Diagnostic performance of intracoronary gradient-based methods by coronary computed tomography angiography for the evaluation of physiologically significant coronary artery stenoses: a validation study with fractional flow reserve

We validated and compared transluminal attenuation gradient (TAG) and corrected coronary opacification (CCO) of coronary computed tomography angiography (CCTA) with invasively measured fractional flow reserve (FFR). One of the major limitations of CCTA is the discrepancy between angiographical stenosis and ischaemia-causing stenosis. Recently two new CCTA analysis methods, TAG and CCO, have been attempted to overcome this limitation but without physiological validation. We measured TAG and CCO of 97 major epicardial coronary arteries from 63 patients who underwent CCTA and followed by invasive coronary angiography and FFR. Diagnostic performance of TAG and CCO was assessed using FFR 0.80 as the reference standard. The overall diagnostic performance of TAG and CCO on a per-vessel basis was moderate and similar (c-statistic 0.696 vs. 0.637, P 0.29). The sensitivity, specificity, positive, and negative predictive values of TAG cut-off 0.654 for FFR 0.80 were 47.5, 91.2, 79.2, and 71.2, and those of CCO cut-off 0.063 were 65.0, 61.4, 54.2, and 71.4. TAG showed an incremental value to the diagnostic performance of CCTA but CCO did not (c-statistic 0.726 vs. 0.809, P 0.025; c-statistic 0.726 vs. 0.784, P 0.09). In net reclassification improvement (NRI) analysis, addition of TAG to CCTA did not result in significant reclassification (NRI 1.0, P 0.41) and addition of CCO to CCTA resulted in negative reclassification (NRI 9.3, P 0.036). Intracoronary attenuation-based CCTA analyses, TAG and CCO, showed moderate correlation with physiological coronary artery stenosis. The incremental value of TAG or CCO to the evaluation of haemodynamically stenosis by CCTA seemed to be limited.