FFR in Stable Coronary Disease and ACS | Ten Points to Remember

Berry C, Corcoran D, Hennigan B, et al.
Fractional Flow Reserve-Guided Management in Stable Coronary Disease and Acute Myocardial Infarction: Recent Developments. Eur Heart J 2015;Jun 2:[Epub ahead of print].

The following are 10 points to remember about fractional flow reserve (FFR)-guided management in stable coronary disease and acute coronary syndrome (ACS):

  1. FFR is an evidence-based diagnostic test of the physiological significance of a coronary artery stenosis.
  2. FFR is a pressure-derived index of the maximal achievable myocardial blood flow in the presence of an epicardial coronary stenosis as a ratio to maximum achievable flow if that artery were normal.
  3. Available evidence suggests that peripheral and central venous routes of adenosine administration are associated with similar minimum FFR values.
  4. In stable coronary artery disease (CAD), the evidence base supports revascularization of lesions with an FFR of ≤0.80, whereas CAD associated with an FFR of >0.80 can be managed medically.
  5. There is prognostic importance of the FFR value (as opposed to an FFR binary cut-off value), and patients who have a low-normal FFR value, i.e. 0.81–0.85, have a higher likelihood of future adverse cardiac events compared with patients with a near normal FFR value, i.e. 0.96–1.0.
  6. The diagnostic validity of FFR is less certain in ACS patients, partly because of concerns that the response to pharmacological vasodilatation may be reduced due to culprit artery microvascular obstruction, leading to false-negative FFR values.
  7. FFR is not valid in the culprit artery of ST-segment elevation myocardial infarction (STEMI) patients. However, FFR may be useful in non-STEMI (NSTEMI) patients since culprit (and nonculprit) antegrade flow is usually preserved.
  8. FFR may be used to assess noninfarct arteries in STEMI patients as part of a staged revascularization approach planned for days or weeks after the initial primary percutaneous coronary intervention.
  9. A large trial of FFR-guided management in NSTEMI patients that is designed and powered to assess health and economic outcomes seems warranted.
  10. The FFR threshold of 0.80 represents the upper limit of a transition zone for flow-limiting coronary disease, and patient-specific factors influence the FFR value. Good clinical practice should take into account all relevant information when making a revascularization decision.

Clinical Topics: Acute Coronary Syndromes, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Stable Ischemic Heart Disease, Interventions and ACS, Interventions and Coronary Artery Disease, Chronic Angina

Keywords: Acute Coronary Syndrome, Adenosine, Coronary Artery Disease, Coronary Disease, Coronary Stenosis, Diagnostic Tests, Routine, Fractional Flow Reserve, Myocardial, Myocardial Infarction, Percutaneous Coronary Intervention, Angina, Stable, Vasodilation

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