Fractional Flow Reserve In Patients Research Articles

P5616Risk stratification of cardiovascular events among patients with functionally non-significant coronary stenosis

Abstract Introduction Deferral of percutaneous coronary intervention (PCI) of a functionally non-significant stenosis is associated with a favorable long-term clinical prognosis. However, to date, there has been limited evidence to stratify the risk for the development of cardiovascular (CV) adverse events in patients who were deferred of PCI due to a greater fractional flow reserve (FFR) than 0.80 at the target lesion. Purpose We aimed to stratify the risk of CV events in patients with functionally significant and non-significant coronary stenosis. Methods This observational study included 458 patients who were proven angiographically intermediate coronary stenoses and were measured FFR, of whom 298 deferred patients with FFR>0.80 and 160 intervened patients with FFR<0.80. The primary endpoint was the incidence of major adverse cardiac and cerebrovascular events (MACCE) including any death, non-fatal myocardial infarction, hospitalization due to heart failure, ischemic stroke and any unplanned revascularization. ROC curve for MACCE indicated the cut-off point of FFR as 0.85 and 0.76 in deferred patients and intervened patients, respectively. Results During the observation period, 27 MACCE (9.1%) in the Deferred group, and 33 MACCE (20.6%) in Intervened group were occurred. Kaplan-Meier curves showed a higher MACCE rate in the Intervened group than Deferred group (hazard ratio (HR): 2.19, 95% confidence interval (CI): 1.29–3.71, Figure A). However, even among patients in the Deferred group, the population with “intermediate” FFR (0.81–0.85) had a significantly higher MACCE rate than those with higher FFR (>0.85) (HR 2.55, 95% CI 1.14–5.69, Figure B). This rate was comparable to that of the Intervened group at the remote phase (at 4-year: 32.0% vs. 35.8%). Conversely, in the Intervened group, there was no statistically significant difference in MACCE rate between patients with higher FFR (0.76–0.80) and those with lower FFR (<0.76) (Log-rank: p=0.21, Figure C). Conclusion The population with relatively low FFR in patients who were deferred PCI by FFR>0.80 had comparable MACCE rate to patients with FFR<0.80. Close observation after the FFR evaluation should be considered in those population.

Fractional flow reserve in patients with reduced ejection fraction.

Fractional flow reserve (FFR) has never been investigated in patients with reduced ejection fraction and associated coronary artery disease (CAD). We evaluated the impact of FFR on the management strategies of these patients and related outcomes. From 2002 to 2010, all consecutive patients with left ventricular ejection fraction (LVEF) ≤50% undergoing coronary angiography with ≥1 intermediate coronary stenosis [diameter stenosis (DS)% 50-70%] treated based on angiography (Angiography-guided group) or according to FFR (FFR-guided group) were screened for inclusion. In the FFR-guided group, 433 patients were matched with 866 contemporary patients of the Angiography-guided group. For outcome comparison, 617 control patients with LVEF >50% were included. After FFR, stenotic vessels per patient were significantly downgraded compared with the Angiography-guided group (1.43 ± 0.98 vs. 1.97 ± 0.84; P < 0.001). This was associated with lower revascularization rate (52% vs. 62%; P < 0.001) in the FFR-guided vs. the Angiography-guided group. All-cause death at 5 years of follow-up was significantly lower in the FFR-guided as compared with Angiography-guided group [22% vs. 31%. HR (95% CI) 0.64 (0.51-0.81); P < 0.001]. Similarly, rate of major adverse cardiovascular and cerebrovascular events (MACCE: composite of all-cause death, myocardial infarction, revascularization, and stroke) was significantly lower in the FFR-guided group [40% vs. 46% in the Angiography-guided group. HR (95% CI) 0.81 (0.67-0.97); P = 0.019]. Higher rates of death and MACCE were observed in patients with reduced LVEF compared with the control cohort. In patients with reduced LVEF and CAD, FFR-guided revascularization was associated with lower rates of death and MACCE at 5 years as compared with the Angiography-guided strategy. This beneficial impact was observed in parallel with less coronary artery bypass grafting and more patients deferred to percutaneous coronary intervention or medical therapy.

Cardiac Computed Tomography - More Than Coronary Arteries? AClinical Update.

