decreased diagnostic accuracy as compared with the cutoff of 2.3 mL·min^-1·g^-1 (72% vs. 82%, P < 0.001). Patients aged more than 70 y (n = 79) had lower hMBF (1.7 mL·min^-1·g^-1) and CFR (2.3) cutoffs than did patients aged 50 y or less, 51-60 y, and 61-70 y (hMBF, 2.3-2.4 mL·min^-1·g^-1; CFR, 2.7). Age-specific cutoffs in patients aged more than 70 y yielded comparable accuracy to the previously established cutoffs (hMBF, 72% vs. 76%, P = 0.664; CFR, 80% vs. 75%, P = 0.289). Conclusion: Patients with and without prior CAD had similar [¹⁵O]H₂O PET cutoffs for detecting FFR-defined significant CAD. Stratifying patients according to sex and age led to different optimal cutoffs; however, these values did not translate into an increased overall accuracy as compared with previously established thresholds for MBF.

Keywords: PET; coronary artery disease; coronary flow reserve; cutoff values; fractional flow reserve; hyperemic myocardial blood flow.