Abstract
BackgroundThe role of change in fractional flow reserve derived from CT (FFRCT) across coronary stenoses (ΔFFRCT) in guiding downstream testing in patients with stable coronary artery disease (CAD) is unknown. ObjectivesTo investigate the incremental value of ΔFFRCT in predicting early revascularization and improving efficiency of catheter laboratory utilization. MaterialsPatients with CAD on coronary CT angiography (CCTA) were enrolled in an international multicenter registry. Stenosis severity was assessed as per CAD-Reporting and Data System (CAD-RADS), and lesion-specific FFRCT was measured 2 cm distal to stenosis. ΔFFRCT was manually measured as the difference of FFRCT across visible stenosis. ResultsOf 4730 patients (66 ± 10 years; 34% female), 42.7% underwent ICA and 24.7% underwent early revascularization. ΔFFRCT remained an independent predictor for early revascularization (odds ratio per 0.05 increase [95% confidence interval], 1.31 [1.26–1.35]; p < 0.001) after adjusting for risk factors, stenosis features, and lesion-specific FFRCT. Among the 3 models (model 1: risk factors + stenosis type and location + CAD-RADS; model 2: model 1 + FFRCT; model 3: model 2 + ΔFFRCT), model 3 improved discrimination compared to model 2 (area under the curve, 0.87 [0.86–0.88] vs 0.85 [0.84–0.86]; p < 0.001), with the greatest incremental value for FFRCT 0.71–0.80. ΔFFRCT of 0.13 was the optimal cut-off as determined by the Youden index. In patients with CAD-RADS ≥3 and lesion-specific FFRCT ≤0.8, a diagnostic strategy incorporating ΔFFRCT >0.13, would potentially reduce ICA by 32.2% (1638–1110, p < 0.001) and improve the revascularization to ICA ratio from 65.2% to 73.1%. ConclusionsΔFFRCT improves the discrimination of patients who underwent early revascularization compared to a standard diagnostic strategy of CCTA with FFRCT, particularly for those with FFRCT 0.71–0.80. ΔFFRCT has the potential to aid decision-making for ICA referral and improve efficiency of catheter laboratory utilization.
Highlights
Physiological assessment with fractional flow reserve (FFR) guides the revascularization in patients with stable coronary artery disease (CAD).[1,2] The application of computational fluid dynamics to a standard coronary computed tomography angiography (CCTA) enables non-invasive FFR measurement (FFRCT) without additional imaging, medications, radiation exposure, or hospital visits.[3]
Among the 3 models, model 3 improved discrimination compared to model 2, with the greatest incremental value for flow reserve derived from CT (FFRCT) 0.71–0.80
In patients with CAD-RADS !3 and lesion-specific FFRCT 0.8, a diagnostic strategy incorporating ΔFFRCT >0.13, would potentially reduce invasive coronary angiography (ICA) by 32.2% (1638–1110, p < 0.001) and improve the revascularization to ICA ratio from 65.2% to 73.1%
Summary
Physiological assessment with fractional flow reserve (FFR) guides the revascularization in patients with stable coronary artery disease (CAD).[1,2] The application of computational fluid dynamics to a standard coronary computed tomography angiography (CCTA) enables non-invasive FFR measurement (FFRCT) without additional imaging, medications, radiation exposure, or hospital visits.[3] Numerous studies have demonstrated the diagnostic performance,[4,5] prognostic value,[6,7] and clinical utility of FFRCT in real-world practice.[7,8,9] FFRCT is derived along the epicardial coronary tree. Paul's Hospital, 1081 Burrard Street, Vancouver, British Columbia, V6Z 1Y6, Canada
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