Abstract
The current management of acute coronary syndromes (ACS) is with an invasive strategy to guide treatment. However, identifying the lesions which are physiologically significant can be challenging. Non-invasive imaging is generally not appropriate or timely in the acute setting, so the decision is generally based upon visual assessment of the angiogram, supplemented in a small minority by invasive pressure wire studies using fractional flow reserve (FFR) or related indices. Whilst pressure wire usage is slowly increasing, it is not feasible in many vessels, patients and situations. Limited evidence for the use of FFR in non-ST elevation (NSTE) ACS suggests a 25% change in management, compared with traditional assessment, with a shift from more to less extensive revascularisation. Virtual (computed) FFR (vFFR), which uses a 3D model of the coronary arteries constructed from the invasive angiogram, and application of the physical laws of fluid flow, has the potential to be used more widely in this situation. It is less invasive, fast and can be integrated into catheter laboratory software. For severe lesions, or mild disease, it is probably not required, but it could improve the management of moderate disease in 'real time' for patients with non-ST elevation acute coronary syndromes (NSTE-ACS), and in bystander disease in ST elevation myocardial infarction. Its practicability and impact in the acute setting need to be tested, but the underpinning science and potential benefits for rapid and streamlined decision-making are enticing.
Highlights
There is a further uncertainty, which applies to to be 0.75–0.85, doubt will remain, and a measured value may measured Fractional flow reserve (FFR), which is that the physiological significance of a lesion, in the acute patient, may not correlate with the presence of vulnerable plaque [77,78,79], probably explaining why long term outcomes are worse in Acute coronary syndrome (ACS) compared with Chronic coronary syndrome (CCS), even with physiological guidance. Virtual (computed) FFR (vFFR), whilst being an improvement over current management, is unlikely to provide a complete treatment strategy
A major attraction of vFFR for patients with ACS is that it can be used at the time of invasive management in a “one-stop shop,” in which coronary anatomy can be revealed alongside lesionspecific ischaemia testing
Because vFFR requires optimal angiographic images, many cases would be excluded using this approach; and it would be subject to the limitations of retrospective studies
Summary
The fundamental limitation of CAG is that it is an anatomical, not a physiological, test which reveals luminal stenoses, with a poor relationship to blood flow and the identification of “significant” coronary artery disease [1]. There is considerable inter-observer variability in lesion assessment [3]. These weaknesses are only partly addressed by using quantitative coronary angiography, which has its own limitations [4]. Assessment is critically dependent upon the quality of the angiographic images; inadequate contrast, insufficient projections, overlapping. Role of vFFR in ACS vessels, excess movement, and lesions located at ostia, branch points and in series pose particular challenges. It cannot reveal the vulnerability or instability of lesions without the assistance of intravascular imaging, this is a limitation of physiological assessment [5]
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