Highlights
- •The gold standard method to assess the functional impact of coronary artery disease (CAD) is invasive coronary angiography (ICA)
- •Non-invasive fractional flow reserve computed tomography (FFRct) identifies hemodynamically significant CAD
- •FFRct has a high sensitivity and specificity for predicting functional CAD among patients with abnormal SPECT studies relative to ICA
- •Addition of FFRct was safe and did not increase risk of MACE or mortality in a real-world setting
- •FFRct usage could potentially reduce the rate of unnecessary invasive imaging in intermediate-high risk patients with suspected CAD
Abstract
Background
Fractional flow reserve computed tomography (FFRct) allows for non-invasive assessment
of hemodynamically significant coronary artery disease (CAD). Real-world data regarding
the diagnostic performance of FFRct is scarce. We aim to validate the diagnostic performance
of FFRct against invasive coronary angiography (ICA) in patients with stable angina
and an abnormal single photon emission computed tomography (SPECT) study.
Methods
This prospective, single-cohort, real-world study enrolled consecutive adult patients
with stable angina and an abnormal SPECT study who were referred for ICA. Prior to
ICA, FFRct analysis was performed. Sensitivity and specificity of FFRct were evaluated
at the patient and vessel level against ICA. Physician intuition-based diagnosis of
hemodynamically significant CAD was also documented prior to ICA.
Results
A total of 66 patients were enrolled; 10 were excluded due to protocol deviation or
missing studies. FFRct achieved 95% sensitivity and 83% specificity at the patient
level, and 78% sensitivity and 88% specificity at the vessel level. FFRct was most
accurate in the left circumflex artery (sensitivity 83%, specificity 92%) and the
least in the left anterior descending artery (80% sensitivity, 78% specificity). FFRct
identified hemodynamically significant CAD more accurately than physician intuition
(sensitivity 95% vs 84%; specificity 83% vs 46%). If physicians had been unblinded
to FFRct, ICA may have been avoided in up to 53% of patients.
Conclusion
We performed a real-world study to validate the diagnostic performance of FFRct against
gold-standard invasive imaging. FFRct has high sensitivity and specificity for the
diagnosis of hemodynamically significant CAD in intermediate-to-high risk patients.
Keywords
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References
- Angiographic versus functional severity of coronary artery stenoses in the FAME study fractional flow reserve versus angiography in multivessel evaluation.J Am Coll Cardiol. 2010; 55: 2816-2821https://doi.org/10.1016/j.jacc.2009.11.096
- Sixty-four slice spiral CT angiography does not predict the functional relevance of coronary artery stenosis in subjects with stable angina.Eur J Nucl Med Mol Imaging. 2007; 34: 4-10https://doi.org/10.1007/s00259-006-0207-2
- Comparison of non-invasive multi-slice computed tomography coronary angiography versus invasive coronary angiography and fractional flow reserve for the evaluation of men with known coronary artery disease.Am J Cardiol. 2009; 104: 653-656https://doi.org/10.1016/j.amjcard.2009.04.045
- 2013 ESC guidelines on the management of stable coronary artery disease: the task force on the management of stable coronary artery disease of the European Society of Cardiology.Eur Heart J. 2013; 34: 2949-3003https://doi.org/10.1093/eurheartj/eht296
- Guidelines on myocardial revascularization.Eur Heart J. 2010; 31: 2501-2555https://doi.org/10.1093/eurheartj/ehq277
- Low diagnostic yield of elective coronary angiography.N Engl J Med. 2010; 10: 895https://doi.org/10.1056/NEJMoa0907272
- Noninvasive assessment of myocardial perfusion.Circ Cardiovasc Imaging. 2009; 2: 412-424https://doi.org/10.1056/NEJMoa0907272
- Diagnosis of ischemia-causing coronary stenosis by non-invasive fractional flow reserve computed from coronary computed tomographic angiograms. Results from the prospective multicenter DISCOVER-FLOW (Diagnosis of ischemia-cuasing stenoses obtained via noninvasive fraction flow Reserve) study.J Am Coll Cardiol. 2011; 58: 1989-1997https://doi.org/10.1016/j.jacc.2011.06.066
- Diagnostic accuracy of fractional flow reserve from anatomic CT angiography.JAMA. 2012; 308: 1237-1245https://doi.org/10.1001/2012.jama.11274