Rapid improvement of scanner and postprocessing technology as well as the introduction of minimally invasive procedures requiring preoperative imaging have led to the broad utilization of cardiac computed tomography (CT) beyond coronary CT angiography (CTA). This review article presents an overview of recent literature on cardiac CT. The goal is to summarize the current guidelines on performing cardiac CT and to list established as well as emerging techniques with a special focus on extracoronary applications. Most recent guidelines for the appropriate use of cardiac CT include the evaluation of coronary artery disease, cardiac morphology, intra- and extracardiac structures, and functional and structural assessment of the myocardium under certain conditions. Besides coronary CTA, novel applications such as the calculation of a CT-derived fractional flow reserve (CT-FFR), assessment of myocardial function and perfusion imaging, as well as pre-interventional planning in valvular heart disease or prior pulmonary vein ablation in atrial fibrillation are becoming increasingly important. Especially these extracoronary applications are of growing interest in the field of cardiac CT and are expected to be gradually implemented in the daily clinical routine. · Coronary artery imaging remains the main indication for cardiac CT. · Novel computational fluid dynamics allow the calculation of a CT-derived fractional flow reserve in patients with known or suspected coronary artery disease. · Cardiac CT delivers information on left ventricular volume as well as myocardial function and perfusion. · CT is the cardinal element for pre-interventional planning in transcatheter valve implantation and pulmonary vein isolation. · Taron J, Foldyna B, Eslami P et al. Cardiac Computed Tomography - More Than Coronary Arteries? A Clinical Update. Fortschr Röntgenstr 2019; 191: 817 - 826.

Evaluation of fractional flow reserve in patients with stable angina: can CT compete with angiography?

We aimed to compare the performance of FFRCT and FFRQCA in assessing the functional significance of coronary artery stenosis in patients suffering from coronary artery disease with stable angina. A total of 101 stable coronary heart disease (CAD) patients with 181 lesions were recruited. FFRCT and FFRQCA were compared using invasive fractional flow reserve (FFR) as a reference standard. Comparisons between FFRCT and FFRQCA were conducted based on strategies of the geometric reconstruction, boundary conditions, and geometric characteristics. The performance of FFRCT and FFRQCA in detecting hemodynamic significance was also investigated. The performance of FFRCT and FFRQCA in discriminating hemodynamically significant lesions was compared. Good correlation and agreement with invasive FFR was found using FFRCT and FFRQCA (r = 0.809, p < 0.001 and r = 0.755, p < 0.001). A significant difference was observed in the complex coronary artery tree, in which relatively better prediction was observed using FFRCT than FFRQCA when analyzing the stenosis distributed in the middle segment of a stenotic branch (p = 0.036). Moreover, FFRCT was found to be better at predicting hemodynamically insignificant stenosis than FFRQCA (p = 0.007), while the performance of the two parameters was similar in discriminating functional significant lesions using an FFR threshold of ≤ 0.8 as a reference standard. FFRCT and FFRQCA could both accurately rule out functional insignificant lesions in stable CAD patients. FFRCT was found to be better for the noninvasive screening of CAD patients with stable angina than FFRQCA. • FFR CT and FFR QCA were both in good correlation and agreement with invasive FFR measurements. • FFR CT is superior in accuracy and consistency compared to FFR QCA in patients with stenoses distributed in left coronary artery. • The noninvasive nature of FFR CT could provide potential benefit for stable CAD patients on disease management.

Angiogram based fractional flow reserve in patients with dual/triple vessel coronary artery disease

ObjectiveTo assess the performance of angiography derived Fractional Flow Reserve (FFRangio) in multivessel disease (MVD) patients undergoing angiography. BackgroundFFR is the reference standard for physiologic assessment of coronary stenosis and guidance of revascularization, especially in patients with MVD, yet it remains grossly underutilized. The non-wire based FFRangio performs well in non-MVD patients, but its accuracy in MVD is unknown. MethodsA prospective clinical study was conducted at Gifu Heart Centre, Japan. Patients underwent physiologic assessment of all relevant coronary lesions using wire-based FFR (wbFFR) and FFRangio. Primary outcome was diagnostic performance (sensitivity, specificity, accuracy) for FFRangio with wbFFR as reference. Other outcomes were the correlation between wbFFR/FFRangio, time required for wbFFR/FFRangio measurements, and the effect of wbFFR/FFRangio on the reclassification of coronary disease severity. ResultsFifty patients (118 lesions in total) were included. Mean age was 72 ± 9 years, 72% were male, 36% had triple vessel disease and the average SYNTAX score was 13.The mean measurement of wbFFR and FFRangio were 0.83 ± 0.12 and 0.81 ± 0.11, respectively. Accuracy, sensitivity and specificity for FFRangio were 92.3% (95% CI 79.1–98.4%), 92.4% (95% CI 84.3–97.2%) and 92.4% (95% CI 87.4–97.3%), respectively. Pearson's r between wbFFR and FFRangio was 0.83. FFRangio measurement was faster than wbFFR (9.6 ± 3.4 vs. 15.0 ± 8.9 min, p < 0.001). ConclusionsIn patients with MVD, FFRangio shows good correlation and excellent diagnostic performance compared to wbFFR, and measuring FFRangio is faster than wbFFR. These results highlight the potential clinical benefits of utilizing FFRangio among patients with MVD.

