European Radiology

, Volume 27, Issue 4, pp 1416–1423 | Cite as

The effect of blood pressure on non-invasive fractional flow reserve derived from coronary computed tomography angiography

  • Akira KurataEmail author
  • Adriaan Coenen
  • Marisa M. Lubbers
  • Koen Nieman
  • Teruhito Kido
  • Tomoyuki Kido
  • Natsumi Yamashita
  • Kouki Watanabe
  • Gabriel P. Krestin
  • Teruhito Mochizuki



The aim of this study is to assess the effect of blood pressure (BP) on coronary computed tomography angiography (CTA) derived computational fractional flow reserve (CTA-FFR).

Materials and methods

Twenty-one patients who underwent coronary CTA and invasive FFR were retrospectively identified. Ischemia was defined as invasive FFR ≤0.80. Using a work-in-progress computational fluid dynamics algorithm, CTA-FFR was computed with BP measured before CTA, and simulated BPs of 60/50, 90/60, 110/70, 130/80, 150/90, and 180/100 mmHg respectively. Correlation between CTA-FFR and invasive FFR was assessed using Pearson test. The repeated measuring test was used for multiple comparisons of CTA-FFR values by simulated BP inputs.


Twenty-nine vessels (14 with invasive FFR ≤0.80) were assessed. The average CTA-FFR for measured BP (134 ± 20/73 ± 12 mmHg) was 0.77 ± 0.12. Correlation between CTA-FFR by measured BP and invasive FFR was good (r = 0.735, P < 0.001). For simulated BPs of 60/50, 90/60, 110/70, 130/80, 150/90, and 180/100 mmHg, the CTA-FFR increased: 0.69 ± 0.13, 0.73 ± 0.12, 0.75 ± 0.12, 0.77 ± 0.11, 0.79 ± 0.11, and 0.81 ± 0.10 respectively (P < 0.05).


Measurement of the BP just before CTA is preferred for accurate CTA-FFR simulation. BP variations in the common range slightly affect CTA-FFR. However, inaccurate BP assumptions differing from the patient-specific BP could cause misinterpretation of borderline significant lesions.

Key Points

The blood pressure (BP) affects the CTA-FFR computation.

Measured BP before CT examination is preferable for accurate CTA-FFR simulation.

Inaccurate BP assumptions can cause misinterpretation of borderline significant lesions.


Coronary artery disease Computed tomography Fractional flow reserve Blood pressure Myocardial ischemia 

Abbreviations and acronyms


blood pressure


coronary artery calcium


coronary artery disease


coronary angiography


CT angiography


fractional flow reserve


diastolic blood pressure


mean arterial pressure


percutaneous coronary intervention


systolic blood pressure





The scientific guarantor of this publication is Koen Nieman. The authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article. The authors state that this work has not received any funding. No complex statistical methods were necessary for this paper.

Institutional Review Board approval was obtained at each institution. Written informed consent was waived by the Institutional Review Board due to retrospective observational nature of the study. Methodology: The study was designed as prospective, observational, multi-centre study.


