CT CORONARY ANGIOGRAM WITH FFR CT – A REVOLUTION IN THE DIAGNOSTIC FLOW OF CORONARY ARTERY DISEASE
Abstract
Background: Within the last few years, advances in CT coronary imaging has revolutionised the diagnostic flow of suspected coronary artery disease. CT coronary angiogram has a high diagnostic accuracy and negative predictive value for diagnosis of coronary disease. Its non-invasive nature makes it a lower risk and lower cost procedure compared to conventional invasive coronary angiogram. However, there is restricted value in anatomical evaluation without input regarding the functional significance of each lesion identified with cross-sectional imaging. The gold standard to assess whether a lesion is haemodynamically significant has been the assessment of FFR (fractional flow reserve). fractional flow reserve is the ratio between maximum coronary flow in the presence of stenosis and in the hypothetical absence of stenosis. This is measured invasively by introducing a pressure wire across the lesion involving intracoronary nitro-glycerine as well as intravenous infusion of adenosine. However, the introduction of FFR CT provides information on functional significance of a lesion only using the CT data set of CT CA. Through complex non-linear equations and supercomputing, it produces a three-dimensional model of the coronary artery giving FFR values at multiple point along every major coronary vessel. It is non-invasive, involves no extra dose or contrast and does not require adenosine stress. A lesion that may appear moderate to severe on CT CA with FFR values above 0.80 can be managed by optimal medical management alone. Together FFR Ct and CTCA provide a comprehensive assessment for CAD leading to a reduction in downstream testing and unnecessary revascularisation procedures.References
Kohli A. CT FFR A paradigm shift in evaluation of coronary artery disease. Kohli A. Indian J Radiol Imaging 2019;29(3):233–5.
Motoyama S, Ito H, Sarai M, Kondo T, Kawai H, Nagahara Y, et al. Plaque Characterization by Coronary Computed Tomography Angiography and the Likelihood of Acute Coronary Events in Mid-Term Follow-Up. J Am Coll Cardiol 2015;28(4);66(4):337–46.
Park HB, Heo R, Ó Hartaigh B, Cho I, Gransar H, Nakazato R, et al. Atherosclerotic plaque characteristics by CT angiography identify coronary lesions that cause ischemia: a direct comparison to fractional flow reserve. JACC Cardiovasc Imaging 2015;8(1):1–10.
Gaur S, Øvrehus KA, Dey D, Leipsic J, Bøtker HE, Jensen JM, Narula J, et al. Coronary plaque quantification and fractional flow reserve by coronary computed tomography angiography identify ischaemia-causing lesions. Eur Heart J 2016;37(15):1220–7.
Kim HY, Lim HS, Doh JH, Nam CW, Shin ES, Koo BK, et al. Physiological severity of coronary artery stenosis depends on the amount of myocardial mass subtended by the coronary artery. JACC Cardiovasc Interv 2016;9(15):1548–60.
Kim HY, Doh JH, Lim HS, Nam CW, Shin ES, Koo BK, et al. Identification of coronary artery side branch supplying myocardial mass that may benefit from revascularization. JACC Cardiovasc Interv 2017;10(6):571–81.
Alfakih K, Byrne J, Monaghan M. CT coronary angiography: a paradigm shift for functional imaging tests. Open Heart 2018;5(1):e000754.
Patel MR, Peterson ED, Dai D, Brennan JM, Redberg RF, Anderson HV, et al. Low diagnostic yield of elective coronary angiography. N Engl J Med 2010;362(10):886–95.
Kern MJ, Lim MJ. Chapter 24: Evaluation of Myocardial and Coronary Blood Flow and Metabolism. Grossman & Bain’s Cardiac Catheterization, Angiography, and Interventions. [Internet]. 8th edition. p.505-544. [cited 2020 Jan]. Available from: https://thoracickey.com/evaluation-of-myocardial-and-coronary-blood-flow-and-metabolism/
Bech GJ, De Bruyne B, Pijls NH, de Muinck ED, Hoorntje JC, Escaned J, et al. “Fractional flow reserve to determine the appropriateness of angioplasty in moderate coronary stenosis: a randomized trial. Circulation 2001;103(24):2928–34.
Tonino PA, De Bruyne B, Pijls NH, Siebert U, Ikeno F, van' t Veer M, et al. Fractional flow reserve versus angiography for guiding percutaneous coronary intervention. N Engl J Med 2009;360(3):213–24.
De Bruyne B, Pijls NH, Kalesan B, Barbato E, Tonino PA, Piroth Z, et al. Fractional Flow Reserve-Guided PCI versus Medical Therapy in Stable Coronary Disease. N Engl J Med 2012;367(11):991–1001.
Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, et al. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. J Am Coll Cardiol 2011;58(24):e44–122.
Task Force Members, Montalescot G, Sechtem U, Achenbach S, Andreotti F, Arden C, et al. 2013 ESC guidelines on the management of stable coronary artery disease: the Task Force on the management of stable coronary artery disease of the European Society of Cardiology. Eur Heart J 2013;34(38):2949–3003.
Taylor CA, Fonte TA, Min JK. Computational fluid dynamics applied to cardiac computed tomography for noninvasive quantification of fractional flow reserve: scientific basis. J Am Coll Cardiol 2013;61(22):2233–41.
Ball C, Pontone G, Rabbat M. Fractional Flow Reserve Derived from Coronary Computed Tomography Angiography Datasets: The Next Frontier in Noninvasive Assessment of Coronary Artery Disease. Biomed Res Int 2018;2018:2680430.
