Abstract
Invasive physiological assessment of the coronary circulation has emerged in recent years as a valuable diagnostic approach in the management of patients with chronic coronary syndrome, overcoming important limitations such as evaluating function from the anatomy and the low spatial resolution associated with angiography or non-invasive tests. The value of hyperemic flow measurements to estimate the functional relevance of coronary stenoses is supported by many studies. The aim of this paper is to review the physiological bases, clinical applications and limitations of myocardial fractional flow reserve, the main index used in the invasive functional assessment of the coronary circulation.
Highlights
It is well established that the presence of myocardial ischemia is one of the most important prognostic factors in patients with coronary artery disease (CAD).[1]
It is known that vessels presenting with fractional flow reserve (FFR) >0.80 can be safely treated conservatively, while an FFR ≤0.80 is a sign of myocardial ischemia
For the evaluation of FFR as a continuous variable across its spectrum of values, statistical modeling suggested the optimal FFR cut-off value to guide revascularization might be 0.67. This observation was corroborated by the registry IRIS-FFR (Interventional Cardiology Research In-cooperation Society Fractional Flow Reserve), which included >8,000 lesions, in which statistical modeling suggested that the optimal FFR threshold to predict cardiac death or myocardial infarction (MI) was 0.64, and that only vessels with FFR ≤0.75 correlated with better clinical outcomes when treated.[17]
Summary
It is well established that the presence of myocardial ischemia is one of the most important prognostic factors in patients with coronary artery disease (CAD).[1]. The value of FFR to ensure presence of myocardial ischemia has already been widely established.[11,12] It is known that vessels presenting with FFR >0.80 can be safely treated conservatively, while an FFR ≤0.80 is a sign of myocardial ischemia Patients in these cases could benefit from percutaneous or surgical revascularization procedures.[13,14,15] it is important to note that FFR reflects a continuum of risk, and there is an inverse relation between FFR values and the risk of adverse clinical events, increasing the potential usefulness of FFR beyond just a binary index. This observation was corroborated by the registry IRIS-FFR (Interventional Cardiology Research In-cooperation Society Fractional Flow Reserve), which included >8,000 lesions, in which statistical modeling suggested that the optimal FFR threshold to predict cardiac death or MI was 0.64, and that only vessels with FFR ≤0.75 correlated with better clinical outcomes when treated.[17]
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