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Coronary CT angiography derived FFR in patients with left main disease.

ABSTRACT: The presence of left main coronary artery disease (LMCAD) is associated with an unfavorable clinical outcome. The clinical utility of FFR_CT testing for non-invasive physiological assessment in LMCAD remains largely unknown. In this single center observational study LMCAD patients were retrospectively identified between November 2015 and December 2017. We evaluated the relationship between LMCAD diameter stenosis and downstream FFR_CT values, and the clinical consequences following FFR_CT testing in patients with LMCAD. The composite endpoint (all-cause death, myocardial infarction, unplanned revascularization) was determined over a median follow-up of 1.1 years. LMCAD was registered in 432 of 3202 (13%) patients having coronary CTA. FFR_CT was prescribed in 213 (49%), while 59 (14%) patients were referred directly to invasive angiography or myocardial perfusion imaging. FFR_CT was performed in 195 (45%) patients. LM stenosis severity was inversely related to downstream FFR_CT values. In patients with simple LMCAD with stenosis ≥ 50%, > 80% had FFR_CT > 0.80 in non-diseased proximal and downstream segments (n = 7). No patients with simple LMCAD and FFR_CT > 0.80 (n = 20) suffered an adverse clinical outcome. FFR_CT testing in patients with LMCAD is feasible. LM stenosis severity is inversely related to FFR_CT value. Patients with LMCAD and FFR_CT > 0.80 have favorable clinical outcomes at short-term follow-up. Large-scale studies assessing the clinical utility and safety of deferring invasive catheterization following FFR_CT testing in patients with LMCAD are warranted.

SUBMITTER: Riedl KA

PROVIDER: S-EPMC8557153 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:OBJECTIVES:The purpose of this study was to determine whether noninvasive fractional flow reserve derived from computed tomography (FFRCT) predicts coronary revascularization and outcomes and whether its addition improves efficiency of referral to invasive coronary angiography (ICA) after coronary computed tomography angiography (CTA). BACKGROUND:FFRCT may improve the efficiency of an anatomic CTA strategy for stable chest pain. METHODS:This observational cohort study included patients with stable chest pain in the PROMISE (PROspective Multicenter Imaging Study for Evaluation of Chest Pain) trial referred to ICA within 90 days after CTA. FFRCT was measured at a blinded core laboratory, and FFRCT results were unavailable to caregivers. We determined the agreement of FFRCT (positive if ?0.80) with stenosis on CTA and ICA (positive if ?50% left main or ?70% other coronary artery), and predictive value for a composite of coronary revascularization or major adverse cardiac events (death, myocardial infarction, or unstable angina). We retrospectively assessed whether adding FFRCT ?0.80 as a gatekeeper could improve efficiency of referral to ICA, defined as decreased rate of ICA without ?50% stenosis and increased ICA leading to revascularization. RESULTS:FFRCT was calculated in 67% (181 of 271) of eligible patients (mean age 62 years; 36% women). FFRCT was discordant with stenosis in 31% (57 of 181) for CTA and 29% (52 of 181) for ICA. Most patients undergoing coronary revascularization had an FFRCT of ?0.80 (91%; 80 of 88). An FFRCT of ?0.80 was a significantly better predictor for revascularization or major adverse cardiac events than severe CTA stenosis (HR: 4.3 [95% confidence interval [CI]: 2.4 to 8.9] vs. 2.9 [95% CI: 1.8 to 5.1]; p = 0.033). Reserving ICA for patients with an FFRCT of ?0.80 could decrease ICA without ?50% stenosis by 44%, and increase the proportion of ICA leading to revascularization by 24%. CONCLUSIONS:In this hypothesis-generating study of patients with stable chest pain referred to ICA from CTA, an FFRCT of ?0.80 was a better predictor of revascularization or major adverse cardiac events than severe stenosis on CTA. Adding FFRCT may improve efficiency of referral to ICA from CTA alone.

Project description:ObjectivesThe addition of CT-derived fractional flow reserve (FFR-CT) increases the diagnostic accuracy of coronary CT angiography (CCTA). We assessed the impact of FFR-CT in routine clinical practice on clinical decision-making and patient prognosis in patients suspected of stable coronary artery disease (CAD).MethodsThis retrospective, single-center study compared a cohort that received CCTA with FFR-CT to a historical cohort that received CCTA before FFR-CT was available. We assessed the clinical management decisions after FFR-CT and CCTA and the rate of major adverse cardiac events (MACEs) during the 1-year follow-up using chi-square tests for independence. Kaplan-Meier curves were used to visualize the occurrence of safety outcomes over time.ResultsA total of 360 patients at low to intermediate risk of CAD were included, 224 in the CCTA only group, and 136 in the FFR-CT group. During follow-up, 13 MACE occurred in 12 patients, 9 (4.0%) in the CCTA group, and three (2.2%) in the FFR-CT group. Clinical management decisions differed significantly between both groups. After CCTA, 60 patients (26.5%) received optimal medical therapy (OMT) only, 115 (51.3%) invasive coronary angiography (ICA), and 49 (21.9%) single positron emission CT (SPECT). After FFR-CT, 106 patients (77.9%) received OMT only, 27 (19.9%) ICA, and three (2.2%) SPECT (p < 0.001 for all three options). The revascularization rate after ICA was similar between groups (p = 0.15). However, patients in the CCTA group more often underwent revascularization (p = 0.007).ConclusionAddition of FFR-CT to CCTA led to a reduction in (invasive) diagnostic testing and less revascularizations without observed difference in outcomes after 1 year.Key points• Previous studies have shown that computed tomography-derived fractional flow reserve improves the accuracy of coronary computed tomography angiography without changes in acquisition protocols. • This study shows that use of computed tomography-derived fractional flow reserve as gatekeeper to invasive coronary angiography in patients suspected of stable coronary artery disease leads to less invasive testing and revascularization without observed difference in outcomes after 1 year. • This could lead to a significant reduction in costs, complications and (retrospectively unnecessary) usage of diagnostic testing capacity, and a significant increase in patient satisfaction.

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Coronary CT angiography derived FFR in patients with left main disease.

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