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Application and Performance of CT-Fractional Flow Reserve in Non-ST-Segment Elevation Myocardial Infarction
Josephine Warren1, Luke Dawson1, Tori McCollom2
1Department of Cardiology, Alfred Hospital, Melbourne, Australia.
Insights
Computed tomography fractional flow reserve (CT-FFR) accurately rules out obstructive coronary artery disease (CAD) in myocardial infarction patients. This non-invasive method enhances diagnostic accuracy beyond standard CT angiography alone.
Area of Science:
- Cardiology
- Radiology
- Medical Imaging
Background:
- Non-ST-segment elevation myocardial infarction (NSTEMI) patients often lack obstructive coronary artery disease (CAD) on invasive angiography.
- A reliable non-invasive method to exclude obstructive CAD is needed for NSTEMI patients.
Purpose of the Study:
- To evaluate the diagnostic performance of computed tomography fractional flow reserve (CT-FFR) in NSTEMI patients.
- To compare CT-FFR accuracy against coronary computed tomography angiography (CCTA) alone and invasive methods.
Main Methods:
- Invasive coronary angiography (ICA) with fractional flow reserve (FFR) measurements served as the gold standard.
- CT-FFR was performed on coronary computed tomography angiography (CCTA) images prior to ICA in NSTEMI inpatients.
- CT-FFR and CCTA performance were assessed against ICA plus FFR for obstructive CAD detection.
Main Results:
- CT-FFR demonstrated strong correlation with invasive FFR (r=0.78).
- Per-vessel analysis showed high accuracy for CT-FFR (AUC 0.93), superior to CCTA alone (AUC 0.87).
- CT-FFR achieved 100% diagnostic accuracy on a per-patient basis.
Conclusions:
- CT-FFR significantly improves diagnostic accuracy for obstructive CAD in NSTEMI patients compared to CCTA alone.
- CT-FFR is a valuable non-invasive tool for NSTEMI evaluation, correlating well with invasive FFR.
Abstract:
Only half of patients with non-ST-segment elevation myocardial infarction (NSTEMI) have obstructive coronary artery disease (CAD) on invasive coronary angiography (ICA). A non-invasive test that can safely rule out obstructive CAD therefore warrants investigation. Computed tomography fractional flow reserve (CT-FFR) enables hemodynamic interrogation of lesions identified on coronary computed tomography angiography (CCTA) but it has not been evaluated in NSTEMI. Inpatients with NSTEMI were recruited to undergo CCTA with CT-FFR prior to ICA. Blinded CT-FFR was performed using Siemens Frontiers cFFR, version 1.4. Invasive FFR was performed on all intermediate lesions with stenoses measuring >30% to <90%. The performance of CT-FFR and CTCA was compared to the gold-standard of ICA plus FFR. Forty patients (131 vessels) were included. The mean age was 61 ± 11 years and 75% were male. CT-FFR showed good correlation with invasive FFR (r = 0.78) and exhibited excellent diagnostic accuracy for obstructive CAD (defined as FFR<0.80 or angiographic stenosis >90%) on a per-vessel analysis, with a sensitivity of 87%, specificity 99%, positive predictive value (PPV) 97%, negative predictive value (NPV) 95% and area under the receiver operating curve (AUC) 0.93, which was superior to CCTA alone (sensitivity 82%, specificity 92%, PPV 82%, NPV 92%, AUC 0.87, p-value for AUC comparison = 0.04). On a per-patient analysis, CT-FFR had a diagnostic accuracy of 100%. In conclusion, CT-FFR provides additive diagnostic accuracy to CCTA in evaluating patients with NSTEMI and exhibits good correlation with invasive FFR.
