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Stress CT Perfusion vs. CT Fractional Flow Reserve
Study Questions:
What are the diagnostic accuracies of coronary computed tomography angiography (cCTA), cCTA plus fractional flow reserve (FFR) derived from cCTA data sets (FFRCT), and cCTA plus static stress-computed tomography perfusion (stress-CTP) for detecting functionally significant coronary artery disease (CAD)?
Methods:
The PERFECTION (PERfusion Versus Fractional Flow Reserve CT Derived In Suspected CoroNary) study was a longitudinal, prospective, consecutive cohort study designed to compare the feasibility and accuracy of integrated cCTA+FFRCT with that of cCTA+stress-CTP for the diagnosis of functionally significant CAD. Symptomatic patients referred for nonemergent invasive coronary angiography (ICA) were screened. Exclusion criteria included low pretest probability of disease, prior myocardial infarction, prior revascularization, inability to sustain a breath-hold, impaired renal function, body mass index >35 kg/m2, presence of an implanted electronic device, and contraindication to the administration of nitrates, beta-blockers, or adenosine. Of 928 patients screened between October 2015 and May 2017, 147 patients were included. FFRCT was analyzed off-site. Stress-CTP was derived from repeat cCTA after intravenous adenosine. ICA was performed within 60 days of cCTA. Coronary stenoses ≥80% were considered significant; stenoses between 30% and 80% were assessed using clinically indicated FFR.
Results:
Vessel-based and patient-based sensitivity, specificity, negative predictive values, positive predictive values, and accuracy rates of cCTA were 99%, 76%, 100%, 61%, and 82%; and 95%, 54%, 94%, 63%, and 73%, respectively. cCTA+FFRCT had vessel-based and patient-based sensitivity, specificity, negative predictive values, positive predictive values, and accuracy rates of 88%, 94%, 95%, 84%, and 92%; and 90%, 85%, 92%, 83%, and 87%, respectively. cCTA+stress-CTP showed vessel-based and patient-based sensitivity, specificity, negative predictive values, positive predictive values, and accuracy rates of 92%, 95%, 97%, 87%, and 94%; and 98%, 87%, 99%, 86%, and 92%, respectively. Both FFRCT and stress-CTP significantly improved specificity and positive predictive values compared to those of cCTA alone. In vessel-based and in patient-based models, the area under the curve to detect flow-limiting stenoses for cCTA, cCTA+FFRCT, and cCTA+CTP were 0.89, 0.93, and 0.92; and 0.90, 0.94, and 0.93, respectively; with significant additional values for 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:
In this highly selected population (~16% of screened nonemergent patients), the addition of CT-based FFR or CT-based static perfusion significantly improved test specificity and positive predictive value for the detection of significant CAD compared to cCTA alone. Whether these tools find clinical utility in broader populations requires additional study.
Clinical Topics: 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: Adenosine, Cardiology Interventions, Coronary Angiography, Constriction, Pathologic, Coronary Artery Disease, Coronary Stenosis, Diagnostic Imaging, Fractional Flow Reserve, Myocardial, Nitrates, Perfusion Imaging, Tomography, X-Ray Computed
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