Fractional flow reserve guided revascularization in daily practice: clinical judgment does not always meet science

Measurement of the fractional flow reserve (FFR) during invasive coronary angiography is the accepted ''gold standard'' for assessing the functional significance of coronary artery lesions by determination of the characteristics of blood flow proximal and distal to a coronary stenosis during pharmacologically-mediated hyperemia. Abnormal FFR is associated with higher cardiac event rate if the coronary lesion is left untreated. On the other hand, it was shown that patients derived no clinical benefit from revascularization of angiographically obstructive lesions which were hemodynamically insignificant according to FFR (>0.8). This editorial comment refers to an observational cohort study which reported that in approximately 20% of real world patients the treatment strategy chosen was discordant with FFR findings. Our comment discusses these findings and concludes that while the standard of care is to treat patients in accordance with their FFR results (when available), it should be recognized that there are some clinical scenarios that may require a treatment strategy that is discordant with FFR result.