Coronary artery disease
Meta-Analysis of Fractional Flow Reserve Versus Quantitative Coronary Angiography and Noninvasive Imaging for Evaluation of Myocardial Ischemia

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We performed a meta-analysis of 31 studies comparing the results of fractional flow reserve (FFR) against quantitative coronary angiography (QCA) and/or noninvasive imaging of the same lesions. Studies were retrieved from PubMed (last search February 2006). Across 18 studies (1,522 lesions), QCA had a random effects sensitivity of 78% (95% confidence interval [CI] 67 to 86) and specificity of 51% (95% CI 40 to 61) against FFR (0.75 cutoff). Overall concordances were 61% for lesions with diameter stenosis 30% to 70%, 67% for stenoses >70%, and 95% for stenoses <30%. Compared with noninvasive imaging (21 studies, 1,249 lesions), FFR had a sensitivity of 76% (95% CI 69 to 82) and specificity of 76% (95% CI 71 to 81) by random effects. Summary receiver-operator characteristic estimates were similar. Most data addressed comparisons with perfusion scintigraphy (976 lesions, sensitivity 75%, specificity 77%), and some data were also available for dobutamine stress echocardiography (273 lesions, sensitivity 82%, specificity 74%). In conclusion, QCA does not predict the functional significance of coronary lesions. FFR shows modest concordance with noninvasive imaging tests. The prognostic implications of discordant FFR and imaging results need further study.

Section snippets

Study eligibility

We considered English-language studies that had performed FFR measurements and quantitative coronary angiographic or/and noninvasive imaging evaluation for the same coronary lesions. We considered all studies in which ≥5 patients had been examined with FFR and ≥1 other eligible method. Studies were considered regardless of the clinical setting (asymptomatic, stable angina, unstable angina, early after myocardial infarction [MI], other) and regardless of whether they addressed native coronary

Selected studies

The search yielded 263 items; 76 reports were retrieved and examined in full text for eligibility. Of those, we excluded 45 (ineligible diagnostic test comparison n = 11, <5 patients n = 1, review n = 2, nonhuman studies n = 1, all patients/no patients with positive results n = 10, duplicate data from same team n = 7, missing information for 2 × 2 table n = 13 [all addressing QCA; 1 also addressed noninvasive imaging against FFR]). Overall, 31 eligible studies were retained for the

Discussion

Our meta-analysis shows that FFR provides largely independent information against QCA. There is extensive lack of concordance between these tests, especially for lesions with 30% to 70% diameter stenosis. Even for lesions with >70% stenosis, FFR may often suggest no functional significance. However, for lesions with <30% stenosis, the FFR result is almost always negative. FFR results often agree with the results of nonimaging studies, but concordance is far from perfect. Independent information

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