Temporal Trends in Fractional Flow Reserve Use in Patients Undergoing Coronary Angiography: A Population-Based Study

BackgroundInvasive fractional flow reserve (FFR) has emerged as an important tool to identify a subset of patients in whom coronary revascularization may be beneficial. Our objective was to evaluate temporal trends in FFR use. MethodsWe identified all coronary angiograms in the CorHealth Ontario Cardiac Registry between the years 2010 and 2015. The primary and secondary outcomes were the age- and sex-adjusted monthly rate of FFR per 100,000 population and per 100 angiograms, respectively. Piecewise regression analyses were used to evaluate the temporal trends in FFR use for the entire cohort, and then stratified by indication (stable coronary artery disease [CAD]) vs acute coronary syndrome [ACS]). ResultsThe study cohort included 379,688 angiograms, of which 122,571 were for stable CAD (32%) and 134,769 were for ACS (36%). Monthly age- and sex-adjusted FFR use rates increased significantly over the study period, from 0.4 to 2.3 per 100,000 people per month. The monthly FFR use rate per 100 angiograms increased from 0.9 to 4.9 per 100 angiograms per month; however, the proportion of positive FFR (< 0.8) results was relatively constant at 28%. There was a more dramatic increase in the use of FFR in the population with stable CAD (1.1 to 8.0 per 100 angiograms/month) compared with the population with ACS (0.6 to 4.5 per 100 angiograms/month). ConclusionsThere was a > 5-fold increase in the use of FFR in patients across Ontario, which was predominantly driven by use in stable CAD. Case selection for FFR use was relatively unchanged with approximately one-quarter of FFR cases being positive over time.

Duration of myocardial early systolic lengthening for diagnosis of coronary artery disease

ObjectiveMyocardial early systolic lengthening (ESL) duration is prolonged in patients with coronary artery disease (CAD). However, the relationship between the fractional flow reserve (FFR), the current gold standard for evaluating...

Comparison of the Diagnostic Performance of Coronary Computed Tomography Angiography-Derived Fractional Flow Reserve in Patients With Versus Without Diabetes Mellitus (from the MACHINE Consortium)

Coronary computed tomography angiography-derived fractional flow reserve (CT-FFR) is a noninvasive application to evaluate the hemodynamic impact of coronary artery disease by simulating invasively measured FFR based on CT data. CT-FFR is based on the assumption of a normal coronary microvascular response. We assessed the diagnostic performance of a machine-learning based application for on-site computation of CT-FFR in patients with and without diabetes mellitus with suspected coronary artery disease. The study population included 75 diabetic and 276 nondiabetic patients who were enrolled in the MACHINE consortium. The overall diagnostic performance of coronary CT angiography alone and in combination with CT-FFR were analyzed with direct invasive FFR comparison in 110 coronary vessels of the diabetic group and in 415 coronary vessels of the nondiabetic group. Per-vessel discrimination of lesion-specific ischemia by CT-FFR was assessed by the area under the receiver operating characteristic curves. The overall diagnostic accuracy of CT-FFR in diabetic patients was 83% and in nondiabetic patients 75% (p = 0.088), showing improvement over the diagnostic accuracy of coronary CT angiography, which was 58% and 65% (p = 0.223), respectively. In addition, the diagnostic accuracy of CT-FFR was similar between diabetic and nondiabetic patients per stratified CT-FFR group (CT-FFR < 0.6, 0.6 to 0.69, 0.7 to 0.79, 0.8 to 0.89, ≥0.9). The area under the curves for diabetic and nondiabetic patients were also comparable, 0.88 and 0.82 (p = 0.113), respectively. In conclusion, on-site machine-learning CT-FFR analysis improved the diagnostic performance of coronary CT angiography and accurately discriminated lesion-specific ischemia in both diabetic and nondiabetic patients suspected of coronary artery disease.

