Reproducibility, Accuracy, and Treatment Impact of Ischemia Severity Assessment From Coronary Angiography　- An ORBITA...

This study aimed to assess the accuracy and intra-operator reproducibility of ischemia assessments from coronary angiography, as performed by interventional cardiologists, and its influence on treatment strategies.

Twenty-two interventionalists predicted fractional flow reserve (predFFR) from 194 angiograms obtained from patients with single-vessel disease in the Objective Randomized Blinded Investigation with Optimal Medical Therapy of Angioplasty in Stable Angina (ORBITA) study. For each case, respondents selected either angio-guided percutaneous coronary intervention (PCI), medication, or a physiology-guided approach. Respondents were divided into high- and low-physiology-use groups based on the frequency of selecting physiology-guided treatment. Physiological strategies were chosen for 60.3% and 23.9% of the cases in the high and low groups, respectively. Correlations between predFFR and measured FFR values were weak (r=0.451; P<0.001), with 84.7% agreement for fractional flow reserve ≤0.80 and 75.0% for severity classification. Intra-operator agreement for treatment strategy in duplicate cases was 76.9%. Bland-Altman analysis showed considerable variability in repeated predFFR estimations (limits of agreement -0.16 to +0.15), exceeding thresholds considered acceptable in clinical practice. Although the diagnostic concordance was similar, the low group made more inappropriate treatment decisions, notably selecting PCIs for non-ischemic lesions, and more often opted for medication in truly ischemic patients compared with the high group (P<0.001).

Visual prediction of ischemia from angiography is limited in accuracy and reproducibility. Physiological assessment remains essential for determining the appropriate treatment.