CCTA characterization of coronary atherosclerosis diffuseness and focality using FFR-CT and plaque burden: results from the PRECISE trial

Introduction: Coronary artery disease (CAD) on coronary computed tomography angiography (CCTA) is typically assessed using a dichotomous ≥ 50 % stenosis threshold. However, CAD diffuseness may also influence patient management and outcomes. The PRECISE trial provides high quality data to examine these relationships. Methods and results: In this PRECISE substudy, patients with stable suspected CAD undergoing CCTA with FFR-CT and quantitative plaque analysis were evaluated. The FFR-CT drop across a stenosis was defined as stenosisFFR-CT, and the drop attributed to diffuse disease as diffuseFFR-CT. Patients with ≥ 50 % stenosis were classified using cohort medians of stenosisFFR-CT and diffuseFFR-CT into four phenotypes: focal (FOC), diffuse (DIF), combined focal and diffuse (DIFFOC), or no hemodynamically significant CAD (NoHEM). Participants without ≥ 50 % stenosis constituted a fifth group. A total of 737 participants were included (mean age 60 ± 10 years, 44 % female): NoHEM (n = 37), DIF (n = 53), FOC (n = 57), DIFFOC (n = 37), and < 50 % stenosis (n = 553). Total plaque volume (TPV) was highest in DIFFOC (262 [175-504] mm3), followed by DIF (210 [97-302] mm3), FOC (209 [88-415] mm3), NoHEM (153 [87-254] mm3), and < 50 % stenosis (7 [0-59] mm3; p < 0.0001). FOC patients more frequently reported typical angina (p = 0.04) while symptom intensity was similar across the phenotypes. Revascularization was performed in 51 % (FOC), 49 % (DIFFOC), 6 % (DIF), 5 % (NoHEM), and 2 % (<50 % stenosis). Conclusion: Focal and mixed CAD phenotypes were clinically similar, aside from more typical angina in focal disease. Revascularization was performed in approximately half of patients with focal patterns, regardless of a diffuse component.