Abstract 16924: Diagnostic Accuracy of Quantification Myocardial Perfusion Ratio Derived From Dynamic CT Perfusion Imaging for Detection of Functionally Significant Stenosis

Introduction: Quantification perfusion ratio (QPR) is defined as the ratio between myocardial blood flow (MBF) in the stenosis-related territory and MBF in the non-stenosis-related territory derived from stress dynamic CT myocardial perfusion (CTP) imaging. Hypothesis: We sought to evaluate whether QPR can be used as a novel non-invasive method for detection of functionally significant coronary artery stenosis compared with fractional flow reserve (FFR). Methods: This study was retrospectively included 25 consecutive patients (32 vessels) with coronary artery disease and examined with CT angiography, CTP, coronary angiography, and FFR. QPR and stress MBF results were compared with invasive FFR using a threshold of 0.80. Results: The QPRvalues were significantly correlated to FFR values (R=0.865,P &lt;0.0001, Fig 1). The area under the receiver operator curve was larger for QPR (0.937) compared with stress MBF (0.812, Fig 2). The diagnostic accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of QPR were 93.8%, 86.7%, 100%, 100%, and 89.5%, respectively. Conclusions: QPR was feasible and provided high diagnostic value for detecting abnormal FFR in patients with stable coronary artery disease.

Reclassification of Treatment Strategy With Instantaneous Wave-Free Ratio and Fractional Flow Reserve: A Substudy From the iFR-SWEDEHEART Trial

ObjectivesThe authors sought to compare reclassification of treatment strategy following instantaneous wave-free ratio (iFR) and fractional flow reserve (FFR). BackgroundiFR was noninferior to FFR in 2 large randomized controlled trials in guiding coronary revascularization. Reclassification of treatment strategy by FFR is well-studied, but similar reports on iFR are lacking. MethodsThe iFR-SWEDEHEART (Instantaneous Wave-Free Ratio Versus Fractional Flow Reserve in Patients With Stable Angina Pectoris or Acute Coronary Syndrome Trial) study randomized 2,037 participants with stable angina or acute coronary syndrome to treatment guided by iFR or FFR. Interventionalists entered the preferred treatment (optimal medical therapy [OMT], percutaneous coronary intervention [PCI], or coronary artery bypass grafting [CABG]) on the basis of coronary angiograms, and the final treatment decision was mandated by the iFR/FFR measurements. ResultsIn the iFR/FFR (n = 1,009/n = 1,004) populations, angiogram-based treatment approaches were similar (p = 0.50) with respect to OMT (38%/35%), PCI of 1 (37%/39%), 2 (15%/16%), and 3 vessels (2%/2%) and CABG (8%/8%). iFR and FFR reclassified 40% and 41% of patients, respectively (p = 0.78). The majority of reclassifications were conversion of PCI to OMT in both the iFR/FFR groups (31.4%/29.0%). Reclassification increased with increasing number of lesions evaluated (odds ratio per evaluated lesion for FFR: 1.46 [95% confidence interval: 1.22 to 1.76] vs. iFR 1.37 [95% confidence interval: 1.18 to 1.59]). Reclassification rates for patients with 1, 2, and 3 assessed vessels were 36%, 52%, and 53% (p < 0.01). ConclusionsReclassification of treatment strategy of intermediate lesions was common and occurred in 40% of patients with iFR or FFR. The most frequent reclassification was conversion from PCI to OMT regardless of physiology modality. Irrespective of the physiological index reclassification of angiogram-based treatment strategy increased with the number of lesions evaluated.

TCT-618 Angiogram Based Fractional Flow Reserve in Patients with Multi-Vessel Disease

Fractional flow reserve (FFR) is the golden standard to detect functionally significant coronary lesions, but for a variety of reasons, FFR measurements remain underutilized. The ability to derive FFR values from coronary angiograms, without the use of a pressure guide wire or hyperemia, could have

P5571Diagnostic performance of quantitative flow ratio in predicting fractional flow reserve in patients with takotsubo syndrome

P5571Diagnostic performance of quantitative flow ratio in predicting fractional flow reserve in patients with takotsubo syndrome

P5619Correlation between dobutamine stress echocardiography and invasive fractional flow reserve in patients with known moderate coronary artery stenosis

P5619Correlation between dobutamine stress echocardiography and invasive fractional flow reserve in patients with known moderate coronary artery stenosis

