Diagnosis of Ischemia-Causing Coronary Stenoses by Noninvasive Fractional Flow Reserve Computed From Coronary Computed Tomographic Angiograms

Koo, Bon‐Kwon; Ērglis, Andrejs; Doh, Joon Hyung; Daniels, David; Jēgere, Sanda; Kim, Hyo–Soo; Dunning, Allison; DeFrance, Tony; Lansky, Alexandra J.; Leipsic, Jonathan; Min, James K.

doi:10.1016/j.jacc.2011.06.066

Cited by 1,113 publications

(390 citation statements)

References 34 publications

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“…Until 2014, adjunctive functional testing at this institution was performed by conventional MPI. Based on local pilot experiences together with published reports on the diagnostic performance of FFR CT testing4, 5, 6 and potential improvements in clinical workflows, we decided in 2014 to replace MPI with FFR CT for functional assessment of CAD determined by coronary CTA. At our institution, frontline MPI of patients with new‐onset chest pain without known CAD is recommended only for those with contraindications to coronary CTA 8.…”

Section: Methodsmentioning

confidence: 99%

“…Based on these techniques, noninvasive fractional flow reserve (FFR) can be computed 3, 4, 5, 6. In studies including patients with known or suspected stable CAD and blinded comparison to FFR, coronary CTA‐derived FFR (FFR CT ) has shown high diagnostic performance 4, 5, 6. Recently, it was demonstrated in stable patients referred to ICA that initial FFR CT assessment reduced the downstream use of ICA procedures, the rate of ICA showing no obstructive CAD, and overall costs 7.…”

Section: Introductionmentioning

confidence: 99%

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Myocardial Perfusion Imaging Versus Computed Tomography Angiography–Derived Fractional Flow Reserve Testing in Stable Patients With Intermediate‐Range Coronary Lesions: Influence on Downstream Diagnostic Workflows and Invasive Angiography Findings

Nørgaard

Gormsen

Bøtker

et al. 2017

JAHA

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BackgroundData on the clinical utility of coronary computed tomography angiography–derived fractional flow reserve (FFRCT) are sparse. In patients with intermediate (40–70%) coronary stenosis determined by coronary computed tomography angiography, we investigated the association of replacing standard myocardial perfusion imaging with FFRCT testing with downstream utilization of invasive coronary angiography (ICA) and the diagnostic yield of ICA (rate of no obstructive disease, and rate of revascularization).Methods and ResultsThis was a single‐center observational study of symptomatic patients with suspected coronary artery disease referred to coronary computed tomography angiography between 2013 and 2015. Patients were divided into 3 historical groups based on the adjunctive functional testing approach: myocardial perfusion imaging (n=1332) or FFRCT “implementation” (n=800) or “clinical use” (n=1391). Propensity score matching was used to estimate the average period effect on outcomes. Patients in the FFRCT clinical use group versus the myocardial perfusion imaging group were older and had higher pretest probability of obstructive disease. After adjusting for baseline risk characteristics, there was a reduction in downstream ICA utilization (absolute risk difference: −4.2; 95% CI, −6.9 to −1.6; P=0.002). In patients referred to ICA, findings of no obstructive coronary artery disease decreased (−12.8%; 95% CI, −22.2 to −3.4; P=0.008) and rate of coronary revascularization increased (14.1%; 95% CI, 3.3–24.9; P=0.01), as did availability of functional information for guidance of revascularization (27.8%; 95% CI, 11.3–44.4; P<0.001) after clinical adoption of FFRCT.ConclusionsReplacing adjunctive myocardial perfusion imaging with FFRCT testing for functional assessment of intermediate stenosis determined by coronary computed tomography angiography in stable coronary artery disease was associated with less ICA utilization, and a higher ICA diagnostic yield. The findings in this observational study needs confirmation in prospective, randomized trials.

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Section: Methodsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Myocardial Perfusion Imaging Versus Computed Tomography Angiography–Derived Fractional Flow Reserve Testing in Stable Patients With Intermediate‐Range Coronary Lesions: Influence on Downstream Diagnostic Workflows and Invasive Angiography Findings

Nørgaard

Gormsen

Bøtker

et al. 2017

JAHA

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“…To further expand the use of physiological‐guided percutaneous coronary intervention, coronary computed tomography angiography– and invasive coronary angiography–based computation methods were developed for less‐invasive FFR approximation 4, 5, 6, 7, 8, 9, 10…”

Section: Introductionmentioning

confidence: 99%

Diagnostic Performance of In‐Procedure Angiography‐Derived Quantitative Flow Reserve Compared to Pressure‐Derived Fractional Flow Reserve: The FAVOR II Europe‐Japan Study

