Prognostic Value of Computed Tomography-Derived Fractional Flow Reserve Comparison With Myocardial Perfusion Imaging

Ahmed Ibrahim Ahmed, Yushui Han, Mahmoud Al Rifai, Talal Alnabelsi, Faisal Nabi, Su Min Chang, Myra Cocker, Chris Schwemmer, Juan C. Ramirez-Giraldo, Neal S. Kleiman, William A. Zoghbi, John J. Mahmarian, Mouaz H. Al-Mallah

Research output: Contribution to journalArticlepeer-review

12 Scopus citations


OBJECTIVES: The aim of this study was to compare the incremental prognostic value of coronary computed tomography (CT) angiography (CCTA)-derived machine learning fractional flow reserve CT (ML-FFRct) versus that of ischemia detected on single-photon emission-computed tomography (SPECT) myocardial perfusion imaging (MPI) on incident cardiovascular outcomes.

BACKGROUND: SPECT MPI and ML-FFRct are noninvasive tools that can assess the hemodynamic significance of coronary atherosclerotic disease.

METHODS: We studied a retrospective cohort of consecutive patients who underwent clinically indicated CCTA and SPECT MPI. ML-FFRct was computed using a ML prototype. The primary outcome was all-cause mortality and nonfatal myocardial infarction (D/MI), and the secondary outcome was D/MI and unplanned revascularization, percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) occurring more than 90 days postimaging. Multiple nested multivariate cox regression was used to model a scenario wherein an initial anatomical assessment was followed by a functional assessment.

RESULTS: A total of 471 patients (mean age: 64 ± 13 year; 53% males) were included. Comorbidities were prevalent (78% hypertension, 66% diabetes, 81% dyslipidemia). ML-FFRct was <0.8 in at least 1 proximal/midsegment was present in 41.6% of patients, and ischemia on MPI was present in 13.8%. After a median follow-up of 18 months, 7% of patients (n = 33) experienced D/MI. On multivariate Cox proportional analysis, the presence of ischemia on MPI but not ML-FFRct significantly predicted D/MI (HR: 2.3; 95% CI: 1.0-5.0; P = 0.047; or HR: 0.7; 95% CI: 0.3-1.4; P = 0.306 respectively) when added to CCTA obstructive stenosis. Furthermore, the model with SPECT ischemia had higher global chi-square result and significantly improved reclassification. Results were similar using the secondary outcome and on several sensitivity analyses.

CONCLUSIONS: In a high-risk patient cohort, SPECT MPI but not ML-FFRct adds independent and incremental prognostic information to CCTA-based anatomical assessment and clinical risk factors in predicting incident outcomes.

Original languageEnglish (US)
Pages (from-to)284-295
Number of pages12
JournalJACC: Cardiovascular Imaging
Issue number2
StatePublished - Feb 2022


  • CCTA
  • ML-FFRct
  • Predictive Value of Tests
  • Myocardial Perfusion Imaging/methods
  • Prognosis
  • Computed Tomography Angiography/methods
  • Humans
  • Middle Aged
  • Male
  • Tomography, X-Ray Computed
  • Coronary Artery Disease/diagnostic imaging
  • Fractional Flow Reserve, Myocardial
  • Female
  • Aged
  • Retrospective Studies
  • Coronary Angiography/methods
  • Percutaneous Coronary Intervention

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Radiology Nuclear Medicine and imaging


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