Noninvasive FFR Derived From Coronary CT Angiography: Management and Outcomes in the PROMISE Trial

Abstract Objectives The purpose of this study was to determine whether noninvasive fractional flow reserve derived from computed tomography (FFR CT ) predicts coronary revascularization and outcomes and whether its addition improves efficiency of referral to invasive coronary angiography (ICA) after coronary computed tomography angiography (CTA). Background FFR CT may improve the efficiency of an anatomic CTA strategy for stable chest pain. Methods This observational cohort study included patients with stable chest pain in the PROMISE trial (PROspective Multicenter Imaging Study for Evaluation of Chest Pain) referred to ICA within 90 days after CTA. FFR CT was measured at a blinded core laboratory, and FFR CT results were unavailable to caregivers. We determined the agreement of FFR CT (positive if ≤0.80) with stenosis on CTA and ICA (positive if ≥50% left main or ≥70% other coronary artery), and predictive value for a composite of coronary revascularization or major adverse cardiac events (death, myocardial infarction, or unstable angina). We retrospectively assessed whether adding FFR CT  ≤0.80 as a gatekeeper could improve efficiency of referral to ICA, defined as decreased rate of ICA without ≥50% stenosis and increased ICA leading to revascularization. Results FFR CT was calculated in 67% (181/271) of eligible patients (mean age 62 years; 36% women). FFR CT was discordant with stenosis in 31% (57/181) for CTA and 29% (52/181) for ICA. Most patients undergoing coronary revascularization had an FFR CT of ≤0.80 (91%; 80/88). An FFR CT of ≤0.80 was a significantly better predictor for revascularization or major adverse cardiac events than severe CTA stenosis (HR: 4.3 [95% confidence interval [CI]: 2.4 to 8.9] vs. 2.9 [95% CI: 1.8 to 5.1]; p = 0.033). Reserving ICA for patients with an FFR CT of ≤0.80 could decrease ICA without ≥50% stenosis by 44%, and increase the proportion of ICA leading to revascularization by 24%. Conclusions In this hypothesis-generating study of patients with stable chest pain referred to ICA from CTA, an FFR CT of ≤0.80 was a better predictor of revascularization or major adverse cardiac events than severe stenosis on CTA. Adding FFR CT may improve efficiency of referral to ICA from CTA alone.