Westra

Andersen

Campo

et al. 2018

JAHA

309

305

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BackgroundQuantitative flow ratio (QFR) is a novel modality for physiological lesion assessment based on 3‐dimensional vessel reconstructions and contrast flow velocity estimates. We evaluated the value of online QFR during routine invasive coronary angiography for procedural feasibility, diagnostic performance, and agreement with pressure‐wire–derived fractional flow reserve (FFR) as a gold standard in an international multicenter study.Methods and Results FAVOR II E‐J (Functional Assessment by Various Flow Reconstructions II Europe‐Japan) was a prospective, observational, investigator‐initiated study. Patients with stable angina pectoris were enrolled in 11 international centers. FFR and online QFR computation were performed in all eligible lesions. An independent core lab performed 2‐dimensional quantitative coronary angiography (2D‐QCA) analysis of all lesions assessed with QFR and FFR. The primary comparison was sensitivity and specificity of QFR compared with 2D‐QCA using FFR as a reference standard. A total of 329 patients were enrolled. Paired assessment of FFR, QFR, and 2D‐QCA was available for 317 lesions. Mean FFR, QFR, and percent diameter stenosis were 0.83±0.09, 0.82±10, and 45±10%, respectively. FFR was ≤0.80 in 104 (33%) lesions. Sensitivity and specificity by QFR was significantly higher than by 2D‐QCA (sensitivity, 86.5% (78.4–92.4) versus 44.2% (34.5–54.3); P<0.001; specificity, 86.9% (81.6–91.1) versus 76.5% (70.3–82.0); P=0.002). Area under the receiver curve was significantly higher for QFR compared with 2D‐QCA (area under the receiver curve, 0.92 [0.89–0.96] versus 0.64 [0.57–0.70]; P<0.001). Median time to QFR was significantly lower than median time to FFR (time to QFR, 5.0 minutes [interquartile range, –6.1] versus time to FFR, 7.0 minutes [interquartile range, 5.0–10.0]; P<0.001).ConclusionsOnline computation of QFR in the catheterization laboratory is clinically feasible and is superior to angiographic assessment for evaluation of intermediary coronary artery stenosis using FFR as a reference standard.Clinical Trial Registration URL: https://www.clinicaltrials.gov. Unique identifier: NCT02959814.

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“…[25][26][27] A meta-analysis on three prospective multi-center FFRCT trials (NXT -Analysis of Coronary Blood Flow Using CT Angiography: Next Steps; DISCOVER-FLOW -Diagnosis of Ischemia-Causing Stenoses Obtained via Noninvasive Fractional Flow Reserve, and DeFACTODetermination of Fractional Flow Reserve by Anatomic Computed Tomographic Angiography) was recently published by Li et al, analyzing the diagnostic accurateness of FFRCT compared to invasively determined FFR (gold standard) and CCTA. The meta-analysis concluded that FFRCT demonstrated a high diagnostic capacity in determining coronary ischemia, with improved accuracy and specificity compared to CCTA.…”

Section: Accuracy Of Ffrctmentioning

confidence: 99%

CT Determination of Fractional Flow Reserve in Coronary Lesions

Mester¹,

Chițu

Raț

et al. 2016

Journal of Interdisciplinary Medicine

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Invasively determined fractional flow reserve (FFR) represents the gold-standard method for the functional evaluation of coronary lesions. Coronary computed tomography angiography (CCTA) provides characterization of the coronary anatomy, with important morphological information on the atherosclerotic plaques, but does not offer a hemodynamic evaluation of coronary artery lesions. CT evaluation of FFR (FFRCT) is a new noninvasive diagnostic method, which provides anatomical and functional assessment of the whole coronary tree, based on computational techniques, with no more radiation or hyperemic agent administration compared with routine CCTA. Recent studies demonstrated the safety and accuracy of FFRCT and its therapeutic use and cost benefits in real-world clinical use.

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Diagnosis of Ischemia-Causing Coronary Stenoses by Noninvasive Fractional Flow Reserve Computed From Coronary Computed Tomographic Angiograms

Abstract: Noninvasive FFR derived from CCTA is a novel method with high diagnostic performance for the detection and exclusion of coronary lesions that cause ischemia.

Cited by 1,113 publications

References 34 publications

Myocardial Perfusion Imaging Versus Computed Tomography Angiography–Derived Fractional Flow Reserve Testing in Stable Patients With Intermediate‐Range Coronary Lesions: Influence on Downstream Diagnostic Workflows and Invasive Angiography Findings

Myocardial Perfusion Imaging Versus Computed Tomography Angiography–Derived Fractional Flow Reserve Testing in Stable Patients With Intermediate‐Range Coronary Lesions: Influence on Downstream Diagnostic Workflows and Invasive Angiography Findings

Diagnostic Performance of In‐Procedure Angiography‐Derived Quantitative Flow Reserve Compared to Pressure‐Derived Fractional Flow Reserve: The FAVOR II Europe‐Japan Study

CT Determination of Fractional Flow Reserve in Coronary Lesions

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