Fractional Flow Reserve Derived from Coronary Computed Tomography Angiography Safely Defers Invasive Coronary Angiography in Patients with Stable Coronary Artery Disease

Objectives: In the United States, the real-world feasibility and outcome of using fractional flow reserve from coronary computed tomography angiography (FFR(CT)) is unknown. We sought to determine whether a strategy that combined coronary computed tomography angiography (CTA) and FFR(CT) could safely reduce the need for invasive coronary angiography (ICA), as compared to coronary CTA alone. Methods: The study included 387 consecutive patients with suspected CAD referred for coronary CTA with selective FFR(CT) and 44 control patients who underwent CTA alone. Lesions with 30–90% diameter stenoses were considered of indeterminate hemodynamic significance and underwent FFR(CT). Nadir FFR(CT) ≤ 0.80 was positive. The rate of patients having ICA, revascularization and major adverse cardiac events were recorded. Results: Using coronary CTA and selective FFR(CT), 121 patients (32%) had at least one vessel with ≥50% diameter stenosis; 67/121 (55%) patients had at least one vessel with FFR(CT) ≤ 0.80; 55/121 (45%) underwent ICA; and 34 were revascularized. The proportion of ICA patients undergoing revascularization was 62% (34 of 55). The number of patients with vessels with 30–50% diameter of stenosis was 90 (23%); 28/90 (31%) patients had at least one vessel with FFR(CT) ≤ 0.80; 8/90 (9%) underwent ICA; and five were revascularized. In our institutional practice, compared to coronary CTA alone, coronary CTA with selective FFR(CT) reduced the rates of ICA (45% vs. 80%) for those with obstructive CAD. Using coronary CTA with selective FFR(CT), no major adverse cardiac events occurred over a mean follow-up of 440 days. Conclusion: FFR(CT) safely deferred ICA in patients with CAD of indeterminate hemodynamic significance. A high proportion of those who underwent ICA were revascularized.