R-AAOCA  carries risk of dynamic vessel compression, with invasive FFR- during dobutamine stress considered the reference standard. A prospective single-center cohort study from Bern, Switzerland, published in JAMA Cardiology, evaluated whether noninvasive imaging could reduce reliance on invasive testing.

The study included 55 adults (mean age 51 years, 67% male) with newly detected R-AAOCA and an intraarterial or /intramural course. Hemodynamic relevance, defined as FFR-dobutamine ≤0.8, was present in 15 patients (27%). Coronary computed tomography angiography (CCTA) using ostial minor axis achieved 100% sensitivity and negative predictive value, with modest specificity of 57% specificity (AUC 0.82). This allowed safe exclusion of hemodynamic disease in 23 patients (42%).

Functional nuclear imaging detected ischemia in 4 patients (7%), yielding sensitivity of 27% but perfect specificity and positive predictive value (100%) and overall accuracy of 80%.

These findings suggest that a stepwise imaging strategy, beginning with CCTA to rule out hemodynamic relevance and using nuclear testing to confirm high-risk cases, may reduce invasive procedures in R-AAOCA.