Fractional Flow Reserve Derived from Coronary Computed Tomography Angiography Safely Defers Invasive Coronary Angiography in Patients with Stable Coronary Artery Disease

Mark Rabbat; Jonathon Leipsic; Jeroen Bax; Brian Kauh; Rina Verma; Demetrios Doukas; Sorcha Allen; Gianluca Pontone; David Wilber; Verghese Mathew; Campbell Rogers; John Lopez

doi:10.3390/jcm9020604

Fractional Flow Reserve Derived from Coronary Computed Tomography Angiography Safely Defers Invasive Coronary Angiography in Patients with Stable Coronary Artery Disease

J Clin Med. 2020 Feb 24;9(2):604. doi: 10.3390/jcm9020604.

Authors

Affiliations

¹ Division of Cardiology, Loyola University Medical Center, Maywood, IL 60153, USA.
² Department of Radiology, St. Paul's Hospital and the University of British Columbia, Vancouver, BC V6T 1Z4, Canada.
³ Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands.
⁴ Division of Cardiology, University of Kentucky, Lexington, KY 40536, USA.
⁵ Department of Cardiovascular Imaging, Cardiologico Monzino, Via Carlo Parea, 4, 20138 Milan MI, Italy.
⁶ HeartFlow, Inc., Redwood City, CA 94063, USA.

Abstract

Objectives: In the United States, the real-world feasibility and outcome of using fractional flow reserve from coronary computed tomography angiography (FFR_CT) is unknown. We sought to determine whether a strategy that combined coronary computed tomography angiography (CTA) and FFR_CT could safely reduce the need for invasive coronary angiography (ICA), as compared to coronary CTA alone.

Methods: The study included 387 consecutive patients with suspected CAD referred for coronary CTA with selective FFR_CT and 44 control patients who underwent CTA alone. Lesions with 30-90% diameter stenoses were considered of indeterminate hemodynamic significance and underwent FFR_CT. Nadir FFR_CT ≤ 0.80 was positive. The rate of patients having ICA, revascularization and major adverse cardiac events were recorded.

Results: Using coronary CTA and selective FFR_CT, 121 patients (32%) had at least one vessel with ≥50% diameter stenosis; 67/121 (55%) patients had at least one vessel with FFR_CT ≤ 0.80; 55/121 (45%) underwent ICA; and 34 were revascularized. The proportion of ICA patients undergoing revascularization was 62% (34 of 55). The number of patients with vessels with 30-50% diameter of stenosis was 90 (23%); 28/90 (31%) patients had at least one vessel with FFR_CT ≤ 0.80; 8/90 (9%) underwent ICA; and five were revascularized. In our institutional practice, compared to coronary CTA alone, coronary CTA with selective FFR_CT reduced the rates of ICA (45% vs. 80%) for those with obstructive CAD. Using coronary CTA with selective FFR_CT, no major adverse cardiac events occurred over a mean follow-up of 440 days.

Conclusion: FFR_CT safely deferred ICA in patients with CAD of indeterminate hemodynamic significance. A high proportion of those who underwent ICA were revascularized.

Keywords: computational fluid dynamics; coronary computed tomography angiography; fractional flow reserve; stable coronary artery disease.