Abstract
Computed tomography derived fractional flow reserve (FFRCT) and computed tomography stress myocardial perfusion imaging (CTP) are techniques to assess haemodynamic significance of coronary stenosis. To compare the diagnostic performance of FFRCT and static rest/stress CTP in detecting fractional flow reserve (FFR) defined haemodynamically-significant stenosis (FFR ≤ 0.8). Fifty-one patients (96 vessels) with suspected coronary artery disease from a single institution planned for elective invasive-angiography prospectively underwent research indicated 320-detector-CT-coronary-angiography (CTA) and adenosine-stress CTP and invasive FFR. Analyses were performed in separate core-laboratories for FFRCT and CTP blinded to FFR results. Myocardial perfusion was assessed visually and semi-quantitatively by transmural perfusion ratio (TPR). Invasive FFR ≤ 0.8 was present in 33% of vessels and 49% of patients. FFRCT, visual CTP and TPR analysis was feasible in 96%, 92% and 92% of patients respectively. Overall per-vessel sensitivity, specificity and diagnostic accuracy for FFRCT were 81%, 85%, 84%, for visual CTP were 50%, 89%, 75% and for TPR were 69%, 48%, 56% respectively. Receiver-operating-characteristics curve analysis demonstrated larger per vessel area-under-curve (AUC) for FFRCT (0.89) compared with visual CTP (0.70; p < 0.001), TPR (0.58; p < 0.001) and CTA (0.70; p = 0.0007); AUC for CTA + FFRCT (0.91) was higher than CTA + visual CTP (0.77, p = 0.008) and CTA + TPR (0.74, p < 0.001). Per-patient AUC for FFRCT (0.90) was higher than visual CTP (0.69; p = 0.0016), TPR (0.56; p < 0.0001) and CTA (0.68; p = 0.001). Based on this selected cohort of patients FFRCT is superior to visually and semi-quantitatively assessed static rest/stress CTP in detecting haemodynamically-significant coronary stenosis as determined on invasive FFR.
Highlights
Ischemia assessment remains the cornerstone management of stable coronary artery disease (CAD), as its presence and burden predicts benefit from revascularization [1, 2]
Both techniques are increasingly used in clinical practice. In this cohort F FRCT is superior to both visual CT stress myocardial perfusion imaging (CTP) and transmural perfusion ratio (TPR) in diagnostic performance on both per vessel and patient basis. While both visual CTP and F FRCT improved the diagnostic performance of CTA when combined, the improvement was higher when combined with FFRCT compared with CTP
Visual CTP had lower AUC when compared with onsite CT-fractional flow reserve (FFR) (0.89 vs. 0.72 p = 0.02) [17]. These results indicate that the diagnostic performance of CTP may potentially vary depending on the scanner used; and whether static or dynamic perfusion assessment is used
Summary
Ischemia assessment remains the cornerstone management of stable coronary artery disease (CAD), as its presence and burden predicts benefit from revascularization [1, 2]. The International Journal of Cardiovascular Imaging (2019) 35:2103–2112 non-invasive CT-derived fractional flow reserve have been demonstrated to accurately predict lesion specific ischemia as determined by invasive fractional flow reserve (FFR) [3, 4]. These techniques differ widely in physiological principles, acquisition requirements, image processing and result interpretation. When significant ischemia is present, the lack of blood flow during vasodilator stress results in lower contrast attenuation in the distal subtended myocardium, which can be determined using static or dynamic acquisition. In dynamic CTP, perfusion can be quantified using mathematical algorithms [5]
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