Abstract Introduction Patients with NSTE-ACS often present with multiple stenoses. While the culprit lesion is usually identified, managing the other lesions remains challenging. This prespecified secondary analysis of a multicenter, single-arm, double-blinded, core-lab adjudicated study aims to evaluate the potential role of fractional flow reserve derived from coronary computed tomography (FFR-CT) in guiding the management of non-culprit lesions. Purpose This study investigates the accuracy of FFR-CT in classifying lesions as hemodynamically significant or non-significant compared with invasive FFR as the gold standard. Methods For the purpose of this prespecified secondary analysis, only patients with an identified culprit lesion and at least one additional stenosis ≥30% in another vessel were eligible. A total of 49 patients with 67 non-culprit lesions were included in this prespecified secondary analysis, derived from the initial cohort of 168 patients enrolled in the initial study. These patients presented with chest pain and elevated high-sensitivity troponin (hs-Tn) levels, underwent coronary computed tomography angiography (CCTA), and subsequently ICA. For both FFR-CT and ICA, hemodynamically significant lesions were defined as having an FFR value of ≤0.8. The primary endpoint was the negative predictive value (NPV) of FFR-CT in ruling out hemodynamically significant lesions in non-culprit vessels.. Secondary endpoints included sensitivity, specificity, positive predictive value (PPV), and overall diagnostic accuracy of FFR-CT. Results Of the 67 non-culprit lesions assessed, FFR-CT classified 33 (49%) as non-significant and 34 (51%) as significant. The NPV of FFR-CT was 94%, with 31 out of 33 lesions classified as non-significant by FFR-CT and confirmed as non-significant by invasive FFR. For the 34 lesions deemed significant by FFR-CT, 26 were confirmed as positive by invasive FFR, yielding a PPV of 76%. FFR-CT demonstrated a sensitivity of 93% and specificity of 79%, resulting in an overall diagnostic accuracy of 85% (Figure 1). Conclusion This analysis highlights the potential of FFR-CT in supporting early decision-making for the treatment of non-culprit lesions in high-risk NSTE-ACS patients with multivessel disease. The high negative predictive value of 94% underscores the ability of FFR-CT to rule out hemodynamically significant lesions, potentially reducing unnecessary invasive coronary angiographies and procedures. By assisting in the management of non-culprit lesions, FFR-CT could help streamline procedural workflows, reduce procedural time, and improve patient outcomes. Given these advantages, FFR-CT holds promise as an essential tool in managing this complex patient population.Figure 1.Diagnostic performance
Zimmerli et al. (2025) studied this question.