From the Department of Diagnostic and Interventional Radiology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Strasse 55, 79106 Freiburg im Breisgau, Germany (M.S., R.S., M.T.H., C.L.S., F.B.); Department of Diagnostic and Interventional Radiology, University of Tübingen, Tübingen, Germany (C.B., K. Nikolaou, P.K., C.P.A.); Department of Computed Tomography, Siemens Healthcare GmbH, Forchheim, Germany (S.F., C.S.); Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, University Medical Center Rotterdam, Rotterdam, the Netherlands (F.M.A.N., K. Nieman); Centre for Advanced Cardiovascular Imaging, William Harvey Research Institute, Barts National Institute for Health Research Biomedical Research Centre, Queen Mary University of London, London, United Kingdom (F.P.); Department of Radiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (R.V.); and Stanford University School of Medicine and Cardiovascular Institute, Stanford, Calif (K. Nieman).
Radiology. 2024 Aug;312(2):e233234. doi: 10.1148/radiol.233234.
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%, > .99), specificities (77% vs 79%, > .99) and vessel-based AUCs (0.84 [95% CI: 0.77, 0.91] vs 0.83 [95% CI: 0.75, 0.91], = .90). Both had higher participant-based specificity than CCTA alone (54%, both < .001) without evidence of a difference in sensitivity between CCTA (94%) and CCTA plus CT perfusion ( = .50) or CCTA plus CT-FFR ( = .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%, = .03) without evidence of a difference in participant-based sensitivity (88% vs 90%, > .99) and vessel-based AUC (0.85 [95% CI: 0.77, 0.93], = .78). Compared with CCTA plus CT perfusion, the sequential approach showed no evidence of a difference in participant-based sensitivity ( > .99), specificity ( = .06), or vessel-based AUC ( = .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 See also the editorial by Sinitsyn in this issue.
背景 CT 衍生的血流储备分数（CT-FFR）和动态 CT 心肌灌注成像提高了冠状动脉 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 灌注以及连续 CCTA 加 CT-FFR 和 CT 灌注对检测血流动力学相关 CAD 的诊断准确性与侵入性血管造影的比较。材料与方法 这是一项前瞻性研究的二次分析，纳入了 2016 年 7 月至 2019 年 9 月期间因胸痛在 9 个中心接受侵入性冠状动脉造影的患者。使用第三代双源 CT 扫描仪进行 CCTA 和 CT 灌注。现场评估 CT-FFR。独立的核心实验室分析单独的 CCTA、CCTA 加 CT 灌注、CCTA 加 CT-FFR 以及包括 CCTA 加 CT-FFR 和 CT 灌注的顺序方法在存在血流动力学相关狭窄的情况下的存在。以有创性血流储备分数的有创性冠状动脉造影为参考标准。比较诊断准确性指标和受试者工作特征曲线（AUC）下面积（AUC）与 Sign 检验和 DeLong 检验。结果 在 105 名参与者（平均年龄，64 岁±8[标准差]；68 名男性）中，49 名（47%）在有创性冠状动脉造影中有血流动力学相关狭窄。基于患者的敏感性方面，CCTA 加 CT-FFR 和 CCTA 加 CT 灌注没有差异（90%比 90%，>.99），特异性（77%比 79%，>.99）和基于血管的 AUC（0.84[95%CI：0.77，0.91]比 0.83[95%CI：0.75，0.91]， =.90）。两者的患者特异性均高于单独的 CCTA（54%，均<.001），而 CCTA（94%）与 CCTA 加 CT 灌注（ =.50）或 CCTA 加 CT-FFR（ =.63）之间的敏感性无差异。与 CCTA 加 CT-FFR 相比，联合 CCTA 加 CT-FFR 与 CT 灌注的序贯方法具有更高的基于患者的特异性（88%比 77%， =.03），而基于患者的敏感性（88%比 90%，>.99）和基于血管的 AUC（0.85[95%CI：0.77，0.93]， =.78）无差异。与 CCTA 加 CT 灌注相比，序贯方法在基于患者的敏感性方面没有差异（>.99），特异性（ =.06）或基于血管的 AUC（ =.54）。结论 在检测血流动力学相关 CAD 方面，CCTA 加 CT-FFR 与 CCTA 加 CT 灌注之间没有证据表明诊断准确性存在差异。与 CCTA 加 CT-FFR 相比，联合 CCTA 加 CT-FFR 与 CT 灌注的序贯方法可提高基于患者的特异性，而敏感性无差异。ClinicalTrials.gov 注册号：NCT02810795©RSNA，2024 请参见本期 Sinitsyn 编辑的社论。
