2019 JACC CI (Complementary role of dynamic CTP and FFRct in suspected CAD)
OBJECTIVES The aims of the study were to test the diagnostic accuracy of integrated evaluation of dynamic myocardial computed tomography perfusion (CTP) on top of coronary computed tomography angiography (cCTA) plus fractional flow reserve computed tomography derived (FFRCT) by using a whole-heart coverage computed tomography (CT) scanner as compared with clinically indicated invasive coronary angiography (ICA) and invasive fractional flow reserve (FFR). BACKGROUND Recently, new techniques such as dynamic stress computed tomography perfusion (stress-CTP) emerged as potential strategies to combine anatomical and functional evaluation in a one-shot scan. However, previous experiences with this technique were associated with high radiation exposure. METHODS Eighty-five consecutive symptomatic patients scheduled for ICA were prospectively enrolled. All patients underwent rest cCTA followed by stress dynamic CTP with a whole-heart coverage CT scanner (Revolution CT, GE Healthcare, Milwaukee, Wisconsin). FFRCT was also measured by using the rest cCTA dataset. The diagnostic accuracy to detect functionally significant coronary artery disease (CAD) in a vessel-based model of cCTA alone, cCTAþFFRCT, cCTAþCTP, or cCTAþFFRCTþCTP were assessed and compared by using ICA and invasive FFR as reference. The overall effective dose of dynamic CTP was also measured. RESULTS The prevalence of obstructive CAD and functionally significant CAD was 77% and 57%, respectively. The sensitivity and specificity of cCTA alone, cCTAþFFRCT, and cCTAþCTP were 83% and 66%, 86% and 75%, and 73% and 86%, respectively. Both the addition of FFRCT and CTP improves the area under the curve (AUC: 0.876 and 0.878, respectively) as compared with cCTA alone (0.826; p < 0.05). The sequential strategy of cCTAþFFRCTþCTP showed the highest AUC (0.919; p < 0.05) as compared with all other strategies. The mean effective radiation dose (ED) for cCTA and stress CTP was 2.8 1.2 mSv and 5.3 0.7 mSv, respectively. CONCLUSIONS The addition of dynamic stress CTP on top of cCTA and FFRCT provides additional diagnostic accuracy with acceptable radiation exposure.