Current State of Computed Tomography Derived Fractional Flow Reserve (FFR-CT) and Its Diagnostic Advantages

Coronary computed tomography angiography (CCTA) is widely used for noninvasive evaluation of coronary artery disease (CAD) and is highly sensitive for detecting anatomic coronary stenosis with a high negative predictive value. However, CCTA is limited in its ability to determine the physiological significance of lesions, resulting in reduced specificity and disagreement with invasive coronary angiography in a substantial proportion of cases. Fractional Flow Reserve derived from CCTA (FFR-CT) was developed to address this anatomic–physiologic discordance by providing noninvasive, lesion-specific functional assessment of ischemia. This narrative review summarizes the current state of FFR-CT technology, its diagnostic performance relative to CCTA alone and invasive FFR, and its evolving role in contemporary CAD evaluation. Across prospective trials and meta-analyses, FFR-CT consistently improves diagnostic accuracy for ischemia-producing lesions, driven primarily by gains in specificity, with favorable agreement to invasive FFR at clinically relevant thresholds. Advances in computational modeling and machine learning have substantially reduced processing times, improving feasibility and workflow integration. Clinical studies demonstrate that incorporation of FFR-CT following CCTA improves selection for invasive coronary angiography, reduces unnecessary diagnostic catheterization, and provides prognostic information beyond anatomic disease burden alone. Important limitations remain, including dependence on CCTA image quality, reduced reliability in heavily calcified or complex coronary anatomy, and uncertainty near ischemic thresholds, necessitating careful interpretation within the clinical context. When applied selectively after high-quality CCTA, FFR-CT offers a robust noninvasive surrogate for invasive coronary physiology and supports a more targeted, physiology-guided diagnostic pathway for patients with suspected CAD.