Derivation and validation of a novel functional FFR _CT score incorporating the burden of coronary stenosis severity and flow impairment to predict clinical events

Abstract

Background: A score combining the burden of stenosis severity on coronary computed tomography angiography (CCTA) and flow impairment by fractional flow reserve derived from computed tomography (FFR _CT) may be a better predictor of clinical events than either parameter alone. Methods: The Functional FFR _CT Score (FFS) combines CCTA and FFR _CT parameters in an allocated point-based system. The feasibility of the FFS was assessed in cohort of 72 stable chest pain patients with matched CCTA and FFR _CT datasets. Validation was performed using 2 cohorts: (a) 4468 patients from the ADVANCE Registry to define its association with revascularization and major adverse cardiovascular events (MACE); (b) 212 patients from the FORECAST trial to determine predictors of MACE. Results: The median calculation time for the FFS was 10 (interquartile range 6–17) seconds, with strong intra-operator and inter-operator agreement (Cohen's Kappa 0.89 (±0.37, p ​< ​0.001) and 0.83 (±0.04, p ​< ​0.001, respectively). The FFS correlated strongly with both the CT-SYNTAX and the Functional CT-SYNTAX scores (rS ​= ​0.808 for both, p ​< ​0.001). In the ADVANCE cohort the FFS had good discriminatory abilities for revascularization with an area under the curve of 0.82, 95 ​% confidence interval (CI) 0.81–0.84, p ​< ​0.001. Patients in the highest FFS tertile had significantly higher rates of revascularization (61 ​% vs 5 ​%, p ​< ​0.001) and MACE (1.9 ​% vs 0.5 ​%, p ​= ​0.001) compared with the lowest FFS tertile. In the FORECAST cohort the FFS was an independent predictor of MACE at 9-month follow-up (hazard ratio 1.04, 95 ​% CI 1.01–1.08, p ​< ​0.01). Conclusion: The FFS is a quick-to-calculate and reproducible score, associated with revascularization and MACE in two distinct populations of stable symptomatic patients.

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