Clinical Management Across CAD-RADS Categories in Patients with Intermediate CT-FFR

Background: Interpretation of intermediate computed tomography-derived fractional flow reserve (CT-FFR) remains uncertain. We evaluated whether Coronary Artery Disease Reporting and Data System (CAD-RADS) severity modifies the association between CT-FFR and downstream management in patients with CT-FFR 0.71-0.80. Methods: This retrospective study included 973 symptomatic patients stratified by index-vessel CAD-RADS category and CT-FFR 0.71-0.75 versus 0.76-0.80. Planned revascularization within 90 days was the primary outcome. Multivariable logistic regression assessed CT-FFR associations and interaction with CAD-RADS; major adverse cardiac and cerebrovascular events (MACCE) were exploratory. Results: Planned revascularization occurred in 39.8% versus 19.3% of patients with CT-FFR 0.71-0.75 versus 0.76-0.80 (adjusted odds ratio [OR], 2.38; 95% confidence interval [CI], 1.72-3.29; p < 0.001). Each 0.01 decrease in CT-FFR was associated with higher odds of revascularization (adjusted OR, 1.23; 95% CI, 1.15-1.32; p < 0.001). The association differed by CAD-RADS category (interaction p = 0.011), with a more pronounced association observed in CAD-RADS 3 (adjusted OR per 0.01 decrease, 1.39; 95% CI, 1.25-1.54). During a median follow-up of 384 days, 31 patients (3.2%) experienced MACCE, with no significant adjusted association with CT-FFR. Conclusions: Among patients with intermediate CT-FFR, lower values were associated with a higher likelihood of planned revascularization, and the magnitude of this association differed across CAD-RADS categories.