Coronary 18F-Sodium Fluoride Uptake Predicts Outcomes in Patients With Coronary Artery Disease

doi:10.1016/j.jacc.2020.04.046

Journal of the American College of Cardiology

Volume 75, Issue 24, 23 June 2020, Pages 3061-3074

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Abstract

Background

Reliable methods for predicting myocardial infarction in patients with established coronary artery disease are lacking. Coronary ¹⁸F-sodium fluoride (¹⁸F-NaF) positron emission tomography (PET) provides an assessment of atherosclerosis activity.

Objectives

This study assessed whether ¹⁸F-NaF PET predicts myocardial infarction and provides additional prognostic information to current methods of risk stratification.

Methods

Patients with known coronary artery disease underwent ¹⁸F-NaF PET computed tomography and were followed up for fatal or nonfatal myocardial infarction over 42 months (interquartile range: 31 to 49 months). Total coronary ¹⁸F-NaF uptake was determined by the coronary microcalcification activity (CMA).

Results

In a post hoc analysis of data collected for prospective observational studies, the authors studied 293 study participants (age: 65 ± 9 years; 84% men), of whom 203 (69%) showed increased coronary ¹⁸F-NaF activity (CMA >0). Fatal or nonfatal myocardial infarction occurred only in patients with increased coronary ¹⁸F-NaF activity (20 of 203 with a CMA >0 vs. 0 of 90 with a CMA of 0; p < 0.001). On receiver operator curve analysis, fatal or nonfatal myocardial infarction prediction was highest for ¹⁸F-NaF CMA, outperforming coronary calcium scoring, modified Duke coronary artery disease index and Reduction of Atherothrombosis for Continued Health (REACH) and Secondary Manifestations of Arterial Disease (SMART) risk scores (area under the curve: 0.76 vs. 0.54, 0.62, 0.52, and 0.54, respectively; p < 0.001 for all). Patients with CMA >1.56 had a >7-fold increase in fatal or nonfatal myocardial infarction (hazard ratio: 7.1; 95% confidence interval: 2.2 to 25.1; p = 0.003) independent of age, sex, risk factors, segment involvement and coronary calcium scores, presence of coronary stents, coronary stenosis, REACH and SMART scores, the Duke coronary artery disease index, and recent myocardial infarction.

Conclusions

In patients with established coronary artery disease, ¹⁸F-NaF PET provides powerful independent prediction of fatal or nonfatal myocardial infarction.

Central Illustration

Key Words

coronary artery disease

coronary computed tomography

coronary event risk prediction

¹⁸F-NaF PET

myocardial infarction

Abbreviations and Acronyms

Agatston unit

confidence interval

CMA

coronary microcalcification activity

computed tomography

ECG

electrocardiogram

¹⁸F-NaF

¹⁸F-sodium fluoride

hazard ratio

MACE

myocardial adverse cardiovascular events

PET

positron emission tomography

REACH

Reduction of Atherothrombosis for Continued Health

ROC

receiver-operating characteristic

SMART

Secondary Manifestations of Arterial Disease

SUV

standard uptake value

TBR

maximum target to background ratio

Cited by (0)

: This research was supported in part by grants (R01HL135557) from the National Heart, Lung, and Blood Institute/National Institutes of Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Dr. Tzolos was supported by a grant from the Dr. Miriam and Sheldon G. Adelson Medical Research Foundation. Drs. Berman, Dey, and Slomka, and Mr. Cadet have received software royalties from Cedars-Sinai Medical Center. Dr. Williams is supported by the British Heart Foundation (FS/11/014, CH/09/002). Dr. van Beek is supported by the Scottish Imaging Network, a Platform of Scientific Excellence (SINAPSE); has received research support from Siemens Healthineers and GE Healthcare; has served on the Advisory Boards for Aidence and Imbio; has been a consultant for Mantholatum; and is the owner of QCTIS, Ltd. Dr. Newby is supported by the British Heart Foundation (CH/09/002, RE/18/5/34216, RG/16/10/32375); and is the recipient of a Wellcome Trust Senior Investigator Award (WT103782AIA). Dr. Slomka has received a grant from the National Institutes of Health and software royalties from Cedars-Sinai. Dr. Dweck is supported by the British Heart Foundation (FS/14/78/31020); and is the recipient of a Sir Jules Thorn Award for Biomedical Research Award (2015). All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

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^∗: Drs. Kwiecinski and Tzolos are co-first authors.

^†: Drs. Slomka and Dweck are co-senior authors.