The impact of noninvasive coronary imaging on patient management and outcome has implications for best practice use and appropriate resource investments.
In the PLATFORM trial, clinical outcomes for patients in whom ICA was deferred on the basis of FFRCT were favorable with a 1-year risk of all-cause death, myocardial infarction, or unplanned hospitalization with urgent revascularization of 1%.33 This finding is in accordance with a recent single-center real-world study of 110 consecutive patients with stable chest pain, moderate CAD, and deferral of ICA in those with FFRCT≥0.80, among whom no adverse cardiac events occurred over a median of 12 months’ follow-up.39 In the Lu PROMISE FFRCT substudy, “blinded” FFRCT≤0.80 was predictive of subsequent revascularization and major adverse cardiac events with a significantly higher hazard ratio than CCTA stenosis assessment alone (hazard ratio, 4.3 vs. 2.9; P=0.033).37 Historical cost simulation analyses indicate that FFRCT guidance for selection of ICA and decision-making on coronary revascularization may reduce costs in stable CAD.40,41 In the PLATFORM trial, among patients with planned ICA, the mean costs were 32% lower in the FFRCT group than in the usual care group.32 The ongoing prospective multicenter multinational longitudinal “Assessing Diagnostic value of Non-Invasive FFRCT in Coronary Care” (ADVANCE) registry will further delineate the clinical utility, prognostic aspects, and cost-effectiveness of FFRCT-guidance in 5000 patients with or without known CAD.42
1. Min JK, Dunning A, Lin FY, et al. Age- and sex-related differences in all-cause mortality risk based on coronary computed tomography angiography
findings: results from the International Multicenter CONFIRM (Coronary CT Angiography Evaluation for Clinical Outcomes: An International Multicenter Registry) of 23,854 patients without known coronary artery disease
. J Am College Cardiol. 2011;58:849–860.
2. Hadamitzky M, Taubert S, Deseive S, et al. Prognostic value of coronary computed tomography angiography
during 5 years of follow-up in patients with suspected coronary artery disease
. Eur Heart J. 2013;34:3277–3285.
3. Chow BJ, Small G, Yam Y, et al. Prognostic and therapeutic implications of statin and aspirin therapy in individuals with nonobstructive coronary artery disease
: results from the CONFIRM (COronary CT Angiography EvaluatioN For Clinical Outcomes: An InteRnational Multicenter registry) registry. Arterioscler Thromb Vasc Biol. 2015;35:981–989.
4. Williams MC, Hunter A, Shah ASV, et al. Use of coronary computed tomographic angiography to guide management of patients with coronary disease. J Am Coll Cardiol. 2016;67:1759–1768.
5. Jorgensen ME, Andersson C, Norgaard BL, et al. Functional testing or coronary computed tomography angiography
in patients with stable coronary artery disease
. J Am Coll Cardiol. 2017;69:1761–1770.
6. Nielsen LH, Ortner N, Norgaard BL, et al. The diagnostic accuracy and outcomes after coronary computed tomography angiography
vs. conventional functional testing in patients with stable angina pectoris: a systematic review and meta-analysis. Eur Heart J Cardiovasc Imaging. 2014;15:961–971.
7. SCOT-HEART Investigators. CT coronary angiography in patients with suspected angina due to coronary heart disease (SCOT-HEART): an open-label, parallel-group, multicentre trial. Lancet. 2015;385:2383–2391.
8. Foy AJ, Dhruva SS, Peterson B, et al. Coronary computed tomography angiography
vs functional stress testing for patients with suspected coronary artery disease
: a systematic review and meta-analysis. JAMA Intern Med. 2017;177:1623–1631.
9. Hoffmann U, Ferencik M, Udelson JE, et al. Prognostic value of noninvasive cardiovascular testing in patients with stable chest pain
: insights from the PROMISE Trial (Prospective Multicenter Imaging Study for Evaluation of Chest Pain). Circulation. 2017;135:2320–2332.
10. Fordyce CB, Douglas PS, Roberts RS, et al. Identification of patients with stable chest pain
deriving minimal value from noninvasive testing: the PROMISE minimal-risk tool, a secondary analysis of a randomized clinical trial. JAMA Cardiol. 2017;2:400–408.
