A 63-year-old man presents to the emergency department with a 3-week history of intermittent chest and epigastric discomfort that occurs when he goes for his usual walk after dinner and is relieved with rest. His symptoms have not improved with over-the-counter antacids. He has a history of hypertension, prediabetes, and dyslipidemia. He takes amlodipine 10 mg once daily, lisinopril 5 mg once daily, rosuvastatin 10 mg once daily, and metformin 500 mg twice daily.
On examination, his temperature is 97.8 degrees F, heart rate is 84 bpm, blood pressure is 132/78 mmHg, respiratory rate is 14, oxygen saturation is 96% on room air, and body mass index is 27 kg/m2. The remainder of the exam is normal. Electrocardiography is normal. Echocardiography demonstrates normal left ventricular ejection fraction with normal regional wall motion. A coronary computed tomography angiogram (CCTA) demonstrates a calcified plaque in the mid-segment of the left circumflex artery that is interpreted as intermediate (50-70%) in severity. After discussing the findings with the patient, you decide to proceed with fractional flow reserve (FFR) derived from CCTA (FFRCT) for further risk stratification of the lesion in the left circumflex artery.
The correct answer is: D. FFRCT information can be estimated for all patients undergoing CCTA.
CCTA along with FFRCT identifies both the anatomic characteristics of coronary atherosclerotic lesions as well as functional data on the hemodynamic effects of these lesions. Using measured invasive angiographic FFR as the reference standard, FFRCT has demonstrated excellent diagnostic performance. Compared with CCTA assessment alone, FFRCT allows improved discrimination of ischemia. When compared with usual care, the use of FFRCT has been demonstrated to safely reduce the rate of downstream invasive angiography, as well as to improve the diagnostic yield of coronary angiography when performed. One limitation of this technique is that not all CCTA images are adequate for the calculation of FFRCT. For example, in the recent PACIFIC (Prospective Comparison of Cardiac PET/CT, SPECT/CT Perfusion Imaging and CT Coronary Angiography With Invasive Coronary Angiography) study, CCTA images were not satisfactory for the estimation of FFRCT in approximately 25% of the study population.
References
- Nørgaard 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;63:1145-55.
- Douglas PS, Pontone G, Hlatky MA, et al. Clinical outcomes of fractional flow reserve by computed tomographic angiography-guided diagnostic strategies vs. usual care in patients with suspected coronary artery disease: the prospective longitudinal trial of FFR(CT): outcome and resource impacts study. Eur Heart J 2015;36:3359-67.
- Fairbairn TA, Nieman K, Akasaka T, et al. Real-world clinical utility and impact on clinical decision-making of coronary computed tomography angiography-derived fractional flow reserve: lessons from the ADVANCE Registry. Eur Heart J 2018;39:3701-1.
- Driessen RS, Danad I, Stuijfzand WJ, et al. Comparison of Coronary Computed Tomography Angiography, Fractional Flow Reserve, and Perfusion Imaging for Ischemia Diagnosis. J Am Coll Cardiol 2019;73:161-73.
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