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Opportunities and challenges of implementing computed tomography fractional flow reserve into clinical practice
  1. Muhummad Sohaib Nazir1,
  2. Tarun K Mittal2,
  3. Jonathan Weir-McCall3,
  4. Koen Nieman4,
  5. Keith Channon5,
  6. Edward D Nicol6
  1. 1 Biomedical Engineering and Imaging Sciences, King’s College London, London, UK
  2. 2 Imaging, Harefield Hospital, London, Middlesex, UK
  3. 3 University of Cambridge School of Clinical Medicine, Biomedical Research Centre, University of Cambridge, Cambridge, United Kingdom, Cambridge, UK
  4. 4 Stanford University School of Medicine and Cardiovascular Institute, Stanford, California, USA
  5. 5 Department of Cardiovascular Medicine, University of Oxford, Oxford, UK
  6. 6 Departments of Cardiology and Radiology, Royal Brompton and Harefield NHS Foundation Trust, Sydney Street, London, SW3 6NP, UK
  1. Correspondence to Dr Edward D Nicol, Departments of Cardiology and Radiology, Royal Brompton and Harefield NHS Foundation Trust, Sydney Street, London, SW3 6NP, UK; e.nicol{at}


CT-derived fractional flow reserve (CT-FFR) uses computational fluid dynamics to derive non-invasive FFR to determine the haemodynamic significance of coronary artery lesions. Studies have demonstrated good diagnostic accuracy of CT-FFR and reassuring short-term clinical outcome data.

As a prerequisite, high-quality CT coronary angiography (CTCA) images are required with good heart rate control and pre-treatment with glyceryl trinitrate, which would otherwise render CTCA as unsuitable for CT-FFR. CT-FFR can determine the functional significance of CAD lesions, and there are supportive data for its use in clinical decision-making. However, the downstream impact on myocardial ischaemic burden or viability cannot be obtained.

Several challenges remain with implementation of CT-FFR, including interpretation, training, availability, resource utilisation and funding. Further research is required to determine which cases should be considered for clinical CT-FFR analysis, with additional practical guidance on how to implement this emerging technique in clinical practice. Furthermore, long-term prognostic data are required before widespread clinical implementation of CT-FFR can be recommended.

While there are several potential opportunities for CT-FFR, at present there remain important systemic and technical limitations and challenges that need to be overcome prior to routine integration of CT-FFR into clinical practice.

  • cardiac computer tomographic (CT) imaging
  • advanced cardiac imaging
  • coronary artery disease
  • chronic coronary disease

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  • Contributors MSN and EDN conceived the idea of the manuscript. MSN drafted the initial manuscript. TKM, JW-M, KN, KC and EDN all critically revised the manuscript. All authors read and approved the final manuscript.

  • Funding MSN is funded by a Clinical Lecturership awarded by the UK National Institute for Health Research.

  • Competing interests KN declares unrestricted, institutional research support from Siemens Healthineers, Bayer Healthcare and HeartFlow Inc.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Patient consent for publication Obtained.

  • Provenance and peer review Commissioned; externally peer reviewed.