Background CT-derived fractional flow reserve (CT-FFR) and dynamic CT myocardial perfusion imaging enhance the specificity of coronary CT angiography (CCTA) for ruling out coronary artery disease (CAD). However, evidence on comparative diagnostic value remains scarce. Purpose To compare the diagnostic accuracy of CCTA plus CT-FFR, CCTA plus CT perfusion, and sequential CCTA plus CT-FFR and CT perfusion for detecting hemodynamically relevant CAD with that of invasive angiography. Materials and Methods This secondary analysis of a prospective study included patients with chest pain referred for invasive coronary angiography at nine centers from July 2016 to September 2019. CCTA and CT perfusion were performed with third-generation dual-source CT scanners. CT-FFR was assessed on-site. Independent core laboratories analyzed CCTA alone, CCTA plus CT perfusion, CCTA plus CT-FFR, and a sequential approach involving CCTA plus CT-FFR and CT perfusion for the presence of hemodynamically relevant stenosis. Invasive coronary angiography with invasive fractional flow reserve was the reference standard. Diagnostic accuracy metrics and the area under the receiver operating characteristic curve (AUC) were compared with the Sign test and DeLong test. Results Of the 105 participants (mean age, 64 years ± 8 [SD]; 68 male), 49 (47%) had hemodynamically relevant stenoses at invasive coronary angiography. CCTA plus CT-FFR and CCTA plus CT perfusion showed no evidence of a difference for participant-based sensitivities (90% vs 90%, P > .99), specificities (77% vs 79%, P > .99) and vessel-based AUCs (0.84 [95% CI: 0.77, 0.91] vs 0.83 [95% CI: 0.75, 0.91], P = .90). Both had higher participant-based specificity than CCTA alone (54%, both P < .001) without evidence of a difference in sensitivity between CCTA (94%) and CCTA plus CT perfusion (P = .50) or CCTA plus CT-FFR (P = .63). The sequential approach combining CCTA plus CT-FFR with CT perfusion achieved higher participant-based specificity than CCTA plus CT-FFR (88% vs 77%, P = .03) without evidence of a difference in participant-based sensitivity (88% vs 90%, P > .99) and vessel-based AUC (0.85 [95% CI: 0.77, 0.93], P = .78). Compared with CCTA plus CT perfusion, the sequential approach showed no evidence of a difference in participant-based sensitivity (P > .99), specificity (P = .06), or vessel-based AUC (P = .54). Conclusion There was no evidence of a difference in diagnostic accuracy between CCTA plus CT-FFR and CCTA plus CT perfusion for detecting hemodynamically relevant CAD. A sequential approach combining CCTA plus CT-FFR with CT perfusion led to improved participant-based specificity with no evidence of a difference in sensitivity compared with CCTA plus CT-FFR. ClinicalTrials.gov registration no.: NCT02810795 © RSNA, 2024 Supplemental material is available for this article. See also the editorial by Sinitsyn in this issue.

中文翻译：

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CT 心肌灌注和 CT-FFR 与侵入性 FFR 对冠状动脉疾病血流动力学相关性的影响。


背景 CT 衍生血流储备分数 （CT-FFR） 和动态 CT 心肌灌注成像增强了冠状动脉 CT 血管造影 （CCTA） 排除冠状动脉疾病 （CAD） 的特异性。然而，关于比较诊断价值的证据仍然很少。目的 比较 CCTA 加 CT-FFR、CCTA 加 CT 灌注和序贯 CCTA 加 CT-FFR 和 CT 灌注检测血流动力学相关 CAD 与有创血管造影的诊断准确性。材料和方法这项前瞻性研究的二次分析包括 2016 年 7 月至 2019 年 9 月在 9 个中心转诊进行有创冠状动脉造影的胸痛患者。使用第三代双源 CT 扫描仪进行 CCTA 和 CT 灌注。CT-FFR 在现场进行评估。独立核心实验室分析了单独 CCTA、CCTA 加 CT 灌注、CCTA 加 CT-FFR 以及涉及 CCTA 加 CT-FFR 和 CT 灌注的序贯方法是否存在血流动力学相关狭窄。有创冠状动脉造影伴有创血流储备分数是参考标准。将诊断准确性指标和受试者工作特征曲线下面积 （AUC） 与 Sign 检验和 DeLong 检验进行比较。结果 在 105 名参与者 （平均年龄，64 岁 ± 8 [SD];68 名男性）中，49 名 （47%） 在有创冠状动脉造影时出现血流动力学相关的狭窄。CCTA 加 CT-FFR 和 CCTA 加 CT 灌注显示没有证据表明基于参与者的敏感性 （90% vs 90%，P > .99）、特异性 （77% vs 79%，P > .99） 和基于血管的 AUC （0.84 [95% CI： 0.77， 0.91] vs 0.83 [95% CI： 0.75， 0.91]，P = .90）。两者基于参与者的特异性均高于单独的 CCTA （54%，均 P < .001） 没有证据表明 CCTA （94%） 和 CCTA 加 CT 灌注 （P = .50） 或 CCTA 加 CT-FFR （P = .63） 之间的敏感性存在差异。CCTA 加 CT-FFR 与 CT 灌注相结合的序贯方法比 CCTA 加 CT-FFR （88% vs 77%，P = .03） 实现了更高的基于参与者的特异性，没有证据表明基于参与者的敏感性 （88% vs 90%，P > .99） 和基于血管的 AUC （0.85 [95% CI： 0.77， 0.93]，P = .78） 存在差异。与 CCTA 加 CT 灌注相比，序贯方法显示没有证据表明基于参与者的敏感性 （P > .99） 、特异性 （P = .06） 或基于血管的 AUC （P = .54） 存在差异。结论 没有证据表明 CCTA 加 CT-FFR 和 CCTA 加 CT 灌注在检测血流动力学相关 CAD 方面的诊断准确性存在差异。CCTA 加 CT-FFR 与 CT 灌注相结合的序贯方法提高了基于受试者的特异性，与 CCTA 加 CT-FFR 相比，没有证据表明敏感性存在差异。ClinicalTrials.gov 注册号：NCT02810795 © RSNA， 2024 本文提供补充材料。另请参见 Sinitsyn 在本期的社论。