Abstract
Quantitative flow ratio (QFR) and fractional flow reserve (FFR) have not yet been compared head to head with perfusion imaging as reference for myocardial ischemia. We aimed to compare the diagnostic accuracy of QFR and FFR with myocardial perfusion scintigraphy (MPS) or cardiovascular magnetic resonance (CMR) as reference. This study is a predefined post hoc analysis of the Dan-NICAD study (NCT02264717). Patients with suspected coronary artery disease by coronary computed tomography angiography (CCTA) were randomized 1:1 to MPS or CMR and were referred to invasive coronary angiography with FFR and predefined QFR assessment. Paired data with FFR, QFR and MPS or CMR were available for 232 vessels with stenosis in 176 patients. Perfusion defects were detected in 57 vessel territories (25%). For QFR and FFR the diagnostic accuracy was 61% and 57% (p = 0.18) and area under the receiver operating curve was 0.64 vs. 0.58 (p = 0.22). Stenoses with absolute indication for stenting due to diameter stenosis > 90% by visual estimate were not classified as significant by either QFR or MPS/CMR in 21% (7 of 34) of cases. The diagnostic performance of QFR and FFR was similar but modest with MPS or CMR as reference. Comparable performance levels for QFR and FFR are encouraging for this pressure wire-free diagnostic method.
Highlights
Fractional flow reserve (FFR) and recently instantaneous wave-free ratio are the gold standard indices for invasive functional assessment of coronary artery stenosisMartin Sejr-Hansen and Jelmer Westra contributed.[1, 2]
A total of 392 patients with coronary computed tomography angiography (CCTA)-identified coronary artery disease were assessed by myocardial perfusion imaging and randomly assigned to myocardial perfusion scintigraphy (MPS) (n = 195) or cardiovascular magnetic resonance (CMR) (n = 197)
Complete paired dataset with perfusion imaging, Quantitative flow ratio (QFR), and FFR were available for 176 patients (90 for MPS and 86 for CMR) and 232 stenosis/perfusion territories (Fig. 1)
Summary
Fractional flow reserve (FFR) and recently instantaneous wave-free ratio (iFR) are the gold standard indices for invasive functional assessment of coronary artery stenosisMartin Sejr-Hansen and Jelmer Westra contributed.[1, 2]. Fractional flow reserve (FFR) and recently instantaneous wave-free ratio (iFR) are the gold standard indices for invasive functional assessment of coronary artery stenosis. FFR remains underused in clinical practice [3, 4]. Quantitative flow ratio (QFR) is a rapid, computed approximation of FFR based on 3D reconstruction of the coronary vessel and estimated contrast flow velocity derived from standard diagnostic invasive coronary angiography (ICA). Present clinical guidelines recommend FFR or iFR measurement in patients with stable angina pectoris and narrowings with a diameter stenosis (DS) of 40–90% by visual assessment, when no other evidence of ischemia is available [13]. Even experienced interventional cardiologists tend to overestimate percent DS, leading to inappropriate deferral of wire-based assessment of visual severe lesions [4]
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