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Published on: April 13, 2015
Assessment of coronary physiology - the evidence and implications
Noman Ali1, Peysh A Patel2, Christopher J Malkin2
1Leeds General Infirmary, Leeds, UK nomanali456@doctors.org.uk.
Insights
Assessing coronary lesions with angiography is limited. Intra-coronary physiology, like fractional flow reserve (FFR), can guide interventions and improve outcomes, with newer methods potentially replacing FFR.
Area of Science:
- Cardiovascular medicine
- Interventional cardiology
Background:
- Angiography alone cannot determine the functional significance of coronary stenoses.
- Ischemia presence is key for revascularization benefit in stable coronary artery disease.
Purpose of the Study:
- To highlight the limitations of angiography in assessing coronary lesions.
- To discuss the role and limitations of fractional flow reserve (FFR) and introduce an alternative technique.
Main Methods:
- Review of existing studies on coronary lesion assessment and intervention guidance.
- Discussion of fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) methodologies.
Main Results:
- Intra-coronary physiology assessment, including FFR, guides percutaneous coronary intervention, especially for borderline stenoses.
- FFR is under-utilized despite evidence suggesting improved clinical outcomes with its routine use.
Conclusions:
- Intra-coronary physiology assessment is crucial for guiding interventions and improving outcomes in coronary artery disease.
- Instantaneous wave-free ratio (iFR) offers a hyperaemia-free alternative to FFR, potentially becoming the new standard.
Abstract:
Use of angiography for the assessment of coronary lesions is limited by its inability to provide information regarding the functional significance of stenoses. A number of studies have demonstrated the presence of ischaemia to be the most important determinant of the benefit associated with coronary revascularisation in stable coronary artery disease. Assessment of intra-coronary physiology can guide percutaneous coronary intervention, and is often used for angiographically borderline stenoses. There is now increasing evidence to suggest that more routine use can improve clinical outcomes. Fractional flow reserve (FFR) is the most established measure of intra-coronary physiology, but is currently under-utilised. The main drawback of FFR is the dependence on a pharmacological infusion to maintain hyperaemia. An alternative technique which measures flow at a specific point in the cardiac cycle (instantaneous wave-free ratio) has been developed which obviates the need for hyperaemia and may replace FFR as the default measure.
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