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Effect of FFRCT on Downstream Testing and Events
Study Questions:
How does computed tomography (CT)-derived fractional flow reserve (FFRCT) impact patient management compared to coronary CT angiography (CCTA) alone?
Methods:
This study examined patients in the ADVANCE registry (Assessing Diagnostic Value of Non-invasive FFRCT in Coronary Care) from 38 sites with CCTA for suspected stable coronary artery disease (CAD); individuals with stenosis 30-90% were recommended for FFRCT. The rate of reclassification by FFRCT over CCTA alone was compared, and the rate of adverse events at 90 days (mortality, myocardial infarction, urgent revascularization) in patients with normal versus abnormal FFRCT were compared.
Results:
From a total of 5,083 patients undergoing CCTA, 4,893 had CCTA submitted for FFRCT, and 4,737 patients had studies adequate for FFRCT analysis. After CCTA alone, the site’s planned management strategy was additional testing, medical therapy, and revascularization in 57.9%, 19.2%, and 22.9%, respectively. After adding FFRCT, the site’s planned management approach was additional testing, medical therapy, and revascularization in 2.9%, 63.5%, and 33.5%, respectively (resulting in 63.5% reclassification). Actual management strategy was medical therapy and revascularization in 75.4% and 24.5%, respectively. The finding of nonobstructive CAD on invasive angiography was lower in patients with FFRCT values ≤0.80 vs. >0.80 (odds ratio, 0.19; 95% confidence interval [CI], 0.15-0.25; p < 0.001). No adverse events were observed at 90 days in patients with FFRCT >0.80, while there were 19 events in patients with FFRCT ≤0.80 (hazard ratio, 20.0; 95% CI, 1.2-326; p < 0.001).
Conclusions:
The addition of FFRCT findings altered the management strategy in nearly two thirds of patients compared to CCTA alone, and a negative FFRCT was associated with a reduced risk of short-term adverse events.
Perspective:
When compared to CCTA alone, the addition of FFRCT analysis altered planned management strategies in nearly two thirds of individuals. The largest shifts were a reduction in planned additional testing (from 58% to 3%) and an increase in planned medical therapy (19% to 64%), while the rate of planned revascularization also increased (23% to 34%). These findings suggest that FFRCT may reduce the need for additional testing after CCTA. While FFRCT does represent an additional test with an incremental cost, it uses the standard CCTA images and does not require the patient to return for another test. However, the long-term outcomes of this approach cannot be evaluated in this study, and durability of the shift in management strategy over a longer-term follow-up is not known. The low rate of events following a negative FFRCT result is encouraging, although the short-term follow-up limits conclusions that can be drawn from this.
Clinical Topics: Cardiac Surgery, Cardiovascular Care Team, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Atherosclerotic Disease (CAD/PAD), Interventions and Coronary Artery Disease, Interventions and Imaging, Angiography, Computed Tomography, Nuclear Imaging
Keywords: Coronary Angiography, Constriction, Pathologic, Coronary Artery Disease, Coronary Stenosis, Diagnostic Imaging, Fractional Flow Reserve, Myocardial, Myocardial Infarction, Myocardial Revascularization, Tomography, X-Ray Computed
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