Do You See What I See? Time for a Standardized Approach to Angiography-Based Decision Making

The relative merit of percutaneous coronary intervention (PCI) for the treatment of stable ischemic heart disease remains a debated issue. Clinical trials that have relied mostly on a visual estimate of angiographic stenosis severity for subject selection have failed to demonstrate a clinical benefit for PCI when compared with guideline-directed medical therapy alone. Meanwhile, studies using a measure of coronary physiology, the fractional flow reserve (FFR), have not only confirmed a benefit for PCI in treatment of lesions assessed as hemodynamically significant (FFR≤0.80) but also shown the potential for unnecessary PCI and associated harm using a visual angiography-guided strategy. Indeed, the discordance between visual estimates and FFR is 65% for lesions judged to have 50% to 70% diameter stenosis and 20% even for those lesions judged to have 70% to 90% diameter stenosis. On the basis of available data, current consensus guidelines in the United States and Europe recommend FFR-guided PCI as class IIa and I indications, respectively. Likewise, the appropriate use criteria for coronary revascularization endorsed by multiple cardiovascular societies incorporate FFR measurements for assessment of borderline lesions.