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Anatomical and Functional Computed Tomography for Diagnosing Hemodynamically Significant Coronary Artery Disease: A
Csilla Celeng1, Tim Leiner1, Pál Maurovich-Horvat2
1Department of Radiology, University Medical Center Utrecht, Utrecht, the Netherlands.
Insights
CT myocardial perfusion (CTP) and fractional flow reserve CT (FFRCT) significantly improve the detection of hemodynamically significant coronary artery disease (CAD) compared to CT angiography (CTA). Integrating CTP and FFRCT into clinical workflows is recommended for better patient management.
Area of Science:
- Cardiovascular Imaging
- Radiology
- Diagnostic Performance
Background:
- Coronary computed tomography (CT) angiography (CTA) provides anatomical detail but limited functional information for coronary artery disease (CAD).
- Emerging CT-based functional techniques aim to assess the hemodynamic significance of CAD.
Purpose of the Study:
- To determine the diagnostic performance of various CT techniques for detecting hemodynamically significant CAD.
- To compare coronary computed tomography (CT) angiography (CTA), CT myocardial perfusion (CTP), fractional flow reserve CT (FFRCT), and transluminal attenuation gradient (TAG) against fractional flow reserve (FFR) as the reference standard.
Main Methods:
- A meta-analysis adhering to PRISMA guidelines was conducted.
- Searches of PubMed, EMBASE, and Web of Science were performed up to September 7, 2017.
- Bayesian random effects analysis was used to calculate pooled sensitivity, specificity, and diagnostic accuracy at vessel and patient levels.
Main Results:
- Fifty-four articles involving 5,330 patients were included.
- CTP (0.86) and FFRCT (0.78) demonstrated substantially higher pooled specificity than CTA (0.61) at the vessel level.
- Combining CTA with FFRCT, CTP, or TAG resulted in high to excellent specificities (0.80–0.92), with superior diagnostic accuracy for CTP and FFRCT compared to CTA alone.
Conclusions:
- CT myocardial perfusion (CTP) and fractional flow reserve CT (FFRCT) significantly improve the identification of hemodynamically significant coronary artery disease (CAD).
- Integration of CTP and FFRCT into clinical workflows is recommended for guiding revascularization decisions.
Objectives:
This meta-analysis determined the diagnostic performance of coronary computed tomography (CT) angiography (CTA), CT myocardial perfusion (CTP), fractional flow reserve CT (FFRCT), the transluminal attenuation gradient (TAG), and their combined use with CTA versus FFR as a reference standard for detection of hemodynamically significant coronary artery disease (CAD).
Background:
CTA provides excellent anatomic, albeit limited functional information for the evaluation of CAD. Recently, various functional CT techniques emerged to assess the hemodynamic consequences of CAD.
Methods:
This meta-analysis was performed in adherence to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. PubMed, EMBASE, and Web of Science were searched from inception until September 7, 2017. Bayesian random effects analysis was used to compute pooled sensitivity, specificity, and the summary receiver-operating characteristic curve of the index tests and compare them with the FFR as a reference standard. Analyses were performed on vessel and patient levels. Because CTA has excellent sensitivity, specificity was considered most relevant. Individual FFRCT values were collected.
Results:
Overall, 54 articles and 5,330 patients were included. At vessel level, pooled specificity of CTP (0.86; 95% confidence interval [CI]: 0.76 to 0.93), FFRCT (0.78; 95% CI: 0.72 to 0.83) and TAG (0.77; 95% CI: 0.61 to 0.89) were substantially higher than that of CTA (0.61; 95% CI: 0.54 to 0.68). The addition of FFRCT, CTP, and TAG to CTA resulted in high to excellent specificities (0.80 to 0.92). The summary receiver-operating characteristic curve at vessel level yielded superior diagnostic accuracy for CTP, FFRCT, and combined CTA and CTP, compared with CTA. A subanalysis of on-site versus off-site FFRCT revealed no substantial differences between the sensitivity (0.84 vs. 0.85) and specificity (0.80 vs. 0.73) of the 2 techniques. In a second subanalysis, dynamic CTP showed higher sensitivity (0.85 vs. 0.72), but had a lower specificity (0.81 vs. 0.90) than static CTP.
Conclusions:
CTP and FFRCT demonstrated a substantial improvement in the identification of hemodynamically significant CAD compared with CTA; therefore, their integration to clinical workflow before revascularization is recommended.
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