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Updated: Jul 16, 2026
Interventional Diagnostic Procedure: A Practical Guide for the Assessment of Coronary Vascular Function
Published on: March 15, 2022
How good are experienced interventional cardiologists at predicting the functional significance of intermediate or
Michael Lindstaedt1, Martin Spiecker, Christian Perings
1Medical Clinic II, University Hospital Bergmannsheil, Bochum, Germany. michael.lindstaedt@rub.de
Insights
Visual assessment of left main coronary artery (LMCA) stenosis is inaccurate. Fractional flow reserve (FFR) is crucial for determining the functional significance of intermediate or equivocal LMCA lesions, as visual assessment by experienced cardiologists yields poor results.
Area of Science:
- Cardiovascular medicine
- Interventional cardiology
- Diagnostic imaging
Background:
- Coronary revascularization decisions often rely on visual stenosis assessment.
- Fractional flow reserve (FFR) is safe and feasible for intermediate left main stem lesions.
- Accurate assessment of intermediate or equivocal left main coronary artery (LMCA) stenoses is critical.
Purpose of the Study:
- To assess the accuracy of visual angiographic interpretation of intermediate/equivocal LMCA stenoses.
- To compare visual assessment against fractional flow reserve (FFR) as the gold standard.
- To evaluate the performance of experienced interventional cardiologists in classifying LMCA lesion significance.
Main Methods:
- Fifty-one patients with intermediate (40-80% diameter stenosis) or equivocal LMCA disease underwent FFR evaluation.
- Four experienced interventional cardiologists, blinded to FFR results, visually assessed angiograms.
- Lesion significance was classified as 'significant', 'not significant', or 'unsure'.
Main Results:
- Reviewers achieved correct lesion classification in approximately 50% of cases, irrespective of FFR threshold.
- Interobserver agreement, beyond chance, averaged only 16%.
- Unanimous correct classification occurred in only 29% of cases, highlighting significant interobserver variability.
Conclusions:
- Angiographic assessment alone is insufficient for determining the functional significance of intermediate/equivocal LMCA stenoses.
- Experienced interventional cardiologists demonstrate limited accuracy and high variability in visual interpretation.
- FFR measurements are essential for reliable decision-making in these challenging cases.
Background:
Decisions for coronary revascularisation are frequently based on visual assessment of the severity of a stenosis. In patients with intermediate left main stem lesions clinical decision making based on FFR is safe and feasible. This study was performed to assess the accuracy of visual angiographic assessment of intermediate or equivocal left main coronary artery (LMCA) stenoses by experienced interventional cardiologists when taking fractional flow reserve (FFR) measurements as the gold standard.
Methods:
Fifty-one patients with intermediate (40-80% diameter stenosis by angiography) or equivocal LMCA disease were evaluated by FFR. Angiograms were then reviewed by 4 experienced interventionalists from different university hospitals blinded to FFR results. Lesions were visually assessed and their significance classified as 'significant', 'not significant', or 'unsure' if the observer was unable to make a decision regarding lesion significance based on the angiogram.
Results:
Results were compared with two different FFR cutoff values (< 0.75 and < or = 0.80) for hemodynamic significance. The 4 reviewers achieved correct lesion classification in no more than approximately 50% of cases each, regardless of FFR threshold. The interobserver agreement between two reviewers in excess of the agreement expected due to chance was outperformed on average by only 16%. Furthermore, interobserver variability was large resulting in unanimously correct lesion classification in only 29% of all cases.
Conclusions:
The functional significance of intermediate and equivocal LMCA stenoses should not be based solely on angiographic assessment even by experienced interventional cardiologists.
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