Recommendation for NHSScotland

• HeartFlow fractional flow reserve computerised tomography (FFRCT) is non-invasive, safe and, by improving specificity, may improve the diagnosis of obstructive versus non-obstructive coronary artery disease (CAD) following computerised tomography-coronary angiography (CT-CA).
• HeartFlow FFRCT may be considered as an option alongside a set of complementary diagnostic tools for patients with stable, recent onset chest pain symptoms who have undergone CT-CA with adequate image quality on a 64-slice (or above) CT scanner.
  • Compared with standard care, using HeartFlow FFRCT may reduce the requirement for invasive coronary angiography (ICA) to further assess patients with CAD, though noting that the quality of supporting clinical-effectiveness evidence was limited.
  • HeartFlow FFRCT should be considered in the context of patients with reported CAD following CT-CA, patient symptoms and the introduction of guideline directed medical therapy.
  • The use of HeartFlow FFRCT should be determined in the context of the diagnostic resources and expertise available to the referring clinician. HeartFlow FFRCT may be of particular value in remote locations, when access to complementary diagnostic tools is limited.
• Use of Heartflow FFRCT has the potential to lead to cost savings, primarily driven by a reduction in referrals for ICA. There is uncertainty about the level of cost savings achievable, due to variations in clinical practice when investigating chest pain and the use of different patient management strategies.

NHSScotland is required to consider the Scottish Health Technologies Group (SHTG) advice.

What were we asked to look at?

HeartFlow FFRCT is a coronary physiologic simulation software that creates three dimensional visualisations of coronary physiology from data acquired from a standard CT-CA image. SHTG was asked to consider HeartFlow guidance produced by NICE, as part of an adaptation for NHSScotland.

Why is this important?

Treating and preventing heart disease is a national clinical priority for Scotland, as outlined in the Heart Disease Action Plan.³ There is a growing demand on interventional cardiac services in Scotland through a combination of increased referrals for ICA, a growth in structural heart intervention and significant pressures on cardiac catheterisation laboratories (Richard Good, Consultant Cardiologist, NHS Golden Jubilee, Personal Communication, June 2021). There are currently six sites in Scotland which conduct percutaneous coronary intervention (PCI), with over 9,000 cases in 2018/19. There were 10,352 diagnostic coronary angiographs (without angioplasty) carried out in 2017/18.⁴

Use of HeartFlow FFRCT data is intended to complement the anatomical information provided by CT-CA to aid diagnosis and management of patients with CAD and minimise the number of unnecessary invasive procedures conducted in patients who turn out to have non-flow-limiting coronary artery stenosis.

Referred by

Scottish Government