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Stress-CPT vs. FFRCT in Suspected CAD
Study Questions:
What is the diagnostic accuracy of coronary computed tomography angiography (cCTA) versus cCTA + fractional flow reserve computed tomography-derived (FFRCT) versus cCTA + stress computed tomography perfusion (stress-CTP) in detecting functionally significant coronary artery lesions using invasive coronary angiography (ICA) plus invasive FFR as the reference standard?
Methods:
The PERFECTION study investigators evaluated 147 consecutive symptomatic patients scheduled for clinically indicated ICA plus invasive FFR, with cCTA, FFRCT, and stress-CTP, for cCTA and integrated cCTA + FFRCT or cCTA + CTP protocols. The overall evaluability (ratio of the number of evaluable coronary artery segments to all coronary artery segments), sensitivity, specificity, negative predictive value and positive predictive value, and accuracy were calculated as compared to ICA plus invasive FFR as reference standard. The McNemar test was used to calculate differences in terms of sensitivity, specificity, negative predictive value, positive predictive value, and accuracy, and area under the receiver operating characteristics (AUC) curves for each model was measured and compared with the DeLong method.
Results:
Vessel- and patient-based sensitivity, specificity, negative predictive value, positive predictive value, and accuracy of cCTA was 99%, 76%, 100%, 61%, 82%, and 95%, 54%, 94%, 63%, 73%, respectively. cCTA + FFRCT showed a vessel- and patient-based sensitivity, specificity, negative predictive value, positive predictive value, and accuracy of 88%, 94%, 95%, 84%, 92%, and 90%, 85%, 92%, 83%, 87%, respectively. Finally, cCTA + stress-CTP showed a vessel- and patient-based sensitivity, specificity, negative predictive value, positive predictive value, and accuracy of 92%, 95%, 97%, 87%, 94%, and 98%, 87%, 99%, 86%, 92%, respectively. Both FFRCT and stress-CTP significantly improved specificity, positive predictive value as compared to cCTA alone. The AUC to detect flow-limiting stenosis of cCTA, cCTA + FFRCT, and cCTA + CTP were 0.89, 0.93, 0.92, and 0.90, 0.94, 0.93 in a vessel- and patient-based model, respectively, with significant additional value of both cCTA + FFRCT and cCTA + CTP versus cCTA alone (p < 0.001), but no differences between cCTA + FFRCT versus cCTA + CTP.
Conclusions:
The authors concluded that FFRCT and stress-CTP in addition to cCTA are valid and comparable tools to evaluate the functional relevance of CAD.
Perspective:
This study reports that both FFRCT and stress-CTP provide additional value in terms of specificity, positive predictive value, and diagnostic accuracy when compared to rest cCTA without a significant difference between these two approaches. These data suggest that in appropriate patients with suspected coronary artery disease, cCTA alone and integrated with FFRCT or CTP is a robust tool to diagnose functionally relevant stenoses. Additional studies are indicated to test these techniques in the general population, as the current study used very narrow exclusion criteria.
Clinical Topics: Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Atherosclerotic Disease (CAD/PAD), Interventions and Coronary Artery Disease, Interventions and Imaging, Angiography, Computed Tomography, Nuclear Imaging
Keywords: Cardiology Interventions, Coronary Angiography, Constriction, Pathologic, Coronary Artery Disease, Diagnostic Imaging, Fractional Flow Reserve, Myocardial, Ischemia, Perfusion Imaging, Secondary Prevention, Tomography, X-Ray Computed
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