Cardiovasc Revasc Med. 2026 Oct 8:S1553-8389(26)00401-X. doi: 10.1016/j.carrev.2026.10.004. Online ahead of print.
ABSTRACT
BACKGROUND: Fractional flow reserve derived from computed tomography (FFR-CT) enables combined anatomical and physiological assessment of coronary artery disease using coronary computed tomography angiography (CCTA) data. Real-world evidence comparing downstream utilization and clinical outcomes following CCTA with versus without FFR-CT remains limited.
OBJECTIVES: To compare invasive coronary angiography (ICA), coronary revascularization, additional cardiac testing, and one-year major adverse cardiovascular events (MACE) among patients undergoing CCTA with versus without FFR-CT.
METHODS: This retrospective cohort study used the TriNetX Research Network, in which 118 healthcare organizations were queried. Adults undergoing CCTA between January 1, 2020, and July 20, 2024, were categorized according to receipt of FFR-CT. The initial cohorts included 17,754 patients receiving FFR-CT and 198,220 undergoing CCTA alone. After 1:1 propensity-score matching on demographic and clinical characteristics, 15,375 patients were retained in each cohort. Outcomes were assessed from days 8 through 365 after the index event. MACE was defined as death, acute myocardial infarction, or ischemic stroke.
RESULTS: Compared with CCTA alone, CCTA with FFR-CT was associated with higher rates of ICA (24.0% vs 12.5%; risk ratio [RR], 1.920; 95% confidence interval [CI], 1.826-2.020), percutaneous coronary intervention (7.6% vs 3.7%; RR, 2.076; 95% CI, 1.883-2.290), and coronary artery bypass grafting (3.3% vs 1.8%; RR, 1.770; 95% CI, 1.533-2.045). Additional noninvasive functional cardiac testing was also more frequent following FFR-CT (7.0% vs 5.1%; RR, 1.370; 95% CI, 1.253-1.497). Conversely, FFR-CT was associated with lower one-year MACE (8.8% vs 10.5%; RR, 0.835; 95% CI, 0.779-0.894), acute myocardial infarction (3.9% vs 4.7%; RR, 0.822; 95% CI, 0.740-0.915), and all-cause mortality (2.0% vs 2.9%; RR, 0.676; 95% CI, 0.585-0.782). All comparisons were significant at p < 0.001.
CONCLUSIONS: In this large propensity-matched cohort, CCTA with FFR-CT was associated with greater downstream invasive and noninvasive testing and higher rates of PCI and CABG, but lower one-year MACE, myocardial infarction, and mortality. These findings may reflect more effective identification of actionable coronary disease; however, differences in underlying anatomical disease severity, site-level practice patterns, and residual confounding preclude causal interpretation.
PMID:42934052 | DOI:10.1016/j.carrev.2026.10.004