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The current knowledge on the pathophysiology of coronary artery stenosis stems from the seminal studies by Lance Gould, who first described the pressure/flow/resistance characteristics, defining the coronary flow reserve as the ratio between hyperaemic and basal flow [1]. From the beginning it was clear, indeed, that this technique had several major limitations, and therefore the concept of fractional flow reserve (FFR) was introduced. The FFR was defined as the ratio of two flows, calculated from two pressure values, obtained during maximal hyperaemia [2]. Consequently, the achievement of hyperaemia is the crucial prerequisite to assess FFR correctly. In this regard, the administration of intravenous (i.v.) adenosine is still considered the gold standard. Even so, the correct achievement of maximal hyperaemia has been acknowledged as one of the major challenges of this technique, leading to significant FFR underutilization worldwide [3].

The ongoing search for simplifying fractional flow reserve assessment: the role of contrast medium