CT‐FFR: Are you ready to totally change 

the way you diagnose Coronary Artery 

Disease?

Madan Mohan MD MRCP FACCCQO, Division of Cardiovascular MedicineUniversity Hospitals Case Medical Center

Assistant ProfessorCase Western Reserve University School of Medicine

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Disclosure Statement of Financial Interest

• No financial disclosures• I will be discussing unapproved indications

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Case

• 55 year old male with atypical chest pain• Hypertension and hyperlipidemia but non

smoker and no diabetes• Normal exam and LVH with strain on EKG• What would you order next?

1. Reassure2. Treadmill EKG3. Stress nuclear4. Direct to angiography5. Something else

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Accuracy of stress tests

390000 pts

Probability of obstructive CAD

41% if positive stress test35% if negative stress test

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CAD: Two fundamental questionsFUNCTION: Is coronary ischemia causing my patient’s symptoms?

• Coronary CT Angiography• Invasive coronary angiography

ANATOMY: Are there stenoses in the coronary arteries?

• Stress testing• Myocardial Perfusion Imaging (e.g. SPECT)• Stress Echocardiography

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FFRCT

Concept of Fractional Flow Reserve

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• A test to determine the functional significance of a stenosis

• Ratio of maximum blood flow in stenotic artery to theoretical maximum blood flow if no stenosis. (pressure is used as surrogate)

• Measured in cath lab

• after IV NTG, and adenosine• Pressure after and before stenosis: Pd / Pa• Thus normal artery has FFR of 1.•

FFR in cath lab

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Pijls et al. JACC. 59:12. 1045-57

FFR in 3 vessel disease

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Pijls et al. JACC. 59:12. 1045-57

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FFR: A “Game Changing” Technology

4.6% vs 8.0%, p=0.04

888 patients with stable CAD FAME 2 (2 yrs) De Bruyne et al, NEJM 2014

What is CT FFR?

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CT FFR is a non-invasive method employing computational fluid dynamics (CFD) for evaluation of the hemodynamic (HD) significance of coronary artery lesions.

“One Stop Shop”• Uses standard images• Post processing

CT FFR values are available at every point on the coronary tree

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FFRCT: The NXT Trial

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•Diagnostic performance of non-invasive fractional flow reserve derived from coronary CT angiography in suspected coronary artery disease: The NXT trial.

–Bjarne L. Nørgaard, MD, PhD et al

•” Conclusions: FFRCT provides high diagnostic accuracy, and discrimination for the diagnosis of hemodynamically significant CAD with invasive FFR as the reference standard. When compared to anatomic testing by coronary CTA, FFRCT leads to a marked increase in specificity.”

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Case ExampleFigure 1. Co-registration of angiography and 3-dimentional CT model. Red lines indicate pressure-wire location for FFR measurements across the serial lesions (A = distal, B = proximal).

Figure 2. FFR gradient across the serial lesions. Red arrows show stepped-up FFR after crossing the stenoses. (A = distal measured point, B = proximal measured point, C = equalization point).

Kantaro Tanaka and Hiram Bezerra

HeartFlow Clinical Trial Case Examples

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Is CT FFR a game changer?

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• Use of FFRCT to select patients for ICA and PCI may result in 30% lower costs and 12% fewer events at one year compared to the most common strategy of ICA and visual guidance for PCI 

Hlatky et al, Clin Cardiol 2013; DOI:10.1002/clc.22205

 $4,500

 $5,500

 $6,500

 $7,500

 $8,500

 $9,500

 $10,500

 $11,500

1.8% 1.9% 2.0% 2.1% 2.2% 2.3%

Cost / Patient

Event Rate

Cath a

nd ang

io‐guid

ed PCI

CTA prior to cath

FFR in 

every v

essel o

f every

 case

FFR CTprior to c

ath

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Estimated Patient Radiation Exposure Based onCAD Diagnostic Pathway

1) ICA visual

Leipsic et al, in preparation

Summary: CT FFR at UH could result in

For non‐ACS patients presenting for evaluation of chest pain

Current Practice

Pathway Using FFRCT

Change

1. Angio without +’ve FFR/FFRCT DiseaseAngio with +’ve FFR/FFRCT DiseasePCI

1,081874913

01,323827

‐ 1,081+449‐86 

2. Clinical Events(1‐yr death / MI) 2.9% 2.2%

26 Patients (Δ25%)

3. Total Costs to HealthSystem (index costs only)

$14.8M $9.6M‐$5.2M (Δ35%)

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Implications for a Health System• Patient

– Fewer invasive procedures which turn out to be negative– Recognize subclinical disease– Greater pre‐procedure understanding of planned PCI– Less Death / MI / Urgent revascularization (DEFER, FAME and FAME 2)

• Physician– Decision making pre‐cath lab– Heart Team as needed

• Hospital– Cath lab operational efficiencies– Longer term effects on fixed costs (CT scanners, SPECT cameras, cath labs)

• Payer– Triple Aim: outcomes, patient experience, costs 

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Triple Aim of Healthcare

Source: The Triple Aim: Care, Health, and Cost; Donald Berwick, Health Affairs 2008

1. Improve the Experienceof Care

2. Improve the Healthof Populations

3. Reduce per capita Costsof Care

FFRCT can reduce dx tests, as well as unnecessary interventions while

simultaneously identifying patients that do need invasive

care.

FFRCT can reduce morbidity and mortality by more accurately

diagnosing patients with coronary artery disease.

FFRCT can reduce the costs of managing CAD

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Is FFRCT

the game changer for diagnosis of CAD?

• Thank you

• Questions?