Agreement of Fractional Flow Reserve Estimated by Computed Tomography With Invasively Measured Fractional Flow Reserve: A Systematic Review and Meta-Analysis

J Am Heart Assoc. 2024 May 21;13(10):e034552. doi: 10.1161/JAHA.124.034552. Epub 2024 May 10.


Background: Fractional flow reserve (FFR) is the ratio of blood pressure measured distal to a stenosis and pressure proximal to a stenosis. FFR can be estimated noninvasively using computed tomography (CT) although the usefulness of this technique remains controversial. This meta-analysis evaluated the agreement of FFR estimated by CT (FFR-CT) with invasively measured FFR. The study also evaluated the diagnostic accuracy of FFR-CT, defined as the ability of FFR-CT to classify lesions as hemodynamically significant (invasive FFR ≤0.8) or insignificant (invasive FFR >0.8).

Methods and results: Forty-three studies reporting on 7291 blood vessels from 5236 patients were included. A moderate positive linear relationship between FFR-CT and invasively measured FFR was observed (Spearman correlation coefficient: 0.67). Agreement between the 2 measures increased as invasively measured FFR values approached 1. The overall diagnostic accuracy, sensitivity and specificity of FFR-CT were 82.2%, 80.9%, and 83.1%, respectively. Diagnostic accuracy of 90% could be demonstrated for FFR-CT values >0.90 and <0.49. The diagnostic accuracy of off-site tools was 79.4% and the diagnostic accuracy of on-site tools was 84.1%.

Conclusions: The agreement between FFR-CT and invasive FFR is moderate although agreement is highest in vessels with FFR-CT >0.9. Diagnostic accuracy varies widely with FFR-CT value but is above 90% for FFR-CT values >0.90 and <0.49. Furthermore, on-site and off-site tools have similar performance. Ultimately, FFR-CT may be a useful adjunct to CT coronary angiography as a gatekeeper for invasive coronary angiogram.

Keywords: CT; diagnostic accuracy; fractional flow reserve; fractional flow reserve‐CT coronary angiography.

Publication types

  • Systematic Review
  • Meta-Analysis
  • Review

MeSH terms

  • Cardiac Catheterization
  • Computed Tomography Angiography* / methods
  • Coronary Angiography* / methods
  • Coronary Artery Disease / diagnosis
  • Coronary Artery Disease / diagnostic imaging
  • Coronary Artery Disease / physiopathology
  • Coronary Stenosis* / diagnosis
  • Coronary Stenosis* / diagnostic imaging
  • Coronary Stenosis* / physiopathology
  • Coronary Vessels / diagnostic imaging
  • Coronary Vessels / physiopathology
  • Fractional Flow Reserve, Myocardial* / physiology
  • Humans
  • Predictive Value of Tests
  • Reproducibility of Results
  • Severity of Illness Index
  • Tomography, X-Ray Computed / methods