11. Patel MR, Peterson ED, Dai D, et al. Low diagnostic yield of elective coronary angiography. N Engl J Med. 2010;362:886–895.
12. Vavalle JP, Shen L, Broderick S, et al. Effect of the presence and type of angina on cardiovascular events in patients without known coronary artery disease
referred for elective coronary angiography. JAMA Cardiol. 2016;1:232–234.
13. National Institute of Health and Clinical Excellence. Chest pain of recent onset: assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin. Clinical guideline CG95. 2016. Available at: www.nice.org.uk/guidance/CG95
. Accessed January 30, 2018.
14. Moss AJ, Williams MC, Newby DE, et al. The updated NICE guidelines: cardiac ct as the first-line test for coronary artery disease
. Curr Cardiovasc Imaging Rep. 2017;10:15.
15. Danad I, Szymonifka J, Twisk JWR, et al. Diagnostic performance of cardiac imaging methods to diagnose ischaemia-causing coronary artery disease
when directly compared with fractional flow reserve
as a reference standard: a meta-analysis. Eur Heart J. 2017;38:991–998.
16. Tonino PA, Fearon WF, De Bruyne B, et al. 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;55:2816–2821.
17. De Bruyne B, Pijls NHJ, Kalesan B, et al. Fractional flow reserve
–guided PCI versus medical therapy in stable coronary disease. N Engl J Med. 2012;367:991–1001.
18. Curzen N, Rana O, Nicholas Z, et al. Does routine pressure wire assessment influence management strategy at coronary angiography for diagnosis of chest pain?: the RIPCORD study. Circ Cardiovasc Interv. 2014;7:248–255.
19. Ahmadi A, Leipsic J, Ovrehus K, et al. P876Lesion-specific and vessel-related determinants of FFR. Eur Heart J. 2017;38 (suppl_1):521–530.
20. Fearon WF, Bornschein B, Tonino PA, et al. Economic evaluation of fractional flow reserve
-guided percutaneous coronary intervention in patients with multivessel disease. Circulation. 2010;122:2545–2550.
21. Johnson NP, Johnson DT, Kirkeeide RL, et al. Repeatability of fractional flow reserve
despite variations in systemic and coronary hemodynamics. JACC Cardiovasc Interv. 2015;8:1018–1027.
22. Morris PD, Ryan D, Morton AC, et al. Virtual fractional flow reserve
from coronary angiography: modeling the significance of coronary lesions: results from the VIRTU-1 (VIRTUal Fractional Flow Reserve
From Coronary Angiography) study. JACC Cardiovasc Interv. 2013;6:149–157.
23. Taylor CA, Fonte TA, Min JK. Computational fluid dynamics
applied to cardiac computed tomography for noninvasive quantification of fractional flow reserve
: scientific basis. J Am Coll Cardiol. 2013;61:2233–2241.
24. Koo BK, Erglis A, Doh JH, et al. Diagnosis of ischemia-causing coronary stenoses by noninvasive fractional flow reserve
computed from coronary computed tomographic angiograms. Results from the prospective multicenter DISCOVER-FLOW (Diagnosis of Ischemia-Causing Stenoses Obtained Via Noninvasive Fractional Flow Reserve
) study. J Am Coll Cardiol. 2011;58:1989–1997.
25. Min JK, Leipsic J, Pencina MJ, et al. Diagnostic accuracy of fractional flow reserve
from anatomic CT angiography. JAMA. 2012;308:1237–1245.
26. Norgaard BL, Leipsic J, Gaur S, et al. Diagnostic performance of noninvasive 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;63:1145–1155.
27. Renker M, Schoepf UJ, Wang R, et al. Comparison of diagnostic value of a novel noninvasive coronary computed tomography angiography
method versus standard coronary angiography for assessing fractional flow reserve
. Am J Cardiol. 2014;114:1303–1308.
28. Coenen A, Lubbers MM, Kurata A, et al. Coronary CT angiography derived fractional flow reserve
: methodology and evaluation of a point of care algorithm. J Cardiovasc Comput Tomogr. 2016;10:105–113.
