2021•Journal of cardiovascular computed tomographyOpen access
Trans-lesional fractional flow reserve gradient as derived from coronary CT improves patient management: ADVANCE registry
Hidenobu Takagi, Jonathon Leipsic, Noah McNamara, Isabella Martin, Timothy Fairbairn, Takashi Akasaka, Bjarne Linde Nørgaard, Daniel S. Berman, Kavitha M. Chinnaiyan, Lynne M. Hurwitz-Koweek, Gianluca Pontone, Tomohiro Kawasaki, Niels Peter Rønnow Sand, Jesper Møller Jensen, Tetsuya Amano, Michael Poon, Kristian Altern Øvrehus, Jeroen Sonck, Mark Rabbat, Sarah Mullen, Bernard De Bruyne, Campbell Rogers, Hitoshi Matsuo, Jeroen J. Bax, Pamela S. Douglas, Manesh R. Patel, Koen Nieman, Abdul Rahman Ihdayhid
Open full text 53 citations
Abstract
Background The role of change in fractional flow reserve derived from CT (FFR CT ) across coronary stenoses (ΔFFR CT ) in guiding downstream testing in patients with stable coronary artery disease (CAD) is unknown. Objectives To investigate the incremental value of ΔFFR CT in predicting early revascularization and improving efficiency of catheter laboratory utilization. Materials Patients with CAD on coronary CT angiography (CCTA) were enrolled in an international multicenter registry. Stenosis severity was assessed as per CAD-Reporting and Data System (CAD-RADS), and lesion-specific FFR CT was measured 2 cm distal to stenosis. ΔFFR CT was manually measured as the difference of FFR CT across visible stenosis. Results Of 4730 patients (66 ± 10 years; 34% female), 42.7% underwent ICA and 24.7% underwent early revascularization. ΔFFR CT remained an independent predictor for early revascularization (odds ratio per 0.05 increase [95% confidence interval], 1.31 [1.26–1.35]; p < 0.001) after adjusting for risk factors, stenosis features, and lesion-specific FFR CT . Among the 3 models ( model 1 : risk factors + stenosis type and location + CAD-RADS; model 2 : model 1 + FFR CT ; model 3 : model 2 + ΔFFR CT ), model 3 improved discrimination compared to model 2 (area under the curve, 0.87 [0.86–0.88] vs 0.85 [0.84–0.86]; p < 0.001), with the greatest incremental value for FFR CT 0.71–0.80. ΔFFR CT of 0.13 was the optimal cut-off as determined by the Youden index. In patients with CAD-RADS ≥3 and lesion-specific FFR CT ≤0.8, a diagnostic strategy incorporating ΔFFR CT >0.13, would potentially reduce ICA by 32.2% (1638–1110, p < 0.001) and improve the revascularization to ICA ratio from 65.2% to 73.1%. Conclusions ΔFFR CT improves the discrimination of patients who underwent early revascularization compared to a standard diagnostic strategy of CCTA with FFR CT , particularly for those with FFR CT 0.71–0.80. ΔFFR CT has the potential to aid decision-making for ICA referral and improve efficiency of catheter laboratory utilization.
Open-access reader