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    Diagnostic performance of noninvasive fractional flow reserve derived from coronary computed tomography angiography in ischemia-causing coronary stenosis: a meta-analysis. Ding Aimin,Qiu Guoqing,Lin Wensheng,Hu Ling,Lu Guangliang,Long Xiang,Hong Xin,Chen Yaohua,Luo Xiaoping,Tang Qinqin,Deng Dongqin Japanese journal of radiology PURPOSE:Fractional flow reserve based on coronary computed tomographic angiography (CCTA; FFR) can evaluate functional severity in coronary artery disease (CAD). This study investigated the diagnostic value of FFR for determining CAD severity. MATERIALS AND METHODS:Medline, Cochrane, EMBASE, and Google Scholar databases were searched until June 16, 2016 using the following search terms: fractional flow reserve, coronary computed tomography angiography, myocardial ischemia. Randomized controlled trials, two-arm prospective studies, and retrospective studies were included in the analysis. RESULTS:Twenty-one studies were included with a total of 2216 subjects and 2798 vessels. FFR, sensitivity per-vessel and per-patient were ≥82% and specificity was ≥73% for diagnosis of ischemia. FFR had better diagnostic accuracy and discrimination than CCTA. CONCLUSION:This study indicates that FFR may be a good tool for screening and diagnosing of myocardial ischemia in patients with CAD. 10.1007/s11604-016-0589-4
    Fractional flow reserve using computed tomography for assessing coronary artery disease: a meta-analysis. Panchal Hemang B,Veeranki Sreenivas P,Bhatheja Samit,Barry Neil,Mahmud Ehtisham,Budoff Matthew,Lavine Steven J,Mamudu Hadii M,Paul Timir K Journal of cardiovascular medicine (Hagerstown, Md.) AIMS:Noninvasive fractional flow reserve (FFR) measurement with computed tomography (FFRCT) is a newly described method for assessing functional significance of coronary disease. The objective of this meta-analysis is to determine the diagnostic performance of FFRCT in the assessment of hemodynamically significant coronary artery stenosis. METHODS:PubMed and the Cochrane Center Register of Controlled Trials were searched from January 2000 through February 2015. Six original studies were found comparing FFRCT to invasive FFR in evaluating hemodynamic significance of coronary lesions (1354 vessels; 812 patients). Lesions were considered hemodynamically significant if invasive FFR was 0.80 or less. FFRCT used the same cutoff as invasive FFR to be considered as a positive test. Sensitivity, specificity, positive and negative likelihood ratios, and diagnostic odds ratio were calculated. RESULTS:One-third of the lesions (n = 443) were hemodynamically significant. The pooled per-vessel analysis showed that the sensitivity, specificity, negative and positive likelihood ratios, and diagnostic odds ratio of FFRCT to diagnose hemodynamically significant coronary disease were 0.84 [95% confidence interval (CI): 0.80-0.87], 0.76 (95% CI: 0.73-0.79), 0.22 (95% CI: 0.17-0.29), 3.48 (95% CI: 2.21-5.47), and 16.82 (95% CI: 8.20-34.49), respectively. CONCLUSION:The results of this meta-analysis demonstrate that FFRCT results correlate closely with invasive coronary angiography and FFR measurement. It is a feasible noninvasive method to assess hemodynamic significance of coronary lesions in patients with stable coronary artery disease. 10.2459/JCM.0000000000000415
