Management of Normal FFR-CT Values Across All Coronary Arteries
Invasive coronary angiography should be deferred, and the patient should be managed with optimized medical therapy alone. 1
Interpretation of Your FFR-CT Results
All FFR-CT values in this patient are normal (>0.80), indicating no hemodynamically significant coronary stenoses:
- Left Main: 0.98 (normal)
- LAD: 0.87 (normal, with translesional gradient 0.05, which is <0.12 and therefore non-significant) 1
- 1st Diagonal: 0.93 (normal)
- Circumflex: 0.94 (normal)
- RCA: 0.87-0.94 (normal) 1
Treatment Algorithm
1. Defer Invasive Coronary Angiography
With lesion-specific CT-FFR >0.80, invasive angiography should be deferred. 1 The 2022 CAD-RADS guidelines explicitly state that anatomical stenosis with lesion-specific CT-FFR >0.80 warrants deferral of invasive angiography. 1 This approach is supported by Class I evidence showing that deferral of PCI or CABG based on FFR >0.80 is safe. 1
2. Optimize Medical Therapy
The patient should receive guideline-directed medical therapy including:
- Antiplatelet therapy (aspirin) 1
- Statin therapy for lipid management 1
- Blood pressure control if hypertensive 1
- Diabetes management if diabetic 1
- Lifestyle modifications including smoking cessation, diet, and exercise 1
3. Symptom Management
- Sublingual nitroglycerin for anginal symptoms if present 1
- Consider beta-blockers or calcium channel blockers for symptom control if needed 1
Clinical Context and Prognostic Implications
Normal FFR-CT values (>0.80) are associated with excellent outcomes and low risk of vessel-related cardiovascular events. 1 The translesional gradient of 0.05 in the LAD is well below the threshold of 0.12 that indicates hemodynamically significant pressure loss, further confirming the absence of flow-limiting disease. 1
Important Caveats
Watch for These Pitfalls:
Diffuse atherosclerosis: If FFR-CT values show gradual decline along vessel length without focal stenosis, this may indicate diffuse disease requiring medical management rather than focal intervention. 1 However, your values remain normal throughout.
Clinical correlation required: Even with normal FFR-CT, if the patient has severe refractory symptoms, consider additional functional testing or clinical reassessment. 1
Borderline values (0.76-0.80): Would require individualized decision-making based on symptoms, lesion location, and translesional gradient. 1 Your patient does not fall into this category.
Follow-Up Strategy
- Continue risk factor modification and medical therapy 1
- Repeat imaging only if clinical status changes or symptoms worsen 1
- Patient education on symptom recognition and when to seek care 1
The evidence strongly supports that revascularization of lesions without FFR <0.80 is not recommended (Class III recommendation, Level of Evidence B). 1 This patient's normal FFR-CT values across all coronary territories indicate no hemodynamically significant disease requiring intervention.