Clinical practice may benefit from FFR-CT for CAD evaluations
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Available data have shown that CT-derived fractional flow reserve is effective in evaluating CAD and should be integrated into clinical practice, according to a researcher.
“Over the years, the time has come that we talk about it in this setting, efficient integration, because it’s really ready, in my opinion, to be integrated,” Jeroen J. Bax, MD, FESC, director of noninvasive imaging and of the echo-lab at Leiden University Medical Center in the Netherlands and immediate past president of the European Society of Cardiology, said during his presentation at the Society of Cardiovascular Computed Tomography Annual Scientific Meeting.
Determining best imaging approach
Although health care providers typically want to perform imaging on every patient, it may not be the best approach for all patients, Bax said during the presentation. Factors that should be considered when determining the pretest probability of CAD include age, sex and the typicality of the complaints. Dyspnea was added to the latest guideline.
“We realized that a lot of patients do not present with chest pain, but they present with dyspnea, and that is a very strong surrogate of relation to coronary artery disease,” Bax said.
All diseases have three components: anatomy, function and biology/inflammation, according to the presentation. The anatomy of CAD is plaque extent, plaque location and plaque severity, which can be accurately assessed by CTA. Information from this imaging modality can then be used to calculate the Coronary Artery Disease - Reporting and Data System (CAD-RADS) score to determine the patient’s risk.
Biology or inflammation, which focuses on plaque constitution, is often neglected, Bax said.
“We know now that patients have in the comparisons that we’ve done in the past with IVUS virtual histology in 2011 that there is calcified and noncalcified lesions and that inflammation plays a major role,” Bax said.
FFR-CT plays a role in determining the hemodynamic significance of stenosis, Bax said, noting the CT scan can be used to calculate vessel-specific FFR using anatomical 3D coronary tree models and computational fluid dynamics to simulate coronary physiology. Bax added that invasive and noninvasive FFR are complementary.
Contribution from studies
Bax said a study that made a contribution to the practical use of FFR was the ADVANCE study published in JACC: Cardiovascular Imaging in 2020, which assessed whether integrating FFR-CT as an adjunct to coronary CTA can significantly change the management of CAD in patients with stable angina. At 1 year, the event rate for CV death and MI was higher in patients with an FFR-CT of 0.8 or less compared with those with an FFR-CT greater than 0.8 (P = .0102).
Another study published this year in the Journal of Clinical Medicine found that cardiologists can safely defer patients from invasive coronary angiography when the FFR-CT is negative. If FFR-CT was positive, 14.4% of patients went for invasive coronary angiography only, 23.3% underwent PCI and 10% underwent CABG. For patients with a negative FFR-CT, 3.1% underwent invasive coronary angiography only and 1% underwent PCI.
The PLATFORM study published in the Journal of the American College of Cardiology in 2016 brings the use of FFR-CT into practice, Bax said. Integrating FFR-CT as a first-line screening tool before invasive coronary angiography can exclude many patients who do not need to go to the catheterization laboratory.
A study published in The International Journal of Cardiovascular Imaging in 2019 found that CTA and FFR-CT had the biggest area under the curve compared with other modalities to assess invasive FFR.
“That tells us at this moment in time that the CTA plus FFR-CT has the highest accuracy,” Bax said.
References:
- Douglas PS, et al. J Am Coll Cardiol. 2016;doi:10.1016/j.jacc.2016.05.057.
- Ko BS, et al. Int J Cardiovasc Imaging. 2019;doi:10.1007/s10554-019-01658-x.
- Kroner ES, et al. Am J Cardiol. 2011;doi:10.1016/j.amjcard.2011.02.337.
- Patel MR, et al. JACC Cardiovasc Imaging. 2020;doi:10.1016/j.jcmg.2019.03.003.
- Rabbat R, et al. J Clin Med. 2020;doi:10.3390/jcm9020604.
Collapse
Bax JJ. Current Topics in Stable Coronary Disease. Presented at: Society of Cardiovascular Computed Tomography Annual Scientific Meeting; July 17-18, 2020 (virtual meeting).
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