  1. 1.
    Miller JM, Rochitte CE, Dewey M et al (2008) Diagnostic performance of coronary angiography by 64-row CT. N Engl J Med 359:2324–2336CrossRefPubMedGoogle Scholar
  2. 2.
    Min JK, Dunning A, Lin FY et al (2011) Age- and sex-related differences in all-cause mortality risk based on coronary computed tomography angiography findings results from the International Multicenter CONFIRM (Coronary CT Angiography Evaluation for Clinical Outcomes: An International Multicenter Registry) of 23,854 patients without known coronary artery disease. J Am Coll Cardiol 58:849–860CrossRefPubMedGoogle Scholar
  3. 3.
    Cheng V, Gutstein A, Wolak A et al (2008) Moving beyond binary grading of coronary arterial stenoses on coronary computed tomographic angiography: insights for the imager and referring clinician. JACC Cardiovasc Imaging 1:460–471CrossRefPubMedGoogle Scholar
  4. 4.
    Leipsic J, Abbara S, Achenbach S et al (2014) SCCT guidelines for the interpretation and reporting of coronary CT angiography: a report of the society of cardiovascular computed tomography guidelines committee. J Cardiovasc Comput Tomogr 8:342–358CrossRefPubMedGoogle Scholar
  5. 5.
    Hachamovitch R, Hayes SW, Friedman JD, Cohen I, Berman DS (2003) Comparison of the short-term survival benefit associated with revascularization compared with medical therapy in patients with no prior coronary artery disease undergoing stress myocardial perfusion single photon emission computed tomography. Circulation 107:2900–2907CrossRefPubMedGoogle Scholar
  6. 6.
    Schwitter J, Wacker CM, van Rossum AC et al (2008) MR-IMPACT: comparison of perfusion-cardiac magnetic resonance with single-photon emission computed tomography for the detection of coronary artery disease in a multicentre, multivendor, randomized trial. Eur Heart J 29:480–489CrossRefPubMedGoogle Scholar
  7. 7.
    Pijls NH, De Bruyne B, Peels K et al (1996) Measurement of fractional flow reserve to assess the functional severity of coronary-artery stenoses. N Engl J Med 334:1703–1708CrossRefPubMedGoogle Scholar
  8. 8.
    De Bruyne B, Pijls NH, Heyndrickx GR, Hodeige D, Kirkeeide R, Gould KL (2000) Pressure-derived fractional flow reserve to assess serial epicardial stenoses: theoretical basis and animal validation. Circulation 101:1840–1847CrossRefPubMedGoogle Scholar
  9. 9.
    De Bruyne B, Bartunek J, Sys SU, Pijls NH, Heyndrickx GR, Wijns W (1996) Simultaneous coronary pressure and flow velocity measurements in humans. Feasibility, reproducibility, and hemodynamic dependence of coronary flow velocity reserve, hyperemic flow versus pressure slope index, and fractional flow reserve. Circulation 94:1842–1849CrossRefPubMedGoogle Scholar
  10. 10.
    Bech GJ, Pijls NH, De Bruyne B et al (1999) Usefulness of fractional flow reserve to predict clinical outcome after balloon angioplasty. Circulation 99:883–888CrossRefPubMedGoogle Scholar
  11. 11.
    Tonino PA, De Bruyne B, Pijls NH et al (2009) Fractional flow reserve versus angiography for guiding percutaneous coronary intervention. N Engl J Med 360:213–224CrossRefPubMedGoogle Scholar
  12. 12.
    Pijls NH, van Schaardenburgh P, Manoharan G et al (2007) Percutaneous coronary intervention of functionally nonsignificant stenosis: 5-year follow-up of the DEFER Study. J Am Coll Cardiol 49:2105–2111CrossRefPubMedGoogle Scholar
  13. 13.
    Taylor CA, Fonte TA, Min JK (2013) Computational fluid dynamics applied to cardiac computed tomography for noninvasive quantification of fractional flow reserve: scientific basis. J Am Coll Cardiol 61:2233–2241CrossRefPubMedGoogle Scholar
  14. 14.
    Koo BK, Erglis A, Doh JH et al (2011) Diagnosis of ischemia-causing coronary stenoses by noninvasive fractional flow reserve computed from coronary computed tomographic angiograms. Results from the prospective multicenter DISCOVER-FLOW (Diagnosis of Ischemia-Causing Stenoses Obtained Via Noninvasive Fractional Flow Reserve) study. J Am Coll Cardiol 58:1989–1997CrossRefPubMedGoogle Scholar
  15. 15.
    Min JK, Leipsic J, Pencina MJ et al (2012) Diagnostic accuracy of fractional flow reserve from anatomic CT angiography. JAMA 308:1237–1245CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Nørgaard BL, Leipsic J, Gaur S et al (2014) Diagnostic performance of noninvasive fractional flow reserve derived from coronary computed tomography angiography in suspected coronary artery disease: the NXT trial (Analysis of Coronary Blood Flow Using CT Angiography: Next Steps). J Am Coll Cardiol 63:1145–1155CrossRefPubMedGoogle Scholar
  17. 17.