Gaur S, Bezerra HG, Lassen JF, Christiansen EH, Tanaka K, Jensen JM, et al. Fractional flow reserve derived from coronary CT angiography: Variation of repeated analyses. J Cardiovasc Comput Tomogr 2014;8(4):307–14.
Nørgaard BL, Leipsic J, Gaur S, Seneviratne S, Ko BS, Ito H, 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. J Am Coll Cardiol 2014;63(12):1145–55.
Driessen RS, Danad I, Stuijfzand WJ, Raijmakers PG, Schumacher SP, van Diemen PA, et al. Comparison of coronary computed tomography angiography, fractional flow reserve, and perfusion imaging for ischemia diagnosis. J Am Coll Cardiol 2019;73(2):161–73.
Nørgaard BL, Hjort J, Gaur S, Hansson N, Bøtker HE, Leipsic J, et al. Clinical use of coronary CTA-derived FFR for decision-making in stable CAD. JACC Cardiovasc Imaging 2017;10(5):541–50.
Patel MR, Nørgaard BL, Fairbairn TA, Nieman K, Akasaka T, Berman DS, et al. 1-Year Impact on Medical Practice and Clinical Outcomes of FFRCT: The ADVANCE Registry. JACC Cardiovasc Imaging 2020;13(1 Pt 1)97–105.
Nørgaard BL, Terkelsen CJ, Mathiassen ON, Grove EL, Bøtker HE, Parner E, et al. Coronary CT angiographic and flow reserve-guided management of patients with stable ischemic heart disease. J Am Coll Cardiol 2018;72(18):2123–34.
Toth GG, Johnson NP, Jeremias A, Pellicano M, Vranckx P, Fearon WF, et al. Standardization of Fractional Flow Reserve Measurements. J Am Coll Cardiol 2016;68(7):742–53.
Kueh SH, Mooney J, Ohana M, Kim U, Blanke P, Grover R, et al. Fractional flow reservederived from coronary computed tomography angiography reclassification rate using value distal to lesion compared to lowest value. J Cardiovasc Comput Tomogr 2017;11(6):462–7.
Jensen JM, Bøtker HE, Mathiassen ON, Grove EL, Øvrehus KA, Pedersen KB, et al. Computed tomography derived fractional flow reserve testing in stable patients with typical angina pectoris: influence on downstream rate of invasive coronary angiography. Eur Heart J Cardiovasc Imaging 2018;19(4):405–14.
Nørgaard BL, Fairbairn TA, Safian RD, Rabbat MG, Ko B, Jensen JM, et al. Coronary CT Angiography derived Fractional Flow Reserve Testing in Patients with Stable Coronary Artery Disease: Recommendations on Interpretation and Reporting. Radiol Cardiothorac Imaging 2019;1(5):e190050.
Curzen NP, Nolan J, Zaman AG, Nørgaard BL, Rajani R. Does the Routine Availability of CT–Derived FFR Influence Management of Patients with Stable Chest Pain Compared to CT Angiography Alone? The FFRCT RIPCORD Study. JACC Cardiovasc Imaging 2016;9(10):1188–94.
Douglas PS, Pontone G, Hlatky MA, Patel MR, Norgaard BL, Byrne RA, et al. Clinical outcomes of fractional flow reserve by computed tomographic angiography-guided diagnostic strategies vs. usual care in patients with suspected coronary artery disease: The prospective longitudinal trial of FFR(CT): outcome and resource impacts study. Eur Heart J 2015;36(47):3359–67.
Collet C, Miyazaki Y, Ryan N, Asano T, Tenekecioglu E, Sonck J, et al. Fractional Flow Reserve derived from Computed Tomographic Angiography in patients with Multivessel CAD. J Am Coll Cardiol 2018;71(24):2756–69.
Kim KH, Doh JH, Koo BK, Min JK, Erglis A, Yang HM, et al. A novel noninvasive technology for treatment planning using virtual coronary stenting and computed tomography-derived computed fractional flow reserve. JACC Cardiovasc Interv 2014;7(1):72–8.
Downloads
Published
Issue
Section
License
Journal of Ayub Medical College, Abbottabad is an OPEN ACCESS JOURNAL which means that all content is FREELY available without charge to all users whether registered with the journal or not. The work published by J Ayub Med Coll Abbottabad is licensed and distributed under the creative commons License CC BY ND Attribution-NoDerivs. Material printed in this journal is OPEN to access, and are FREE for use in academic and research work with proper citation. J Ayub Med Coll Abbottabad accepts only original material for publication with the understanding that except for abstracts, no part of the data has been published or will be submitted for publication elsewhere before appearing in J Ayub Med Coll Abbottabad. The Editorial Board of J Ayub Med Coll Abbottabad makes every effort to ensure the accuracy and authenticity of material printed in J Ayub Med Coll Abbottabad. However, conclusions and statements expressed are views of the authors and do not reflect the opinion/policy of J Ayub Med Coll Abbottabad or the Editorial Board.
USERS are allowed to read, download, copy, distribute, print, search, or link to the full texts of the articles, or use them for any other lawful purpose, without asking prior permission from the publisher or the author. This is in accordance with the BOAI definition of open access.
AUTHORS retain the rights of free downloading/unlimited e-print of full text and sharing/disseminating the article without any restriction, by any means including twitter, scholarly collaboration networks such as ResearchGate, Academia.eu, and social media sites such as Twitter, LinkedIn, Google Scholar and any other professional or academic networking site.