Meta-Analysis of Diagnostic Performance of Coronary Computed Tomography Angiography, Computed Tomography Perfusion, and Computed Tomography-Fractional Flow Reserve in Functional Myocardial Ischemia Assessment Versus Invasive Fractional Flow Reserve.
We sought to compare the diagnostic performance of coronary computed tomography angiography (CCTA), computed tomography perfusion (CTP), and computed tomography (CT)-fractional flow reserve (FFR) for assessing the functional significance of coronary stenosis as defined by invasive FFR in patients with known or suspected coronary artery disease (CAD). CCTA has proved clinically useful for excluding obstructive CAD because of its high sensitivity and negative predictive value (NPV); however, the ability of CTA to identify functionally significant CAD has remained challenging. We searched PubMed/Medline for studies evaluating CCTA, CTP, or CT-FFR for the noninvasive detection of obstructive CAD compared with catheter-derived FFR as the reference standard. Pooled sensitivity, specificity, PPV, NPV, likelihood ratios, and odds ratio of all diagnostic tests were assessed. Eighteen studies involving a total of 1,535 patients were included. CTA demonstrated a pooled sensitivity of 0.92, specificity 0.43, PPV of 0.56, and NPV of 0.87 on a per-patient level. CT-FFR and CTP increased the specificity to 0.72 and 0.77, respectively (p = 0.004 and p = 0.0009) resulting in higher point estimates for PPV 0.70 and 0.83, respectively. There was no improvement in the sensitivity. The CTP protocol involved more radiation (3.5 mSv CCTA vs 9.6 mSv CTP) and a higher volume of iodinated contrast (145 ml). In conclusion, CTP and CT-FFR improve the specificity of CCTA for detecting functionally significant stenosis as defined by invasive FFR on a per-patient level; both techniques could advance the ability to noninvasively detect the functional significance of coronary lesions.
Division of Cardiology, Department of Medicine, University of Virginia Health System, Charlottesville, Virginia.
Jorge A
JA
Gonzalez
Division of Cardiology, Department of Medicine, MedStar Washington Hospital Center, Washington, District of Columbia.
Michael J
MJ
Lipinski
Department of Radiology, University of Virginia Health System, Charlottesville, Virginia.
Lucia
L
Flors
Division of Cardiology, Department of Medicine, University of Virginia Health System, Charlottesville, Virginia.
Peter W
PW
Shaw
Division of Cardiology, Department of Medicine, University of Virginia Health System, Charlottesville, Virginia; Department of Radiology, University of Virginia Health System, Charlottesville, Virginia.
Christopher M
CM
Kramer
Division of Cardiology, Department of Medicine, University of Virginia Health System, Charlottesville, Virginia; Department of Radiology, University of Virginia Health System, Charlottesville, Virginia; Department of Biomedical Engineering and Cardiovascular Imaging Center, University of Virginia Health System, Charlottesville, Virginia. Electronic address: ms5pc@virginia.edu.
Michael
M
Salerno
D017023:Coronary Angiography / Q000379:methods*; D023921:Coronary Stenosis / Q000175:diagnosis*; D019317:Evidence-Based Medicine; D053805:Fractional Flow Reserve, Myocardial; D006801:Humans; D017202:Myocardial Ischemia / Q000175:diagnosis*; D011237:Predictive Value of Tests; D011379:Prognosis; D011875:Radionuclide Angiography / Q000379:methods*; D012680:Sensitivity and Specificity; D012720:Severity of Illness Index; D015899:Tomography, Emission-Computed, Single-Photon / Q000379:methods*; D014057:Tomography, X-Ray Computed / Q000379:methods*