Dawn of new era: Diagnostic Accuracy of Fractional Flow Reserve - Computed Tomography in progressive coronary artery disease
Presenter
Saad Ur Rahman, MBBS, Carle Foundation Hospital, Urbana, IL
Saad Ur Rahman, MBBS1, Krishna Prasad Kurpad, MBBS2, Muhammad Umair Rana, MBBS1 and Ahmad Shihabi, MD FACC2, (1)Carle Foundation Hospital, Urbana, IL, (2)Carle Heart and Vascular Institute, Urbana, IL
Learning Objectives:
- get a better understanding of Computed Tomography Fractional Flow reserve.
- realize the importance of early utilization of CT-FFR and other non-invasive imaging before moving forward with invasive coronary angiography
Keywords: Acute Coronary Syndromes (ACS), Coronary, Drug-eluting Stent (DES), Imaging & Physiology and Stable Ischemic Heart Disease (SIHD)
Introduction: Fractional flow reserve derived from coronary computed tomography (FFRCT) is a non-invasive technique that has high sensitivity and specificity to assess underlying coronary artery disease (CAD) progression. It also has excellent long-term prognostic value to suggest the absence of CAD. We present a good learning case where the utilization of FFRCT provided an excellent estimation of progressive CAD leading to guideline-directed early management and positive outcomes. Clinical Case: A 38-year-old male presented to the hospital with atypical chest pain for the last 2 days. Lab work including troponin levels and electrocardiogram (EKG) was unremarkable. FFRCT showed non-calcified plaque in the proximal to mid-left anterior descending (LAD) artery with a calcium score of zero and a non-hemodynamically significant lesion of 0.83. The patient was recommended aggressive risk factor modification with smoking cessation and guideline-directed management. He remained non-compliant with these recommendations. After one year, he came back to the hospital for exertional chest pain. His lab work and EKG were again unremarkable. Another FFRCT was requested which continued to show a non-calcified plaque in the same region with a calcium score of zero but progression of stenosis in LAD with an FFRCT value indicating hemodynamically significant stenosis at 0.72. Intravascular ultrasound (IVUS) showed cross-sectional area stenosis > 75% and a lumen cross-sectional area of 3.2 mm2. A coronary angiogram was ordered that confirmed stenosis of 80% in the region of mid-LAD which was treated with the placement of a drug-eluting stent. Discussion: FFRCT analysis provides valuable information regarding flow and pressure across the entire coronary tree and standardized criteria for interpretation. Lesions greater than 0.80 are usually considered hemodynamically insignificant and the patient can be safely treated with optimal medical treatment. Those ranging between 0.76 and 0.80 require additional risk stratification. Any value less than 0.76 provides evidence of high-risk anatomy with significant stenosis requiring further invasive angiography.