title: Fractional Flow Reserve and Coronary Computed Tomographic Angiography: A Review and Critical Analysis.
abstract: Invasive fractional flow reserve (FFR) is now the gold standard for intervention. Noninvasive functional imaging analyses derived from coronary computed tomographic angiography (CTA) offer alternatives for evaluating lesion-specific ischemia. CT-FFR, CT myocardial perfusion imaging, and transluminal attenuation gradient/corrected contrast opacification have been studied using invasive FFR as the gold standard. CT-FFR has demonstrated significant improvement in specificity and positive predictive value compared with CTA alone for predicting FFR of ≤0.80, as well as decreasing the frequency of nonobstructive invasive coronary angiography. High-risk plaque characteristics have also been strongly implicated in abnormal FFR. Myocardial computed tomographic perfusion is an alternative method with promising results; it involves more radiation and contrast. Transluminal attenuation gradient/corrected contrast opacification is more controversial and may be more related to vessel diameter than stenosis. Important considerations remain: (1) improvement of CTA quality to decrease unevaluable studies, (2) is the diagnostic accuracy of CT-FFR sufficient? (3) can CT-FFR guide intervention without invasive FFR confirmation? (4) what are the long-term outcomes of CT-FFR-guided treatment and how do they compare with other functional imaging-guided paradigms? (5) what degree of stenosis on CTA warrants CT-FFR? (6) how should high-risk plaque be incorporated into treatment decisions? (7) how will CT-FFR influence other functional imaging test utilization, and what will be the effect on the practice of cardiology? (8) will a workstation-based CT-FFR be mandatory? Rapid progress to date suggests that CTA-based lesion-specific ischemia will be the gatekeeper to the cardiac catheterization laboratory and will transform the world of intervention.
authors.affiliation: From the Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York (H.S.H., J.N.); Department of Cardiology, Stanford University School of Medicine, CA (W.F.F.). harvey.hecht@mountsinai.org.
authors.forename: Harvey S
authors.initials: HS
authors.lastname: Hecht
authors.affiliation: From the Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York (H.S.H., J.N.); Department of Cardiology, Stanford University School of Medicine, CA (W.F.F.).
authors.forename: Jagat
authors.initials: J
authors.lastname: Narula
authors.affiliation: From the Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York (H.S.H., J.N.); Department of Cardiology, Stanford University School of Medicine, CA (W.F.F.).
authors.forename: William F
authors.initials: WF
authors.lastname: Fearon
mesh_terms: D000072226:Computed Tomography Angiography / Q000379:methods*; D017023:Coronary Angiography / Q000379:methods*; D023921:Coronary Stenosis / Q000000981:diagnostic imaging* / Q000503:physiopathology*; D053805:Fractional Flow Reserve, Myocardial / Q000502:physiology*; D006801:Humans; D055414:Myocardial Perfusion Imaging / Q000379:methods; D016032:Randomized Controlled Trials as Topic / Q000379:methods
keywords: atherosclerotic plaque; cardiac catheterization; coronary angiography; myocardial perfusion imaging; sensitivity and specificity