FFR-CT: Technical Advances and Implementation in Clinical Practice

Fractional flow reserve derived from coronary computed tomography angiography (FFR- CT) has emerged as a non-invasive modality for the functional assessment of coronary artery disease. By using computational fluid dynamics, particularly in its most extensively validated off-site implementation, FFR-CT enables lesion-specific estimation of pressure gradients across coronary stenoses without the need for invasive catheterization. This narrative review summarizes the technical foundations of FFR-CT as well as the evidence demonstrating that FFR-CT enhances the diagnostic accuracy of coronary CT angiography alone by improving specificity for hemodynamically significant stenoses when compared with invasive fractional flow reserve. Beyond diagnosis, FFR-CT provides incremental prognostic information, supporting risk stratification and guiding revascularization deci- sions. Suggestions for clinical implementation of FFR-CT and guidance on interpreting results within the appropriate clinical context are provided. Despite these advantages, limi- tations remain, including dependence on image quality, reduced performance in heavily calcified vessels, assumptions regarding hyperemic flow conditions, and limited validation in certain populations. While computational fluid dynamics-based FFR-CT remains the most commonly adopted approach in clinical settings, machine learning-based on-site FFR-CT is rapidly evolving and is expected to become a reliable alternative. As technical refinements continue, FFR-CT is poised to play an expanding role in precision-guided management of coronary artery disease.