    Combined diagnostic performance of coronary computed tomography angiography and computed tomography derived fractional flow reserve for the evaluation of myocardial ischemia: A meta-analysis. Tan Xiao Wei,Zheng Qishi,Shi Luming,Gao Fei,Allen John Carson,Coenen Adriaan,Baumann Stefan,Schoepf U Joseph,Kassab Ghassan S,Lim Soo Teik,Wong Aaron Sung Lung,Tan Jack Wei Chieh,Yeo Khung Keong,Chin Chee Tang,Ho Kay Woon,Tan Swee Yaw,Chua Terrance Siang Jin,Chan Edwin Shih Yen,Tan Ru San,Zhong Liang International journal of cardiology BACKGROUND:To evaluate the combined diagnostic accuracy of coronary computed tomography angiography (CCTA) and computed tomography derived fractional flow reserve (FFRct) in patients with suspected or known coronary artery disease (CAD). METHODS:PubMed, The Cochrane library, Embase and OpenGray were searched to identify studies comparing diagnostic accuracy of CCTA and FFRct. Diagnostic test measurements of FFRct were either extracted directly from the published papers or calculated from provided information. Bivariate models were conducted to synthesize the diagnostic performance of combined CCTA and FFRct at both "per-vessel" and "per-patient" levels. RESULTS:7 articles were included for analysis. The combined diagnostic outcomes from "both positive" strategy, i.e. a subject was considered as "positive" only when both CCTA and FFRct were "positive", demonstrated relative high specificity (per-vessel: 0.91; per-patient: 0.81), high positive likelihood ratio (LR+, per-vessel: 7.93; per-patient: 4.26), high negative likelihood ratio (LR-, per-vessel: 0.30; per patient: 0.24) and high accuracy (per-vessel: 0.91; per-patient: 0.81) while "either positive" strategy, i.e. a subject was considered as "positive" when either CCTA or FFRct was "positive", demonstrated relative high sensitivity (per-vessel: 0.97; per-patient: 0.98), low LR+ (per-vessel: 1.50; per-patient: 1.17), low LR- (per-vessel: 0.07; per-patient: 0.09) and low accuracy (per-vessel: 0.57; per-patient: 0.54). CONCLUSION:"Both positive" strategy showed better diagnostic performance to rule in patients with non-significant stenosis compared to "either positive" strategy, as it efficiently reduces the proportion of testing false positive subjects. 10.1016/j.ijcard.2017.02.053
    Diagnostic performance of cardiac imaging methods to diagnose ischaemia-causing coronary artery disease when directly compared with fractional flow reserve as a reference standard: a meta-analysis. Danad Ibrahim,Szymonifka Jackie,Twisk Jos W R,Norgaard Bjarne L,Zarins Christopher K,Knaapen Paul,Min James K European heart journal Aims:The aim of this study was to determine the diagnostic performance of single-photon emission computed tomography (SPECT), stress echocardiography (SE), invasive coronary angiography (ICA), coronary computed tomography angiography (CCTA), fractional flow reserve (FFR) derived from CCTA (FFRCT), and cardiac magnetic resonance (MRI) imaging when directly compared with an FFR reference standard. Method and results:PubMed and Web of Knowledge were searched for investigations published between 1 January 2002 and 28 February 2015. Studies performing FFR in at least 75% of coronary vessels for the diagnosis of ischaemic coronary artery disease (CAD) were included. Twenty-three articles reporting on 3788 patients and 5323 vessels were identified. Meta-analysis was performed for pooled sensitivity, specificity, likelihood ratios (LR), diagnostic odds ratio, and summary receiver operating characteristic curves. In contrast to ICA, CCTA, and FFRCT reports, studies evaluating SPECT, SE, and MRI were largely retrospective, single-centre and with generally smaller study samples. On a per-patient basis, the sensitivity of CCTA (90%, 95% CI: 86-93), FFRCT (90%, 95% CI: 85-93), and MRI (90%, 95% CI: 75-97) were higher than for SPECT (70%, 95% CI: 59-80), SE (77%, 95% CI: 61-88), and ICA (69%, 95% CI: 65-75). The highest and lowest per-patient specificity was observed for MRI (94%, 95% CI: 79-99) and for CCTA (39%, 95% CI: 34-44), respectively. Similar specificities were noted for SPECT (78%, 95% CI: 68-87), SE (75%, 95% CI: 63-85), FFRCT (71%, 95% CI: 65-75%), and ICA (67%, 95% CI: 63-71). On a per-vessel basis, the