P4628Clinical significance of fractional flow reserve in patients with vasospastic angina and organic coronary stenosis

P4628Clinical significance of fractional flow reserve in patients with vasospastic angina and organic coronary stenosis

3288CT-derived fractional flow reserve in patients with stable angina pectoris: A real world follow-up study

3288CT-derived fractional flow reserve in patients with stable angina pectoris: A real world follow-up study

P3661Estimation of fractional flow reserve in patients with intermediate coronary artery disease; usefulness of estimated fractional flow reserve value by using clinical and angiographic factors

P3661Estimation of fractional flow reserve in patients with intermediate coronary artery disease; usefulness of estimated fractional flow reserve value by using clinical and angiographic factors

Intravascular ultrasound characteristics in patients with intermediate coronary lesions and borderline fractional flow reserve measurements

Revascularization of borderline fractional flow reserve (FFR) is controversial and the morphologic characteristics of borderline FFR lesions are not well known. The objective of this study was to determine the intravascular ultrasound (IVUS) characteristics in intermediate coronary lesions with borderline FFR in patients with intermediate coronary artery stenosis (40%–70% diameter stenosis).Both IVUS and FFR were performed in a total of 228 left anterior descending arteries. We divided them into 3 groups by FFR value: ischemic (n = 46, FFR < 0.75), borderline (n = 71, FFR 0.75 to ≤0.80), and non-ischemic (n = 111, FFR > 0.80). We compared the IVUS parameters, including minimum lumen area, lesion length, plaque burden, and volumetric analysis among the 3 groups.In the IVUS analysis, the minimum lumen area was smaller (2.5 ± 0.6 vs. 2.7 ± 0.7 vs. 3.4 ± 1.2 mm2, P < .001); lesion length was longer (23.6 ± 8.4 vs. 23.6 ± 7.4 vs. 17.4 ± 6.8 mm, P < .001); plaque burden was larger (76.1 ± 9.6 vs. 73.9 ± 7.5 vs. 69.8 ± 9.5%, P < .001); plaque volume was larger (173.0 ± 78.3 vs. 167.7 ± 75.0 vs. 129.5 ± 79.1 mm3, P < .01); and percent atheroma volume was larger (57.9 ± 7.5 vs. 57.6 ± 6.6 vs. 53.9 ± 8.0%, P < .01) in the ischemic and borderline groups compared with the non-ischemic group, respectively. However, post-hoc analyses showed there were no significant differences between the ischemic and borderline group for all IVUS parameters.There were no differences in IVUS characteristics between borderline and functionally significant FFR, but the amount of atheromatous plaque was more severe in these 2 groups than in the non-ischemic group.

Safety of the Deferral of Coronary Revascularization on the Basis of Instantaneous Wave-Free Ratio and Fractional Flow Reserve Measurements in Stable Coronary Artery Disease and Acute Coronary Syndromes

ObjectivesThe aim of this study was to investigate the clinical outcomes of patients deferred from coronary revascularization on the basis of instantaneous wave-free ratio (iFR) or fractional flow reserve (FFR) measurements in stable angina pectoris (SAP) and acute coronary syndromes (ACS). BackgroundAssessment of coronary stenosis severity with pressure guidewires is recommended to determine the need for myocardial revascularization. MethodsThe safety of deferral of coronary revascularization in the pooled per-protocol population (n = 4,486) of the DEFINE-FLAIR (Functional Lesion Assessment of Intermediate Stenosis to Guide Revascularisation) and iFR-SWEDEHEART (Instantaneous Wave-Free Ratio Versus Fractional Flow Reserve in Patients With Stable Angina Pectoris or Acute Coronary Syndrome) randomized clinical trials was investigated. Patients were stratified according to revascularization decision making on the basis of iFR or FFR and to clinical presentation (SAP or ACS). The primary endpoint was major adverse cardiac events (MACE), defined as the composite of all-cause death, nonfatal myocardial infarction, or unplanned revascularization at 1 year. ResultsCoronary revascularization was deferred in 2,130 patients. Deferral was performed in 1,117 patients (50%) in the iFR group and 1,013 patients (45%) in the FFR group (p < 0.01). At 1 year, the MACE rate in the deferred population was similar between the iFR and FFR groups (4.12% vs. 4.05%; fully adjusted hazard ratio: 1.13; 95% confidence interval: 0.72 to 1.79; p = 0.60). A clinical presentation with ACS was associated with a higher MACE rate compared with SAP in deferred patients (5.91% vs. 3.64% in ACS and SAP, respectively; fully adjusted hazard ratio: 0.61 in favor of SAP; 95% confidence interval: 0.38 to 0.99; p = 0.04). ConclusionsOverall, deferral of revascularization is equally safe with both iFR and FFR, with a low MACE rate of about 4%. Lesions were more frequently deferred when iFR was used to assess physiological significance. In deferred patients presenting with ACS, the event rate was significantly increased compared with SAP at 1 year.

