Computed Tomography-derived Fractional Flow Reserve: Clinical Review for Cardiologist

Abstract Coronary artery disease remained a major global health burden, and although coronary computed tomography angiography provided detailed anatomical information, it lacked physiological assessment of lesion significance. Computed tomography derived fractional flow reserve integrated computational modeling with coronary computed tomography angiography, enabling combined anatomical and functional evaluation of coronary artery disease. This review summarized recent advances in computed tomography derived fractional flow reserve with respect to diagnostic accuracy, prognostic value, and clinical application. A systematic literature search was conducted in PubMed and Scopus using predefined keywords for English language articles published between 2022 and 2025. Study selection followed the PICO framework, including adult patients with suspected or established coronary artery disease, comparison with invasive fractional flow reserve or standard coronary computed tomography angiography, and outcomes related to diagnostic performance, clinical decision making, and prognosis. Of 911 retrieved records, 23 studies met the inclusion criteria after duplicate removal and eligibility screening. The included studies showed that computed tomography derived fractional flow reserve improved the specificity and overall diagnostic accuracy of coronary computed tomography angiography, reduced unnecessary invasive coronary angiography, and supported more appropriate revascularization decision making. In addition, computed tomography derived fractional flow reserve provided prognostic information for major adverse cardiovascular events and demonstrated consistent performance across diverse clinical settings, including transcatheter aortic valve replacement and acute coronary syndromes. Overall, computed tomography derived fractional flow reserve represented a reliable noninvasive modality that integrated anatomical and functional assessment and supported broader clinical implementation in the evaluation of coronary artery disease.