Fractional Flow Reserve Derived From Computed Tomographic Angiography in Patients With Multivessel CAD

Carlos Collet, Yosuke Miyazaki, Nicola Ryan, Taku Asano, Erhan Tenekecioglu, Jeroen Sonck, Daniele Andreini, Manel Sabate, Salvatore Brugaletta, Rodney H. Stables, Antonio Bartorelli, Robbert J. de Winter, Yuki Katagiri, Ply Chichareon, Giovanni Luigi De Maria, Pannipa Suwannasom, Rafael Cavalcante, Hans Jonker, Marie angèle Morel, Bernard CosynsArie P. Kappetein, David T. Taggart, Vasim Farooq, Javier Escaned, Adrian Banning, Yoshinobu Onuma, Patrick W. Serruys

Research output: Contribution to journalArticlepeer-review


Background: The functional SYNTAX score (FSS) has been shown to improve the discrimination for major adverse cardiac events compared with the anatomic SYNTAX score (SS) while reducing interobserver variability. However, evidence supporting the noninvasive FSS in patients with multivessel coronary artery disease (CAD) is scarce. Objectives: The purpose of this study was to assess the feasibility of and validate the noninvasive FSS derived from coronary computed tomography angiography (CTA) with fractional flow reserve (FFRCT) in patients with 3-vessel CAD. Methods: The CTA-SS was calculated in patients with 3-vessel CAD included in the SYNTAX II (SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery II) study. The noninvasive FSS was determined by including only ischemia-producing lesions (FFRCT ≤0.80). SS derived from different imaging modalities were compared using the Bland-Altman and Passing-Bablok method, and the agreement on the SS tertiles was investigated with Cohen's Kappa. The risk reclassification was compared between the noninvasive and invasive physiological assessment, and the diagnostic accuracy of FFRCT was assessed by the area under the receiver-operating characteristic curve using instantaneous wave-free ratio as a reference. Results: The CTA-SS was feasible in 86% of patients (66 of 77), whereas the noninvasive FSS was feasible in 80% (53 of 66). The anatomic SS was overestimated by CTA compared with conventional angiography (27.6 ± 6.4 vs. 25.3 ± 6.9; p < 0.0001) whereas the calculation of the FSS yielded similar results between the noninvasive and invasive imaging modalities (21.6 ± 7.8 vs. 21.2 ± 8.8; p = 0.589). The noninvasive FSS reclassified 30% of patients from the high- and intermediate-SS tertiles to the low-risk tertile, whereas invasive FSS reclassified 23% of patients from the high- and intermediate-SS tertiles to the low-risk tertile. The agreement on the classic SS tertiles based on Kappa statistics was slight for the anatomic SS (Kappa = 0.19) and fair for the FSS (Kappa = 0.32). The diagnostic accuracy of FFRCT to detect functional significant stenosis based on an instantaneous wave-free ratio ≤0.89 revealed an area under the receiver-operating characteristics curve of 0.85 (95% CI: 0.79 to 0.90) with a sensitivity of 95% (95% CI: 89% to 98%), specificity of 61% (95% CI: 48% to 73%), positive predictive value of 81% (95% CI: 76% to 86%), and negative predictive value of 87% (95% CI: 74% to 94%). Conclusions: Calculation of the noninvasive FSS is feasible and yielded similar results to those obtained with invasive pressure-wire assessment. The agreement on the SYNTAX score tertile classification improved with the inclusion of the functional component from slight to fair agreement. FFRCT has good accuracy in detecting functionally significant lesions in patients with 3-vessel CAD. (A Trial to Evaluate a New Strategy in the Functional Assessment of 3-Vessel Disease Using SYNTAX II Score in Patients Treated With PCI; NCT02015832)

Original languageEnglish
Pages (from-to)2756-2769
Number of pages14
JournalJournal of the American College of Cardiology
Issue number24
Publication statusPublished - Jun 19 2018


  • coronary artery bypass graft
  • coronary computed tomography angiography
  • coronary physiology
  • drug-eluting stents
  • functional SYNTAX score
  • multivessel disease
  • percutaneous coronary intervention
  • SYNTAX score

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine


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