One-Dimensional Mathematical Model-Based Automated Assessment of Fractional Flow Reserve in a Patient with Silent Myocardial Ischemia.

Patient: Male, 58Final Diagnosis: Coronary artery disease • silent myocardial ischemiaSymptoms: Silent myocardial ischemiaMedication: —Clinical Procedure: Noninvasive assessmant of fractional flow reserve • left descening artery revascularizationSpecialty: CardiologyObjective:Unusual setting of medical careBackground:Noninvasive assessment of the fractional flow reserve (FFR) in patients with coronary artery disease plays an important role in determining the need for revascularization. It is particularly relevant for patients with a borderline stenoses and painless myocardial ischemia. Our article describes the first clinical experience in the Russian Federation of using an automated method of noninvasive assessment of the fractional flow reserve (FFRct) with a one-dimensional (1-D) mathematical model in a patient with painless myocardial ischemia.Case Report:A 58-year-old male patient who underwent stent implantation in the left circumflex coronary artery (LCX) due to an acute non-ST-elevation posterior myocardial infarction had borderline stenoses of the left anterior descending artery (LAD). After stent implantation, there were no relapse angina symptoms on drug treatment, and according to our examination guideline for patients with borderline stenoses, a treadmill test was performed. The test was positive; therefore, FFR assessment was recommended, with coronary multi-slice CT being performed. The following results were obtained: FFRct LAD – 0.57; FFRct LCX – 0.88. An invasive assessment of FFR was also performed as a reference standard and revealed: FFR LAD – 0.6; FFR LCX – 0.88, and simultaneously a LAD percutaneous coronary intervention (PCI) was performed. Three months later, the patient underwent a stress test, which revealed no evidence of induced ischemia.Conclusions:Our method of noninvasive assessment of FFR has shown encouraging results, but we believe that larger-scale studies are needed to establish it as common clinical practice.

CT-based total vessel plaque analyses improves prediction of hemodynamic significance lesions as assessed by fractional flow reserve in patients with stable angina pectoris

BackgroundCoronary stenosis and plaque evaluation by coronary computed tomography angiography (CTA) may contribute to identify hemodynamically relevant lesions. We evaluated the most stenotic lesion including plaques proximal to it versus a total vessel analyses combined with stenosis for ischemia. MethodsPatients scheduled for clinically indicated invasive coronary angiography (ICA) for suspected coronary artery disease underwent coronary CTA and ICA including fractional flow reserve (FFR) as part of the NXT trial (clinicaltrials.govNCT01757678). Stenoses were visually graded ≤50%, 51–70%, and >70% on coronary CTA. Semi-automated plaque analyses were performed using a proximal to the FFR pressure sensor location (including the most severe lesion to the coronary ostium) versus a total vessel (vessel diameter ≥2 mm) approach. Coronary stenosis and plaque parameters were evaluated for discrimination of ischemia by logistic regressions and combined models analyzed using receiver operating characteristics (ROC) with invasive FFR≤ 0.80 as reference standard. ResultsIn 254 patients, mean (±SD) age 64 (±10) years, 64% male, a coronary CTA stenosis >50% was present in 239 (49%) vessels. Invasive FFR was ≤0.80 in 100 (21%) vessels. Coronary stenosis severity and low-density non-calcified plaque (LD-NCP) volume were independent predictors of ischemia in the “proximal” and “total-vessel” analyses. Stenosis severity + total vessel LD-NCP assessment performed better than stenosis severity + proximal LD-NCP evaluation (Area under curve [AUC] (95%CI): 0.83 (0.78–0.87) vs 0.81 (0.76–0.86), p-value = 0.009), whereas stenosis severity + proximal LD-NCP performed better than stenosis alone (AUC (95%CI): 0.81 (0.76–0.86) vs 0.78 (0.73–0.83), p-value = 0.019). ConclusionAdding total vessel high-risk plaque volume to stenosis severity improves discrimination of ischemia in coronary CTA performed in patients with stable angina pectoris.