Clinical use of coronary computed tomography angiography-derived fractional flow reserve: expert consensus by an...

Coronary computed tomography angiography (CCTA)-derived fractional flow reserve (CT-FFR) has emerged as a critical tool for assessing functional ischemia in coronary artery disease (CAD). This expert consensus, developed by an international working group, provides a comprehensive overview of the clinical applications, diagnostic performance, and future perspectives of CT-FFR.

The consensus highlights the use of CT-FFR as an indicator for abnormal coronary physiology, demonstrating superior diagnostic performance over anatomical CCTA alone, with pooled accuracy of 71%-91%, sensitivity of 76%-98% and specificity of 61%-94% at the per-vessel level, particularly in intermediate lesions. It also addresses factors influencing CT-FFR's diagnostic performance, including technical, physiological, and measurement-related considerations. The document discusses the role of CT-FFR in decision-making, serving as a gatekeeper for invasive coronary angiography (ICA) and aiding in percutaneous coronary intervention (PCI) planning. Additionally, CT-FFR shows promise as a prognostic marker, with lower CT-FFR values associated with a higher risk of major adverse cardiovascular events (MACE). Economic evaluations indicate that CT-FFR is cost-effective compared to traditional non-invasive strategies. The consensus also explores the application of CT-FFR in complex lesions and non-atherosclerotic diseases, such as myocardial bridging and anomalous aortic origin of coronary arteries. Future directions include the development of more accurate CT-FFR approaches and the exploration of CT-FFR-based risk stratification.

This consensus aims to provide guidance for radiologists, cardiologists, and other healthcare professionals, promoting the standardized and evidence-based use of CT-FFR in clinical practice.

Question Inconsistent implementation and evidence gap of CT-derived fractional flow reserve need an international consensus to optimize functional assessment of coronary artery disease and downstream management. Findings This consensus standardizes CT-derived fractional flow reserve application, validating its diagnostic performance (accuracy 71%-91%, sensitivity 76%-98%, specificity 61%-94%), utility in guiding revascularization, and prognostic value. Clinical relevance Standardized CT-derived fractional flow reserve use can optimize patient management by effectively reducing unnecessary invasive coronary angiography, guiding targeted revascularization, and improving risk prediction based on lesion-specific physiology.