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Outcomes Using FFRCT-Guided Management
Study Questions:
What are the real-world clinical outcomes following a diagnostic strategy including first-line coronary computed tomography angiography (CTA) with selective fractional flow reserve (FFRCT) testing?
Methods:
The study investigators reviewed the results of 3,674 consecutive patients with stable chest pain evaluated with CTA and FFRCT testing to guide downstream management in patients with intermediate stenosis (30-70%). The composite endpoint (all-cause death, myocardial infarction, hospitalization for unstable angina, and unplanned revascularization) was determined in four patient groups: 1) CTA stenosis <30%, optimal medical treatment (OMT), and no additional testing; 2) FFRCT >0.80, OMT, no additional testing; 3) FFRCT ≤0.80, OMT, no additional testing; and 4) FFRCT ≤0.80, OMT, and referral to invasive coronary angiography. Patients were followed for a median of 24 (range: 8-41) months. Cumulative incidence of event was analyzed using time-to-event analysis with time since the coronary CTA test as time scale.
Results:
FFRCT was available in 677 patients, and the test result was negative (>0.80) in 410 (61%) patients. In 75% of the patients with FFRCT >0.80, maximum coronary stenosis was ≥50%. The cumulative incidence proportion (95% confidence interval [CI]) of the composite endpoint at the end of follow-up was comparable in groups 1 (2.8%; 95% CI, 1.4-4.9%) and 2 (3.9%; 95% CI, 2.0-6.9%) (p = 0.58), but was higher (when compared with group 1) in groups 3 (9.4%; p = 0.04) and 4 (6.6%; p = 0.08). Risk of myocardial infarction was lower in group 4 (1.3%) than in group 3 (8%; p < 0.001).
Conclusions:
The authors concluded that in patients with intermediate range coronary stenosis, FFRCT is effective in differentiating patients, who do not require further diagnostic testing or intervention from higher-risk patients.
Perspective:
This study reports that among symptomatic patients without known coronary artery disease (CAD) undergoing first-line coronary CTA, the presence of intermediate range CAD and FFRCT >0.80 was associated with favorable clinical outcomes similar to the prognosis in patients without or with minimal evidence of CAD. Furthermore, the risk of an unfavorable outcome was increased in patients with a positive FFRCT result who were not referred to coronary angiography. This study highlights the feasibility of selective FFRCT testing for decision making in patients with intermediate range CAD determined by first-line CTA in real-world clinical practice. Additional large-scale studies with longer follow-up are needed to further assess the risks/benefits of first-line coronary CTA with selective FFRCT testing and its impact on hard outcomes.
Clinical Topics: Cardiovascular Care Team, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Interventions and Imaging, Angiography, Computed Tomography, Nuclear Imaging
Keywords: ESC18, ESC Congress, Angina, Unstable, Chest Pain, Angiography, Coronary Angiography, Constriction, Pathologic, Coronary Stenosis, Diagnostic Imaging, Fractional Flow Reserve, Myocardial, Myocardial Infarction, Myocardial Ischemia, Secondary Prevention, Tomography, Tomography, X-Ray Computed
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