Non-Invasive Fractional Flow Reserve (FFR) for Ischemic Heart Disease

FFRct (noninvasive, CT-derived fractional flow reserve using FDA-approved software) is considered reasonable for intermediate-risk patients with acute or stable chest pain when CCTA demonstrates 40–90% proximal or mid coronary stenosis and for patients with persistent ischemic symptoms despite maximally tolerated medical therapy; it can serve as an alternative to stress testing. FFRct is contraindicated or not reasonable in multiple scenarios including prior coronary grafts, intracoronary stents, prosthetic valves, recent MI (≤30 days), suspicion of acute coronary syndrome, post-heart transplant, pacemaker/ICD leads, newly diagnosed systolic heart failure without prior left-heart catheterization, and when CCTA image quality is insufficient or stenoses are <40% or >90%. Coverage requires a completed/interpreted CCTA with percent stenosis/location documented, provision of CCTA images for FDA-approved post-processing, and documentation of risk status and prior medical therapy per cited guidelines and the ISCHEMIA trial.