29. Ko BS, Cameron JD, Munnur RK, et al. Noninvasive CT-derived FFR based on structural and fluid analysis: a comparison with invasive FFR for detection of functionally significant stenosis. JACC Cardiovasc Imaging. 2017;10:663–673.
30. Norgaard BL, Leipsic J. From newton to the coronaries: computational fluid dynamics
has entered the clinical scene. JACC Cardiovasc Imaging. 2016;9:700–702.
31. Norgaard BL, Gaur S, Leipsic J, et al. Influence of coronary calcification on the diagnostic performance of CT angiography derived FFR in coronary artery disease
: a substudy of the NXT trial. JACC Cardiovasc Imaging. 2015;8:1045–1055.
32. Hlatky MA, De Bruyne B, Pontone G, et al. Quality-of-life and economic outcomes of assessing fractional flow reserve
with computed tomography angiography: PLATFORM. J Am Coll Cardiol. 2015;66:2315–2323.
33. Douglas PS, De Bruyne B, Pontone G, et al. 1-Year outcomes of FFRCT-guided care in patients with suspected coronary disease: the PLATFORM study. J Am Coll Cardiol. 2016;68:435–445.
34. Jensen JM, Bøtker HE, Mathiassen ON, et al. Computed tomography derived fractional flow reserve
testing in stable patients with typical angina pectoris: influence on downstream rate of invasive coronary angiography. Eur Heart J Cardiovasc Imaging. 2018;19:405–414.
35. Nørgaard BL, Gormsen LC, Botker HE, et al. Myocardial perfusion imaging versus computed tomography angiography-derived fractional flow reserve
testing in stable patients with intermediate-range coronary lesions: influence on downstream diagnostic workflows and invasive angiography findings. J Am Heart Assoc. 2017;6:8.
36. Curzen NP, Nolan J, Zaman AG, et al. Does the routine availability of CT-derived FFR influence management of patients with stable chest pain
compared to CT angiography alone?: The FFRCT RIPCORD Study. JACC Cardiovasc Imaging. 2016;9:1188–1194.
37. Lu MT, Ferencik M, Roberts RS, et al. Noninvasive FFR derived from coronary CT angiography: management and outcomes in the PROMISE trial. JACC Cardiovasc Imaging. 2017;10:1350–1358.
38. Gaur S, Taylor CA, Jensen JM, et al. FFR derived from coronary CT angiography in nonculprit lesions of patients with recent STEMI. JACC Cardiovasc Imaging. 2017;10:424–433.
39. Norgaard BL, Hjort J, Gaur S, et al. Clinical use of coronary CTA-derived FFR for decision-making in stable CAD. JACC Cardiovasc Imaging. 2017;10:541–550.
40. Hlatky MA, Saxena A, Koo BK, et al. Projected costs and consequences of computed tomography-determined fractional flow reserve
. Clin Cardiol. 2013;36:743–748.
41. Kimura T, Shiomi H, Kuribayashi S, et al. Cost analysis of non-invasive fractional flow reserve
derived from coronary computed tomographic angiography in Japan. Cardiovasc Interv Ther. 2015;30:38–44.
42. Chinnaiyan KM, Akasaka T, Amano T, et al. Rationale, design and goals of the HeartFlow assessing diagnostic value of non-invasive FFRCT in Coronary Care (ADVANCE) registry. J Cardiovasc Comput Tomogr. 2017;11:62–67.
43. Leipsic J, Yang TH, Thompson A, et al. CT angiography (CTA) and diagnostic performance of noninvasive fractional flow reserve
: results from the Determination of Fractional Flow Reserve
by Anatomic CTA (DeFACTO) study. AJR Am J Roentgenol. 2014;202:989–994.
44. Abbara S, Blanke P, Maroules CD, et al. 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;10:435–449.
45. Taylor CA, Gaur S, Leipsic J, et al. Effect of the ratio of coronary arterial lumen volume to left ventricle myocardial mass derived from coronary CT angiography on fractional flow reserve
. J Cardiovasc Comput Tomogr. 2017;11:429–436.