Visual vs. Quantitative Assessment of Coronary Stenosis Severity

Study Questions:

Is physician-based visual assessment (PVA) of angiographic stenosis severity accurate when compared to quantitative coronary angiography (QCA)?


This study evaluated patients enrolled in the PEACE (Patient-Centered Evaluative Assessment of Cardiac Events) cohort across 35 hospitals in 18 provinces in China from 2012-2013. A total of 1,295 patients underwent QCA by two core laboratories. Differences between PVA and QCA were evaluated and stratified by presence of acute myocardial infarction (AMI) at presentation, across hospitals and physicians.


The mean percent diameter (standard deviation), as reported by PVA, was 16.0 % (11.5%) greater than that measured by QCA among patients presenting without AMI, and 10.2% (12.3%) among patients with AMI (p < 0.001 for both). For lesions >70%, by PVA, only half were graded >70% by QCA. This was mainly evident for non-AMI lesions. There was wide variation in differences between PVA and QCA across hospitals and physicians. Less than 1% of lesions underwent physiological assessment.


Among patients undergoing PCI in China, PVA overestimated coronary stenosis compared to QCA, with significant variation across hospitals and physicians.


Similar to previous studies, this study highlights the known limitations of angiography alone for grading severity of coronary stenosis. Based on this study, PVA grossly overestimates extent of coronary stenosis when compared to core laboratory-based QCA assessment, especially among patients with non-AMI lesions. Furthermore, when evaluating lesions classified as >70% by PVA, QCA confirmed severity >70% in only half of the patients. The evidence supporting and mandating use of physiological assessment with fractional flow reserve or instantaneous wave-free ratio prior to percutaneous coronary intervention is mounting, and angiography alone should be used sparingly to guide revascularization.

Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Aortic Surgery, Interventions and ACS, Interventions and Imaging, Angiography, Nuclear Imaging

Keywords: Acute Coronary Syndrome, Angiography, Constriction, Pathologic, Coronary Angiography, Coronary Stenosis, Diagnostic Imaging, Fractional Flow Reserve, Myocardial, Myocardial Infarction, Myocardial Revascularization, Patient Outcome Assessment, Percutaneous Coronary Intervention

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