highest sensitivity was for CCTA (pooled sensitivity, 91%: 88-93), MRI (91%: 84-95), and FFRCT (83%, 78-87), with lower sensitivities for ICA (71%, 69-74), and SPECT (57%: 49-64). Per-vessel specificity was highest for MRI (85%, 79-89), FFRCT (78%: 78-81), and SPECT (75%: 69-80), whereas ICA (66%: 64-68) and CCTA (58%: 55-61) yielded a lower specificity. Conclusions:In this meta-analysis comparing cardiac imaging methods directly to FFR, MRI had the highest performance for diagnosis of ischaemia-causing CAD, with lower performance for SPECT and SE. Anatomic methods of CCTA and ICA yielded lower specificity, with functional assessment of coronary atherosclerosis by SE, SPECT, and FFRCT improving accuracy. 10.1093/eurheartj/ehw095
    Anatomical and Functional Computed Tomography for Diagnosing Hemodynamically Significant Coronary Artery Disease: A Meta-Analysis. Celeng Csilla,Leiner Tim,Maurovich-Horvat Pál,Merkely Béla,de Jong Pim,Dankbaar Jan W,van Es Hendrik W,Ghoshhajra Brian B,Hoffmann Udo,Takx Richard A P JACC. Cardiovascular imaging OBJECTIVES:This meta-analysis determined the diagnostic performance of coronary computed tomography (CT) angiography (CTA), CT myocardial perfusion (CTP), fractional flow reserve CT (FFR), the transluminal attenuation gradient (TAG), and their combined use with CTA versus FFR as a reference standard for detection of hemodynamically significant coronary artery disease (CAD). BACKGROUND:CTA provides excellent anatomic, albeit limited functional information for the evaluation of CAD. Recently, various functional CT techniques emerged to assess the hemodynamic consequences of CAD. METHODS:This meta-analysis was performed in adherence to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. PubMed, EMBASE, and Web of Science were searched from inception until September 7, 2017. Bayesian random effects analysis was used to compute pooled sensitivity, specificity, and the summary receiver-operating characteristic curve of the index tests and compare them with the FFR as a reference standard. Analyses were performed on vessel and patient levels. Because CTA has excellent sensitivity, specificity was considered most relevant. Individual FFR values were collected. RESULTS:Overall, 54 articles and 5,330 patients were included. At vessel level, pooled specificity of CTP (0.86; 95% confidence interval [CI]: 0.76 to 0.93), FFR (0.78; 95% CI: 0.72 to 0.83) and TAG (0.77; 95% CI: 0.61 to 0.89) were substantially higher than that of CTA (0.61; 95% CI: 0.54 to 0.68). The addition of FFR CTP, and TAG to CTA resulted in high to excellent specificities (0.80 to 0.92). The summary receiver-operating characteristic curve at vessel level yielded superior diagnostic accuracy for CTP, FFR, and combined CTA and CTP, compared with CTA. A subanalysis of on-site versus off-site FFR revealed no substantial differences between the sensitivity (0.84 vs. 0.85) and specificity (0.80 vs. 0.73) of the 2 techniques. In a second subanalysis, dynamic CTP showed higher sensitivity (0.85 vs. 0.72), but had a lower specificity (0.81 vs. 0.90) than static CTP. CONCLUSIONS:CTP and FFR demonstrated a substantial improvement in the identification of hemodynamically significant CAD compared with CTA; therefore, their integration to clinical workflow before revascularization is recommended. 10.1016/j.jcmg.2018.07.022