- NXT trial study group. Diagnostic performance of non-invasive fractional flow reserve derived from coronary computed tomography angiography in suspected coronary artery disease: the NXT trial (Analysis of coronary blood flow using CT angiography: next Steps).J Am Coll Cardiol. 2014; 63: 1145-1155https://doi.org/10.1016/j.jacc.2013.11.043
- Clinical outcomes of fractional flow reserve by computed tomographic angiography-guided diagnostic strategies vs. usual care in patients with suspected coronary artery disease: the prospective longitudinal trial of FFRct: outcome and resource impacts study.Eur Heart J. 2015; 36: 3359-3367https://doi.org/10.1093/eurheartj/ehv444
- 2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease: a report of the american College of Cardiology/American Heart Association task force on clinical practice guidelines: an update of the 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention, 2011 ACCF/AHA guideline for coronary artery bypass graft surgery, 2012 ACC/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and Management of Patients with Stable Ischemic Heart Disease, 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction, 2014 AHA/ACC guideline for the Management of Patients with non-ST-elevation acute coronary syndromes, and 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and Management of Patients Undergoing Noncardiac Surgery.Circulation. 2016; 134: e123-e155https://doi.org/10.1161/CIR.0000000000000404
- SCCT guidelines for the performance and acquisition of coronary computed tomographic angiography: a report of the society of cardiovascular computed tomography guidelines committee: endorsed by the north american Society for Cardiovascular Imaging (NASCI).J Cardiovasc Comput Tomogr. 2016; 10: 435-449https://doi.org/10.1016/j.jcct.2016.10.002
- Content Analysis: An Introduction to Its Methodology.2nd edition. Sage Publications, Thousand Oaks, CA2004
- Myocardial perfusion and viability imaging in coronary artery disease: clinical value in diagnosis, prognosis, and therapeutic guidance.Am J Med. 2021; 134: 968-975https://doi.org/10.1016/j.amjmed.2021.03.011
- 2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology/American Heart Association task force on practice guidelines, and the American Association for Thoracic Surgery, preventive cardiovascular nurses association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons.J Am Coll Cardiol. 2014; 64: 1929-1949https://doi.org/10.1016/j.jacc.2014.07.017
- Comparison of coronary computed tomography angiography, fractional flow reserve, and perfusion imaging for ischemia diagnosis.J Am Coll Cardiol. 2019; 73: 161-173https://doi.org/10.1016/j.jacc.2018.10.056
- Noninvasive FFR derived from coronary CT angiography: management and outcomes in the PROMISE trial.JACC Cardiovasc Imaging. 2017; 10: 1350-1358https://doi.org/10.1016/j.jcmg.2016.11.024
- Prospective comparison of FFR derived from coronary CT angiography with SPECT perfusion imaging in stable coronary artery disease: the ReASSESS study.JACC Cardiovasc Imaging. 2018; 11: 1640-1650https://doi.org/10.1016/j.jcmg.2018.05.004
- Importance of measurement site on assessment of lesion-specific ischemia and diagnostic performance by coronary computed tomography angiography-derived fractional flow reserve.J Cardiovasc Comput Tomogr. 2021; 15: 114-120https://doi.org/10.1016/j.jcct.2020.08.005
- Real-world clinical utility and impact on clinical decision making of coronary computed tomography angiography-derived fractional flow reserve: lessons from the ADVACE registry.Eur Heart J. 2018; 39: 3701-3711https://doi.org/10.1093/eurheartj/ehy530
- 1-Year impact on medical practice and clinical outcomes of FFR CT: the ADVANCE registry.JACC Cardiovasc Imaging. 2020; 13: 97-105https://doi.org/10.1016/j.jcmg.2019.03.003
- Fractional flow reserve derived from computed tomography coronary angiography in the assessment and management of stable chest pain: the FORECAST randomized trial.Eur Heart J. 2021; 42: 3844-3852https://doi.org/10.1093/eurheartj/ehab444
Article Info
Publication History
Published online: August 12, 2022
Accepted:
August 9,
2022
Received in revised form:
August 8,
2022
Received:
May 17,
2022
Identification
Copyright
© 2022 Elsevier Inc. All rights reserved.
