Low FFR-CT signals higher risk after coronary CTA

Clinical takeaway: In patients undergoing coronary CTA for suspected stable coronary artery disease, lower FFR-CT values identify progressively higher risk for future cardiovascular events independent of traditional risk factors and stenosis severity, with values ≤0.70 marking a particularly high-risk group.

FFR-CT is increasingly used to assess the physiologic significance of coronary stenoses detected on CT angiography (CTA), but its long-term prognostic value has remained uncertain. Prior studies were limited by smaller cohorts, composite endpoints, and shorter follow-up.

In this nationwide English cohort, investigators analyzed 7,836 patients who underwent clinically indicated FFR-CT after coronary CTA and followed them for a median of 3.1 years. During follow-up, 2.4% experienced an MI, 0.9% died from cardiovascular causes, 3.3% died from any cause, and 20.1% underwent coronary revascularization.

Risk increased steadily as FFR-CT values declined. Compared with patients whose stenosis-specific FFR-CT was >0.80, those with values of 0.51 to 0.70 had roughly a threefold higher risk of MI, while values ≤0.50 were associated with about a threefold higher risk of both MI and cardiovascular death after adjustment for cardiovascular risk factors and coronary stenosis severity. Borderline values (0.71 to 0.80) were linked to more revascularizations but showed a weaker association with hard clinical outcomes.

Adding FFR-CT to a model that already included clinical risk factors and CTA-defined stenosis severity modestly improved prediction of MI and cardiovascular death. Investigators also found that an FFR-CT value of 0.67 best identified patients at increased risk for future cardiovascular events. Notably, patients with normal stenosis-specific FFR-CT had very low event rates, with only about 1.5% experiencing MI or cardiovascular death within 3 years.

“FFR-CT is additive to clinical risk factors and stenosis severity in discriminating future MI and cardiovascular death and reclassifying risk,” the authors wrote, noting that FFR-CT ≤0.70 identifies patients at the highest risk who may benefit most from intensive preventive therapy.

Source: Bell JS, et al. (2026 Sep 22) Circulation. Prognostic Value of Coronary Computed Tomography Angiography-Derived Fractional Flow Reserve From a Large Nationwide Cohort