Invasive Coronary Physiology in Contemporary Practice: From Lesion Selection to Comprehensive PCI Guidance and...

Area of Science:

• Cardiology
• Interventional Cardiology
• Physiology

Background:

• Invasive coronary physiology has advanced from assessing intermediate stenoses to a comprehensive diagnostic and treatment framework for coronary artery disease (CAD).
• Contemporary approaches focus on catheterization laboratory applications, optimizing percutaneous coronary intervention (PCI), and evaluating patients with angina and non-obstructive coronary arteries (ANOCA/INOCA).

Purpose of the Study:

• To provide an updated, catheterization laboratory-centered overview of current invasive coronary physiology.
• To emphasize its role in optimizing PCI and evaluating ANOCA/INOCA.

Main Methods:

• A narrative review of contemporary evidence, including randomized trials, consensus documents, and guideline recommendations.
• Examination of key physiological indices: fractional flow reserve (FFR), non-hyperemic pressure ratios (NHPRs), coronary flow reserve (CFR), and index of microcirculatory resistance (IMR).
• Evaluation of emerging tools like longitudinal vessel analysis and pullback pressure gradient (PPG), and their applications in pre- and post-PCI assessment, physiology-imaging integration, and functional testing in ANOCA/INOCA.

Main Results:

• Physiology-guided PCI demonstrates improved clinical outcomes and resource utilization compared to angiography-guided strategies.
• Longitudinal vessel assessment and PPG aid in characterizing focal versus diffuse CAD, enhancing procedural planning and predicting post-PCI results.
• Post-PCI assessment identifies residual ischemia and guides optimization, while combined microvascular and vasomotor assessment in ANOCA/INOCA enables mechanism-based individualized therapy.

Conclusions:

• Contemporary invasive coronary physiology offers a multidimensional approach integrating epicardial, microvascular, and vasomotor factors.
• This framework supports personalized decision-making, optimizes revascularization, and reduces unnecessary interventions.
• It represents a cornerstone of modern coronary care, enhancing diagnostic precision and therapeutic strategies.