Fractional flow reserve (FFR) as a guide to treat coronary artery disease

The presence and extent of myocardial ischemia are the major determinants of prognosis in patients with coronary artery disease (CAD). Unlike coronary angiography alone, fractional flow reserve (FFR) has enabled interventional cardiologists to accurately determine whether coronary atherosclerotic plaques are responsible for myocardial ischemia, and therefore deserve to be revascularized. Areas covered: An overview on the role of FFR in the diagnosis and treatment of coronary artery disease, as well as the potential related controversies is provided. Authors describe the coronary physiology underneath this technique and all the procedural aspects in the catheterization laboratory. The landmark trials and the current applications in different coronary lesions and syndromes are also described and potential future research involving FFR and comparisons with other methodologies for the evaluation of coronary physiology are introduced. Expert commentary: FFR is still unsurpassed in diagnostic performance when compared to non-hyperemic indices and noninvasive techniques, and remains the gold standard for the detection of ischemia-inducing coronary stenoses. FFR-guided PCI has been demonstrated superior to an angiography-guided PCI and over medical therapy alone, and ongoing investigation will clarify whether it could perform better, or at least equalize the results of cardiac surgery in patients with severe multivessel disease.