Projected costs and consequences of computed tomography-determined fractional flow reserve

Background Randomized trials have shown that fractional flow reserve (FFR) guided percutaneous coronary intervention (PCI) improves clinical outcome and reduces costs compared with visually guided PCI. FFR has been measured during invasive coronary angiography (ICA), but can now be derived noninvasively from coronary computed tomography (CT) angiography (cCTA) images (FFR_CT). The potential value of FFR_CT in clinical decision making is unknown. Hypothesis Use of FFR_CT can reduce costs and improve outcomes among patients with suspected coronary artery disease. Methods We used clinical data from 96 patients in the DISCOVER-FLOW (Diagnosis of Ischemia-Causing Stenoses Obtained Via Noninvasive Fractional Flow Reserve) study and outcomes data from the literature to project the initial management costs and 1-year death/myocardial infarction rates associated with 5 clinical strategies: (1) ICA with PCI based on visual angiographic assessment, (2) ICA with FFR _ICA-guided PCI, (3) cCTA followed by ICA and PCI based on visual assessment, (4) cCTA followed by ICA with FFR_ICA-guided PCI, and (5) cCTA FFR_CT and PCI of lesions with FFR_CT ≤0.80. Results The projected initial management costs were highest for the ICA/visual strategy ($10 702), and lowest for the cCTA/FFR_CT/ICA strategy ($7674). The use of FFR_CT to select patients for ICA and PCI would result in 30% lower costs and 12% fewer events at 1 year compared with the most commonly used ICA/visual strategy. Conclusions A strategy of using FFR_CT to guide the selection of patients for ICA and PCI might reduce costs and improve clinical outcomes in patients with suspected coronary artery disease.