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Background  Data on the clinical utility of coronary computed tomography angiography–derived fractional flow reserve ( FFR CT  ) are sparse. In patients with intermediate (40–70%) coronary stenosis determined by coronary computed tomography angiography, we investigated the association of replacing standard myocardial perfusion imaging with  FFR CT   testing with downstream utilization of invasive coronary angiography ( ICA ) and the diagnostic yield of  ICA  (rate of no obstructive disease, and rate of revascularization).    Methods and Results  This was a single‐center observational study of symptomatic patients with suspected coronary artery disease referred to coronary computed tomography angiography between 2013 and 2015. Patients were divided into 3 historical groups based on the adjunctive functional testing approach: myocardial perfusion imaging (n=1332) or  FFR CT   “implementation” (n=800) or “clinical use” (n=1391). Propensity score matching was used to estimate the average period effect on outcomes. Patients in the  FFR CT   clinical use group versus the myocardial perfusion imaging group were older and had higher pretest probability of obstructive disease. After adjusting for baseline risk characteristics, there was a reduction in downstream  ICA  utilization (absolute risk difference: −4.2; 95% CI, −6.9 to −1.6;  P =0.002). In patients referred to  ICA , findings of no obstructive coronary artery disease decreased (−12.8%; 95% CI, −22.2 to −3.4;  P =0.008) and rate of coronary revascularization increased (14.1%; 95% CI, 3.3–24.9;  P =0.01), as did availability of functional information for guidance of revascularization (27.8%; 95% CI, 11.3–44.4;  P <0.001) after clinical adoption of  FFR CT  .    Conclusions  Replacing adjunctive myocardial perfusion imaging with  FFR CT   testing for functional assessment of intermediate stenosis determined by coronary computed tomography angiography in stable coronary artery disease was associated with less  ICA  utilization, and a higher  ICA  diagnostic yield. The findings in this observational study needs confirmation in prospective, randomized trials.

journal of the american heart association

Myocardial Perfusion Imaging Versus Computed Tomography Angiography–Derived Fractional Flow Reserve Testing in Stable Patients With Intermediate‐Range Coronary Lesions: Influence on Downstream Diagnostic Workflows and Invasive Angiography Findings