Late Outcomes of Patients in the Emergency Department With Acute Chest Pain Evaluated With Computed Tomography-Derived Fractional Flow Reserve.

Computed tomography (CTA)-derived fractional flow reserve (FFR _CT ) guides the need for invasive coronary angiography (ICA). Late outcomes after FFR _CT are reported in stable ischemic heart disease but not in acute chest pain in the emergency department (ACP-ED). The objectives are to assess the risk of death, myocardial infarction (MI), revascularization, and ICA after FFR _CT . From 2015 to 2018, 389 low-risk patients with ACP-ED (negative biomarkers, no electrocardiographic ischemia) underwent CTA and FFR _CT and were entered into a prospective institutional registry; patients were followed up for 41 ± 10 months. CTA stenosis ≥50% was present in 81% of the patients. Positive (FFR _CT ≤0.80) and negative FFR _CT were observed in 124 (32%) and 265 patients (68%), respectively. ICA was performed in 108 of 124 patients (87%) with positive FFR _CT and 89 of 265 patients (34%) with negative FFR _CT (p <0.00001). Revascularization was performed in 87 of 124 (70%) patients with positive FFR _CT and in 22 of 265 (8%) with negative FFR _CT (p <0.00001). Appropriateness of revascularization was established by blinded adjudication of ICA and invasive FFR using practice guidelines; revascularization was appropriate in 81 of 124 (65%) and 6 of 265 (2%) of FFR _CT -positive and -negative patients, respectively (p <0.00001). At follow-up, for patients with positive versus negative FFR _CT , the rates were 0.8% versus 0% for death (p = 0.32) and 1.6% versus 0.4% for MI (p = 0.24). In conclusion, in low-risk patients with ACP-ED who underwent CTA and FFR _CT , the risk of late death (0.2%) and MI (0.7%) are low. Negative FFR _CT is associated with excellent long-term prognosis, and positive FFR _CT predicts obstructive disease requiring revascularization. FFR _CT can safely triage patients with ACP-ED and reduce unnecessary ICA and revascularization.
Competing Interests: Declaration of competing interest Dr. Fonte is an employee of HeartFlow, Inc. and owns equity or stocks. The remaining authors have no competing interests to declare.
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