    Coenen A, Lubbers MM, Kurata A et al (2015) Fractional flow reserve computed from noninvasive CT angiography data: diagnostic performance of an on-site clinician-operated computational fluid dynamics algorithm. Radiology 274:674–683CrossRefPubMedGoogle Scholar
  18. 18.
    Sharma P, Itu L, Zheng X et al (2012) A framework for personalization of coronary flow computations during rest and hyperemia. Conf Proc IEEE Eng Med Biol Soc 2012:6665–6668PubMedGoogle Scholar
  19. 19.
    Stanforth PR, Gagnon J, Rice T et al (2000) Reproducibility of resting blood pressure and heart rate measurements the HERITAGE family study. Ann Epidemiol 10:271–277CrossRefPubMedGoogle Scholar
  20. 20.
    Itu L, Sharma P, Mihalef V, Kamen A, Suciu C, Comaniciu D (2012) A patient-specific reduced-order model for coronary circulation. Conf Proc IEEE Inter Symp Biomed Imag 2012:832–835Google Scholar
  21. 21.
    Choy JS, Kassab GS (2008) Scaling of myocardial mass to flow and morphometry of coronary arteries. J Appl Physiol 104:1281–1286CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Murray CD (1926) The physiological principle of minimum work. I. The vascular system and the cost of blood volume. Proc Natl Acad Sci U S A 12:207–214CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Kim HJ, Vignon-Clementel IE, Coogan JS, Figueroa CA, Jansen KE, Taylor CA (2010) Patient-specific modeling of blood flow and pressure in human coronary arteries. Ann Biomed Eng 38:3195–3209CrossRefPubMedGoogle Scholar
  24. 24.
    Wilson RF, Wyche K, Christensen BV, Zimmer S, Laxson DD (1990) Effects of adenosine on human coronary arterial circulation. Circulation 82:1595–1606CrossRefPubMedGoogle Scholar
  25. 25.
    Pijls NH (2013) Fractional flow reserve to guide coronary revascularization. Circ J 77:561–569CrossRefPubMedGoogle Scholar
  26. 26.
    Leonardi RA, Townsend JC, Patel CA et al (2013) Left ventricular end-diastolic pressure affects measurement of fractional flow reserve. Cardiovasc Revasc Med 14:218–2122CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Ohtsuka S, Kakihana M, Sugishita Y, Ito I (1987) Effects of the rise in aortic pressure on coronary flow reserve in dogs. Comparison between constriction of the descending thoracic aorta and injection of methoxamine. Jpn Heart J 28:403–412CrossRefPubMedGoogle Scholar
  28. 28.
    Verdier-Watts F, Rioufol G, Mewton N et al (2014) Influence of arterial hypotension on fractional flow reserve measurements. EuroInterventionGoogle Scholar
  29. 29.
    Gaur S, Øvrehus KA, Dey D et al (2016) Coronary plaque quantification and fractional flow reserve by coronary computed tomography angiography identify ischaemia-causing lesions. Eur Heart JGoogle Scholar
  30. 30.
    Coenen A, Lubbers MM, Kurata A et al (2016) Coronary CT angiography derived fractional flow reserve: methodology and evaluation of a point of care algorithm. J Cardiovasc Comput Tomogr 10:105–113CrossRefPubMedGoogle Scholar
  31. 31.
    Baumann S, Wang R, Schoepf UJ et al (2015) Coronary CT angiography-derived fractional flow reserve correlated with invasive fractional flow reserve measurements--initial experience with a novel physician-driven algorithm. Eur Radiol 25:1201–1207CrossRefPubMedGoogle Scholar
  32. 32.
    Nørgaard BL, Jensen JM, Leipsic J (2015) Fractional flow reserve derived from coronary CT angiography in stable coronary disease: a new standard in non-invasive testing? Eur Radiol 25:2282–2290CrossRefPubMedGoogle Scholar
  33. 33.
    Plank F, Burghard P, Friedrich G et al (2016) Quantitative coronary CT angiography: absolute lumen sizing rather than %stenosis predicts hemodynamically relevant stenosis. Eur RadiolGoogle Scholar

Copyright information

© European Society of Radiology 2016

Authors and Affiliations

  • Akira Kurata
    • 1
    • 2
    Email author
  • Adriaan Coenen
    • 2
    • 3
  • Marisa M. Lubbers
    • 2
    • 3
  • Koen Nieman
    • 2
    • 3
  • Teruhito Kido
    • 1
  • Tomoyuki Kido
    • 4
  • Natsumi Yamashita
    • 5
  • Kouki Watanabe
    • 6
  • Gabriel P. Krestin
    • 2
  • Teruhito Mochizuki
    • 1
  1. 1.Department of RadiologyEhime University Graduate School of MedicineToonJapan
  2. 2.Department of RadiologyErasmus University Medical CenterRotterdamthe Netherlands
  3. 3.Departmenet of CardiologyErasmus University Medical CenterRotterdamthe Netherlands
  4. 4.Department of RadiologyMatsuyama Saiseikai HospitalMatsuyamaJapan
  5. 5.Division of Clinical Biostatistics, Section of Cancer Prevention and EpidemiologyClinical Research Center, National Hospital Organization Shikoku Cancer CenterMatsuyamaJapan
  6. 6.Department of CardiologyMatsuyama Saiseikai HospitalMatsuyamaJapan

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