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Fractional Flow Reserve Measurement by Computed Tomography: An Alternative to the Stress Test.

ABSTRACT: Recent advances in computed tomographic technology have contributed towards improving coronary computed tomography angiography (CCTA) in determining the severity of coronary artery disease anatomically. Although the viability of CCTA has most often been confined to anatomical assessment, recent development has enabled evaluation of the haemodynamic significance of coronary artery disease. In light of this, CCTA-derived fractional flow reserve (FFRCT), a novel imaging modality, now permits the physiological assessment of coronary artery disease. To date, several studies have documented the diagnostic performance of FFRCT, and more trials are being performed that will further substantiate this technique. The present paper provides an overview and discussion of the available evidence for FFRCT in the clinical setting as well as potential future directions of FFRCT.

SUBMITTER: Lee JH

PROVIDER: S-EPMC5808503 | biostudies-literature | 2016 Oct

REPOSITORIES: biostudies-literature

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Fractional Flow Reserve Measurement by Computed Tomography: An Alternative to the Stress Test.

Lee Ji Hyun JH Hartaigh Bríain Ó BÓ Han Donghee D Rizvi Asim A Lin Fay Y FY Min James K JK

Interventional cardiology (London, England) 20161001 2

Recent advances in computed tomographic technology have contributed towards improving coronary computed tomography angiography (CCTA) in determining the severity of coronary artery disease anatomically. Although the viability of CCTA has most often been confined to anatomical assessment, recent development has enabled evaluation of the haemodynamic significance of coronary artery disease. In light of this, CCTA-derived fractional flow reserve (FFR<sub>CT</sub>), a novel imaging modality, now per ...[more]

PMID: 29588715

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Project description:Amongst patients with suspected obstructive coronary artery disease (CAD), less than a third of patients have obstructive disease on invasive coronary angiography (ICA) and fewer still have flow-limiting obstructive disease as determined by invasive fractional flow reserve (FFR). FFR is a powerful tool in guiding revascularization of flow-limiting lesions which in turn improves clinical outcome in those with haemodynamically significant obstructive disease. However FFR is infrequently performed due to the cost, time and patient discomfort the procedure entails. Further advances in non-invasive imaging has allowed FFR to be derived non-invasively by applying computational fluid dynamic (CFD) modeling to the coronary computed tomography angiography (CCTA) dataset without the need to induce hyperemia or modify the standard CCTA acquisition protocol. FFR derived from CCTA has been shown to have excellent correlation with invasive FFR and remains diagnostically robust in presence of reduced signal-to-noise ratio (SNR), coronary calcification and motion artifact. More recently, new data have emerged evaluating the clinical impact of fractional flow reserve computed tomography (FFRCT) on the assessment and management of patients with stable chest pain. One such study is the Prospective LongitudinAl trial of FFRCT: Outcome and Resource IMpacts (PLATFORM) study which showed an improved patient selection for ICA using CCTA-FFRCT approach by increasing the likelihood of identifying obstructive CAD at ICA amongst those intended for invasive testing. CCTA-FFRCT may therefore serve as efficacious gatekeeper to ICA that enriches the ICA population. The utility of FFRCT has also helped deepened our understanding of CAD. Through CFD modeling, it is now recognized that there are mechanistic forces of wall shear stress (WSS) and axial plaque force acting on coronary plaques. This has created further interest in exploring the possible interplay between these mechanistic forces on the development of coronary plaque and vulnerability of these plaques to rupture.

Project description:BackgroundIn the United States, functional stress testing is the primary imaging modality for patients with stable symptoms suspected to represent coronary artery disease (CAD). Coronary computed tomography angiography (CTA) is excellent at identifying anatomic coronary artery disease (CAD). The application of computational fluid dynamics to coronary CTA allows fractional flow reserve (FFR) to be calculated noninvasively (FFRCT). The relationship of noninvasive stress testing to coronary CTA and FFRCT in real-world clinical practice has not been studied.MethodsWe evaluated 206 consecutive patients at Loyola University Chicago with suspected CAD who underwent noninvasive stress testing followed by coronary CTA and FFRCT when indicated. Patients were categorized by stress test results (positive, negative, indeterminate, and equivocal). Duke treadmill score (DTS), METS, exercise duration, and chest pain with exercise were analyzed. Lesions ≥ 50%stenosis were considered positive by coronary CTA. FFRCT < 0.80 was considered diagnostic of ischemia.ResultsTwo hundred and six patients had paired noninvasive stress test and coronary CTA/FFRCT results. The median time from stress test to coronary CTA was 49 days. Average patient age was 60.3 years, and 42% were male. Of the 206 stress tests, 75% were exercise (70% echocardiographic, 26% nuclear, and 4% EKG). There were no associations of stress test results with CAD > 50% or FFRCT < 0.80 (p = 0.927 and p = 0.910, respectively). Of those with a positive stress test, only 30% (3/10) had CAD > 50% and only 50% (5/10) had FFRCT < 0.80. Chest pain with exercise did not correlate with CAD > 50% or FFRCT < 0.80 (p = 0.66 and p = 0.12, respectively). There were no significant correlations between METS, DTS, or exercise duration and FFRCT (r = 0.093, p = 0.274; r = 0.012, p = 0.883; and r = 0.034, p = 0.680; respectively).ConclusionNoninvasive stress testing, functional capacity, chest pain with exercise, and DTS are not associated with anatomic or functional CAD using a diagnostic strategy of coronary CTA and FFRCT.

Dataset Information

Fractional Flow Reserve Measurement by Computed Tomography: An Alternative to the Stress Test.

Publications

Fractional Flow Reserve Measurement by Computed Tomography: An Alternative to the Stress Test.

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