    Additional diagnostic value of new CT imaging techniques for the functional assessment of coronary artery disease: a meta-analysis. Hamon Michèle,Geindreau Damien,Guittet Lydia,Bauters Christophe,Hamon Martial European radiology OBJECTIVES:To determine the diagnostic performance of cardiac computed tomography (CT)-based modalities including coronary CT angiography (CTA), stress myocardial CT perfusion (stress CTP), computer simulation of fractional flow reserve by CT (FFR), and transluminal attenuation gradients (TAG), for the diagnosis of hemodynamic significant coronary artery disease (CAD), using invasive fractional flow reserve as the reference standard. METHODS:PubMed and Cochrane databases were searched for original articles until July 2018. Diagnostic accuracy results were pooled at per-patient and per-vessel level using random effect models. RESULTS:Fifty articles were included in the meta-analysis (3024 subjects). The per-patient analysis per imaging modality demonstrated a pooled positive likelihood ratio (PLR) of 1.78 (95% confidence interval CI 1.49-2.11), 4.58 (95% CI 3.54-5.91), and 3.45 (95% CI 2.38-5.00) for CTA, stress CTP, and FFR respectively. Per-patient specificity of stress CTP (82%, 95% CI 76-86) and FFR (72%, 95% CI 68-76) were higher than for CTA (48%, 95% CI 44-51). At the vessel level, PLR was 2.42 (95% CI 1.93-3.02), 7.72 (95% CI 5.50-10.83), 3.50 (95% CI 2.73-4.78), 1.97 (95% CI 1.32-2.93) for CTA, stress CTP, FFR, and TAG respectively. CONCLUSION:With improved PLR and specificity, stress CTP and FFR have incremental value over CTA for the detection of functionally significant CAD. KEY POINTS:• New functional CT imaging techniques, such as stress CTP and FFR, improve diagnostic accuracy of coronary CTA to predict hemodynamically relevant stenosis. • TAG yields poor diagnostic performance. • Combination of CTA and some functional CT techniques (stress CTP and FFR) might become a "must" to improve diagnostic accuracy of CAD and to reduce unnecessary invasive coronary angiography. 10.1007/s00330-018-5919-8
    Computed tomography angiography-derived fractional flow reserve (CT-FFR) for the detection of myocardial ischemia with invasive fractional flow reserve as reference: systematic review and meta-analysis. Zhuang Baiyan,Wang Shuli,Zhao Shihua,Lu Minjie European radiology OBJECTIVES:A method named computed tomography angiography-derived fractional flow reserve (FFR) is an alternative method for detecting hemodynamically significant coronary stenosis. We carried out a meta-analysis to derive reliable assessment of the diagnostic performances of FFR and compare the diagnostic accuracy with CCTA using FFR as reference. METHODS:We searched PubMed, EMBASE, The Cochrane Library, and Web of science for relevant articles published from January 2008 until May 2019 using the following search terms: FFR, noninvasive FFR, non-invasive FFR, noninvasive fractional flow reserve, non-invasive fractional flow reserve, and CCTA. Pooled estimates of sensitivity and specificity with the corresponding 95% confidence intervals (CIs) and the summary receiver operating characteristic curve (sROC) were determined. RESULTS:Sixteen studies published between 2011 and 2019 were included with a total of 1852 patients and 2731 vessels. The pooled sensitivity and specificity for FFR at the per-patient level was 89% (95% CI, 85-92%) and 71% (95% CI, 61-80%), respectively, while on the per-vessel basis was 85% (95% CI, 82-88%) and 82% (95% CI, 75-87%), respectively. No apparent difference in the sensitivity at per-patient and per-vessel level between FFR and CCTA was observed (0.89 versus 0.93 at per-patient; 0.85 versus 0.88 at per-vessel). However, the specificity of FFR was higher than CCTA (0.71 versus 0.32 at per-patient analysis; 0.82 versus 0.46 at per-vessel analysis). CONCLUSIONS:FFR obtained a high diagnostic performance and is a viable alternative to FFR for detecting coronary ischemic lesions. KEY POINTS:• Noninvasive FFRhas higher specificity for anatomical and physiological assessment of coronary artery stenosis compared with CCTA. • Noninvasive FFRis a viable alternative to invasive FFR for the detection and exclusion of coronary lesions that cause ischemia. 10.1007/s00330-019-06470-8