Diagnostic Accuracy of Fractional Flow Reserve From Anatomic CT Angiography

Abstract

ORONARY COMPUTED TOMOgraphic (CT) angiography is a noninvasive test that enables direct visualization of coronary artery disease (CAD) and correlates favorably with invasive coronary angiography (ICA) for measures of stenosis severity. 1 However, CT cannot determine the hemodynamic significance of CAD, and even among CTidentified obstructive stenoses confirmed by ICA, fewer than half are ischemia-causing. 2,3 These findings underscore an unreliable relationship of stenosis severity to ischemia and have raised concerns that use of CT may pre-cipitate unnecessary ICA and coronary revascularization for patients who do not have ischemia. 4,5 These concerns stem from recent randomized trials that have identified no survival benefit for patients who undergo angiographically based coronary revascularization. 6,7 As an ad-junct to ICA, fractional flow reserve (FFR) has served as a useful tool to determine the likelihood that a coronary For editorial comment see p 1269.

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

“…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…”

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

“…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.…”

Diagnostic accuracy and discrimination of ischemia by fractional flow reserve CT using a clinical use rule: Results from the Determination of Fractional Flow Reserve by Anatomic Computed Tomographic Angiography study

“…4,21 This expands the usefulness of coronary CTA by combining anatomic and functional assessment and raises the potential of coronary CTA to help define those patients that may derive benefit from invasive angiography and possible revascularization. Furthermore, FFR CT analysis provides functional information at all locations in the coronary tree adding a richness of information which may be useful in clinical decision making.…”

“…The diagnostic accuracy of FFR CT for the detection of lesion-specific ischemia has recently been compared with that of coronary CTA alone using invasive FFR as the reference standard. 4 The DISCOVER-FLOW trial demonstrated improved diagnostic accuracy of FFR CT vs coronary CTA stenosis at a per-vessel level when compared to invasive FFR. 5 The Determination of Fractional Flow Reserve by Anatomic Computed Tomographic Angiography (DeFACTO) study also demonstrated improved diagnostic accuracy and improved discriminatory power of FFR CT compared to coronary CTA alone for the diagnosis of ischemia in stable patients with CAD at a lesion-specific level, including those with intermediate stenosis.…”