Abstract
The assessment of functional severity of moderate coronary stenoses is challenging. Coronary angiography remains the standard technique for diagnosis, although, due to its limitations, it is frequently insufficient to detect relevant myocardial ischemia. Fractional flow reserve (FFR) is defined as the ratio between the mean hyperemic coronary artery pressure distal to the lesion and mean pressure in the aorta. The FFR measurement is currently supported by guidelines to evaluate the hemodynamic significance of lesions. Proper identification of patients that have the potential to benefit from revascularization is crucial. Based on already published literature, we focus on the long-term follow-up of patients with FFR-driven treatment. We also provide a review of specific clinical cases such as borderline FFR values, comorbidities or lesions in anatomical risk locations, in which interpretation can be challenging during the physiological assessment. The aim of this paper is to provide an overview of the evidence of FFR implementation in daily clinical practice and determine issues that raise doubts.
Highlights
Precise identification of significant stenosis in coronary artery disease (CAD) is of major importance during the treatment and decision-making process
A recent, multicenter study based on the J-CONFIRM registry investigated outcomes of deferred revascularization in a group of 1263 patients in whom the large majority of lesions (84.6%) demonstrated fractional flow reserve (FFR) > 0.80.40 The primary endpoint was target vessel failure (TVF), which consists of cardiac death, target vesselrelated myocardial infarction (MI) or clinically-driven target vessel revascularization (TVR)
In comparison with previous records[46,47] where cardiac events were reported in about 10% of women after percutaneous coronary intervention (PCI), the present study revealed that patient-oriented composite outcome (POCO) was reported in only 4.9% of women in deferred arms throughout the time of observation
Summary
Precise identification of significant stenosis in coronary artery disease (CAD) is of major importance during the treatment and decision-making process. The current European Society of Cardiology (ESC) guidelines recommend FFR and instantaneous wave-free ratio (iFR) measurement (both tools with IA class of recommendations) to assess the severity of intermediate-grade lesions in cases where there is no evidence of ischemia in non-invasive tests or in multivessel disease.[4] Only FFR is recommended to guide revascularization (IIa B); there. FFR should be considered for risk stratification in patients with conflicting results from noninvasive testing (IIa/B).[7] The guidelines indicate the need for randomized trials comparing the iFR-guided treatment strategy of patients with intermediate lesions compared with medical therapy. The ADVISE-in-practice study reported the correlation between an iFR threshold of 0.9 and FFR threshold of 0.8.12 Meta-analysis of 2 trials, Functional Lesion Assessment of Intermediate Stenosis to Guide Revascularisation (DEFINE-FLAIR) and The Instantaneous Wave-Free Ratio versus Fractional Flow Reserve in Patients with Stable Angina Pectoris or Acute Coronary Syndrome (iFR-SWEDEHEART), reported that iFRguided management was not inferior to FFR guidance in respect to death, myocardial infarction (MI) and unplanned revascularization.[13]
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