Noninvasive FFR derived from coronary CT angiography in the management of coronary artery disease: technology and clinical update

Figures & data

Figure 1 Per-vessel diagnostic performance of CT-derived FFR and CCTA stenosis to FFR ≤0.80.

Abbreviations: CT, computed tomography; FFR, fractional flow reserve; CCTA, coronary computed tomographic angiography.

Table 1 Diagnostic performance of CT-derived FFR

Authors	Patients (vessels)	Vessels with FFR <0.8	Prevalence of intermediate stenosis,%	Correlation of CT-FFR to FFR	Per-vessel
					Accuracy	Sensitivity	Specificity	Positive predictive value	Negative predict value	AUC
Three-dimensional FFRCT
Koo et al^Citation29 (DISCOVER-FLOW)	103 (159)	58 (36.5%)	43.4 (vessels)	0.68	84.3	87.9	82.2	73.9	92.2	0.90
Min et al^Citation30 (DeFACTO)	252 (407)	137 (54.4%)	36.9 (vessels)	0.63	73a	90a	54a	67a	84a	0.81a
Nørgaard et al^Citation31 (NXT)	254 (468)	135 (28%)	92.5 (patients)	0.82	86	84	86	61	95	0.9
One-dimensional cFFR
Renker et al^Citation32	53 (67)	20 (29.9%)	58 (vessels)	0.66	–	85	85	71	97	0.92
Coenen et al^Citation24	106 (189)	80 (42.3%)	76.2 (vessels)	0.59	74.6	87.5	65.1	64.8	87.7	0.83
Baumann et al^Citation33	28 (36)	–	–	0.74	–	–	–	–	–	–
Wang et al^Citation34	32 (32)	8 (25%)	–	0.75	–	100	91	75	100	0.86

Note:

a Per-patient analysis.

Abbreviations: CT, computed tomography; FFR, fractional flow reserve; AUC, area under the curve.

Figure 2 Bland-Altman Plot of FFR and FFR derived from CT.

Notes: (A) Correlation of 3D FFR_CT to FFR. Reprinted from Journal of the American College of Cardiology, Vol 63, Nørgaard BL, Leipsic J, Gaur S, et al; NXT Trial Study Group, Diagnosis of ischemia-causing coronary stenoses by noninvasive fractional flow reserve computed from coronary computed tomographic angiograms. Results from the prospective multicenter discover-flow (diagnosis of ischemia-causing stenoses obtained via noninvasive fractional flow reserve) study, Pages No. 1989–1997, Copyright (2011), with permission from Elsevier.²⁹ Reprinted from Journal of the American College of Cardiology, Vol 58/edition 19, Koo BK, Erglis A, Doh JH, et al, Diagnostic performance of noninvasive fractional flow reserve derived from coronary computed tomography angiography in suspected coronary artery disease: the NXT trial (analysis of coronary blood flow using CT angiography: next steps), Pages No. 1145–1155, Copyright (2014), with permission from Elsevier.³¹ (B) Correlation of 1D cFFR to FFR. Reprinted from The American Journal of Cardiology, Vol 114/edition 9, Renker M, Schoepf UJ, Wang R, et al, Comparison of diagnostic value of a novel noninvasive coronary computed tomography angiography method versus standard coronary angiography for assessing fractional flow reserve, Pages No. 1303–1308, Copyright (2014), with permission from Elsevier.³² Coenen et al, reprinted, with permission, from Radiology 2014;274:674–683. © RSNA.²⁴
Abbreviations: 3D, three-dimensional; FFR, fractional flow reserve; 1D, one-dimensional; CT, computed tomography; CTA, computed tomographic angiography.

Table 2 Diagnostic performance of CT-derived FFR for intermediate stenosis

Authors	Patients (vessels)	Vessels with FFR <0.8	Stenosis severity, %	Correlation to invasive FFR	AUC	Per-vessel
						Accuracy	Sensitivity	Specificity	Positive predictive value	Negative predict value
Three-dimensional FFRCT
Min et al^Citation38 (DISCOVER-FLOW)	60 (69)	32 (46.4%)	40–69	0.60	0.95	86.4	90.3	82.9	82.4	90.6
Nakazato et al^Citation39 (DeFACTO)	82 (150)	35 (23%)	30–69	0.50	0.79	71	74	67	41	90
Nørgaard et al^Citation31 (NXT)	235 (–)	–	30–70	–	–	80a	85a	79a	63a	92a
One-dimensional cFFR
Coenen et al^Citation24	(–) 144	63 (43.8%)	25–69	–	–	71.5	87.3	59.3	62.5	85.7

Note:

a Per-patient analysis.

Abbreviations: CT, computed tomography; FFR, fractional flow reserve; AUC, area under the curve.

Table 3 Image quality and CT-derived FFR

Authors	Initial patient number in the study	Exclude patients for coronary CT angiography	Exclude patients for FFRCT	Coronary calcium scores (mean ± SD)	Beta blocker, %	Nitroglycerin, %	Heart rate during the CT scan (mean ± SD: beats/minutes)	Mean total processing time for FFRCT
Three-dimensional FFRCT
Koo et al^Citation29 (DISCOVER-FLOW)	–	–	–	–	–	–	63.9±8.5	5 hours
Min et al^Citation30 (DeFACTO)	285	31 (10.9%) (nondiagnostic image quality)	0	381.5±401.0	72	75	–	–
Norgaard et al^Citation31 (NXT)	365	1 (0.3%) (atrial fibrillation)	44 (12.1%) (image artifacts)	302 (mean)	78	99.6	63±10 (range: 37–110)	1–4 hours
One-dimensional cFFR
Renker et al^Citation32	53	0	0	–	–	–	70.2±12.6	37.5±13.8 minutes
Coenen et al^Citation24	122	16 (13.1%) 10: CAC score >2,000 4: nondiagnostic image quality 2: image failure		555±542	–	100	66±13	30 minutes to 2 hours (3D coronary segmentation) 5–10 minutes (the computation)
Baumann et al^Citation33	28	0	0	539.2±601.6	–	–	71.5±12.2	51.9±9.0 minutes

Abbreviations: CT, computed tomography; FFR, fractional flow reserve; AUC, area under the curve; CAC, coronary artery calcium; 3D, three-dimensional.

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