Focus of the Report: This report focuses on fractional flow reserve (FFR), determined noninvasively via computed tomography (FFRCT), to detect coronary artery blockages, identified by coronary computed tomography angiography (CCTA), that may be responsible for myocardial ischemia in patients with known or suspected coronary artery disease (CAD).

Technology Description: FFRCT is a noninvasive alternative to FFR testing that involves computer-assisted processing of CCTA images to estimate changes in blood pressure inside coronary arteries that have partial or intermediate stenosis. By using information from CCTA to model fluid dynamics of the coronary arteries, FFRCT seeks to determine whether the stenotic lesion causes an appreciable reduction in blood flow to the heart, which may lead to myocardial ischemia or infarction, and whether the lesion can be treated medically or if it requires a percutaneous coronary intervention (PCI), such as balloon angioplasty and stenting. FFRCT is an alternative to invasive assessment of FFR that uses a pressure-sensing wire inserted into the coronary arteries. A stenosis with an FFRCT value ≥ 0.80 creates a small drop in blood pressure, has a low probability of causing inducible ischemia, and is not considered to need PCI. FFRCT is performed using already obtained CCTA images at a center equipped with the specialized software.

Controversy: FFRCT requires additional radiation exposure during CCTA. FFRCT may be less accurate than invasive FFR testing and the incidence of complications due to invasive FFR and PCI is low; these complications can usually be readily managed with no long-term consequences. In addition, PCI cannot be performed during FFRCT, which is noninvasive; therefore, patients may require an additional procedure upon identification of a clinically significant coronary artery stenosis that is not suitable for medical therapy and for which PCI is deemed appropriate.

Key Questions:

  • How accurate is FFRCT for the detection of hemodynamically significant stenosis?

  • How accurate is FFRCT relative to invasive FFR and other methods for assessment of coronary artery stenosis?

  • How accurate is FFRCT for prognosis of patients with CAD?

  • Does FFRCT provide information that can be relied on to guide management of patients who have coronary artery stenosis?

  • Is FFRCT as reliable or more reliable than invasive FFR and other noninvasive methods for guidance of patient management?

  • Is FFRCT safe?

  • Which patients might be suitable candidates for FFRCT?

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