title: Diagnostic Accuracy of Fast Computational Approaches to Derive Fractional Flow Reserve From Diagnostic Coronary Angiography: The International Multicenter FAVOR Pilot Study.
abstract: The aim of this prospective multicenter study was to identify the optimal approach for simple and fast fractional flow reserve (FFR) computation from radiographic coronary angiography, called quantitative flow ratio (QFR).
  
  
  
  A novel, rapid computation of QFR pullbacks from 3-dimensional quantitative coronary angiography was developed recently.
  
  
  
  QFR was derived from 3 flow models with: 1) fixed empiric hyperemic flow velocity (fixed-flow QFR [fQFR]); 2) modeled hyperemic flow velocity derived from angiography without drug-induced hyperemia (contrast-flow QFR [cQFR]); and 3) measured hyperemic flow velocity derived from angiography during adenosine-induced hyperemia (adenosine-flow QFR [aQFR]). Pressure wire-derived FFR, measured during maximal hyperemia, served as the reference. Separate independent core laboratories analyzed angiographic images and pressure tracings from 8 centers in 7 countries.
  
  
  
  The QFR and FFR from 84 vessels in 73 patients with intermediate coronary lesions were compared. Mean angiographic percent diameter stenosis (DS%) was 46.1 ± 8.9%; 27 vessels (32%) had FFR ≤ 0.80. Good agreement with FFR was observed for fQFR, cQFR, and aQFR, with mean differences of 0.003 ± 0.068 (p = 0.66), 0.001 ± 0.059 (p = 0.90), and -0.001 ± 0.065 (p = 0.90), respectively. The overall diagnostic accuracy for identifying an FFR of ≤0.80 was 80% (95% confidence interval [CI]: 71% to 89%), 86% (95% CI: 78% to 93%), and 87% (95% CI: 80% to 94%). The area under the receiver-operating characteristic curve was higher for cQFR than fQFR (difference: 0.04; 95% CI: 0.01 to 0.08; p < 0.01), but did not differ significantly between cQFR and aQFR (difference: 0.01; 95% CI: -0.04 to 0.06; p = 0.65). Compared with DS%, both cQFR and aQFR increased the area under the receiver-operating characteristic curve by 0.20 (p < 0.01) and 0.19 (p < 0.01). The positive likelihood ratio was 4.8, 8.4, and 8.9 for fQFR, cQFR, and aQFR, with negative likelihood ratio of 0.4, 0.3, and 0.2, respectively.
  
  
  
  The QFR computation improved the diagnostic accuracy of 3-dimensional quantitative coronary angiography-based identification of stenosis significance. The favorable results of cQFR that does not require pharmacologic hyperemia induction bears the potential of a wider adoption of FFR-based lesion assessment through a reduction in procedure time, risk, and costs.
authors.affiliation: Biomedical Instrument Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China. Electronic address: sxtu@sjtu.edu.cn.
authors.forename: Shengxian
authors.initials: S
authors.lastname: Tu
authors.affiliation: Department of Cardiology, Aarhus University Hospital, Skejby, Denmark.
authors.forename: Jelmer
authors.initials: J
authors.lastname: Westra
authors.affiliation: Department of Cardiology, Guangdong General Hospital, Guangzhou, China.
authors.forename: Junqing
authors.initials: J
authors.lastname: Yang
authors.affiliation: Department of Cardiology, Thoraxcentrum Twente, Medisch Spectrum Twente, and Health Technology and Services Research, MIRA Institute, University of Twente, Enschede, the Netherlands.
authors.forename: Clemens
authors.initials: C
authors.lastname: von Birgelen
authors.affiliation: Cardiovascular Research Centre, OLV Hospital, Aalst, Belgium.
authors.forename: Angela
authors.initials: A
authors.lastname: Ferrara
authors.affiliation: Cardiovascular Research Centre, OLV Hospital, Aalst, Belgium; Department of Advanced Biomedical Sciences, University of Naples, Federico II, Naples, Italy.
authors.forename: Mariano
authors.initials: M
authors.lastname: Pellicano
authors.affiliation: Department of Cardiology and Angiology, University of Giessen, Giessen, Germany.
authors.forename: Holger
authors.initials: H
authors.lastname: Nef
authors.affiliation: Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Ferrara, Italy.
authors.forename: Matteo
authors.initials: M
authors.lastname: Tebaldi
authors.affiliation: Department of Cardiology, Clinical Research Center, Kyushu Medical Center, Fukuoka, Japan.
authors.forename: Yoshinobu
authors.initials: Y
authors.lastname: Murasato
authors.affiliation: Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut.
authors.forename: Alexandra
authors.initials: A
authors.lastname: Lansky
authors.affiliation: Cardiovascular Research Centre, OLV Hospital, Aalst, Belgium; Department of Advanced Biomedical Sciences, University of Naples, Federico II, Naples, Italy.
authors.forename: Emanuele
authors.initials: E
authors.lastname: Barbato
authors.affiliation: Department of Cardiology, Thoraxcentrum Twente, Medisch Spectrum Twente, and Health Technology and Services Research, MIRA Institute, University of Twente, Enschede, the Netherlands.
authors.forename: Liefke C
authors.initials: LC
authors.lastname: van der Heijden
authors.affiliation: Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands.
authors.forename: Johan H C
authors.initials: JHC
authors.lastname: Reiber
authors.affiliation: Department of Cardiology, Aarhus University Hospital, Skejby, Denmark.
authors.forename: Niels R
authors.initials: NR
authors.lastname: Holm
authors.affiliation: Cardiovascular Research Centre, OLV Hospital, Aalst, Belgium; The Lambe Institute for Translational Medicine and Curam, National University of Ireland, Galway, and Saolta University Healthcare Group, Galway, Ireland.
authors.forename: William
authors.initials: W
authors.lastname: Wijns
mesh_terms: D000241:Adenosine / Q000008:administration & dosage; D061605:Administration, Intravenous; D000368:Aged; D019540:Area Under Curve; D001783:Blood Flow Velocity; D006328:Cardiac Catheterization; D002681:China; D003198:Computer Simulation; D017023:Coronary Angiography; D023921:Coronary Stenosis / Q000000981:diagnostic imaging* / Q000503:physiopathology; D003331:Coronary Vessels / Q000000981:diagnostic imaging* / Q000503:physiopathology; D005060:Europe; D005240:Feasibility Studies; D005260:Female; D053805:Fractional Flow Reserve, Myocardial; D006801:Humans; D006940:Hyperemia / Q000503:physiopathology; D007564:Japan; D008297:Male; D008875:Middle Aged; D008955:Models, Cardiovascular; D055414:Myocardial Perfusion Imaging / Q000379:methods*; D010865:Pilot Projects; D011237:Predictive Value of Tests; D011379:Prognosis; D011446:Prospective Studies; D012372:ROC Curve; D011857:Radiographic Image Interpretation, Computer-Assisted / Q000379:methods*; D012039:Regional Blood Flow; D015203:Reproducibility of Results; D012720:Severity of Illness Index; D013997:Time Factors; D014481:United States; D014665:Vasodilator Agents / Q000008:administration & dosage; D057188:Workflow
chemical_list: D014665:Vasodilator Agents; D000241:Adenosine
keywords: cardiovascular physiology; fractional flow reserve; quantitative coronary angiography