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Clinical use of coronary artery pressure flow measurements

Morton J Kern, MD, MSCAI, FAHA, FACC
Section Editor
Donald Cutlip, MD
Deputy Editor
Gordon M Saperia, MD, FACC


Myocardial revascularization with either percutaneous coronary intervention or coronary artery bypass graft surgery is indicated when there is documentation of significant obstruction to coronary blood flow associated with myocardial ischemia in patients for whom medical therapy is expected to lead to suboptimal outcomes. In most cases, coronary artery stenoses with greater than 80 percent diameter reduction as seen on coronary angiography are associated with myocardial ischemia, the extent of which may or may not have been assessed with prior noninvasive testing.

In some patients, the coronary angiogram demonstrates one or more lesions that are not severely stenosed or appear hemodynamically "benign." For lesions associated with narrowing in the range of 40 to 80 percent diameter reduction [1,2], also called intermediate severity stenoses, obtaining coronary artery physiologic data, usually coronary artery pressure and flow, can facilitate clinical decision making regarding need for revascularization, particularly in individuals without noninvasive stress test documentation of myocardial ischemia (figure 1).


Sensor tipped angioplasty guidewires have been developed and are used to measure pressure and flow across a coronary stenosis in the catheterization lab [3-8]. The use of coronary pressure guidewires is generally safe and typically adds a few minutes to the total procedure time for the assessment of each lesion.

Fractional flow reserve (FFR) measures the pressures proximal to (aortic pressure) and distal to (guidewire pressure) stenotic lesions at maximal flow and creates a pressure ratio, representing the proportion of flow across that stenosis (waveform 1). For accurate FFR measurements, pressures obtained during hyperemia are required. Maximal blood flow (hyperemia) is most commonly induced by intravenous (140 mcg/kg/min) or intracoronary adenosine (right coronary artery 50 to 100 mcg, left coronary artery 100 to 200 mcg bolus ). The ratio of distal coronary pressure to aortic pressure (as recorded from the guide catheter) during maximal hyperemia is called the FFR. A normal value is 1, while values <0.80 are associated with provocable ischemia with an accuracy >90 percent [9]. The occurrence of false negative and false positive FFR values is rare.

FFR measurements in intermediate severity lesions have some inherent limitations. Both false positive and negative FFR values are uncommon but exist. The most common reasons to have a false negative FFR (ie, a high FFR) is guide catheter pressure damping (preventing flow into the vessel), failure to induce hyperemia (wrong concentration, poor intravenous infusion), or acute coronary syndrome with an impaired myocardial bed acutely that then improves over time. The initially high FFR, while not truly false, may be lower after the bed and the myocardial flow improve.

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Literature review current through: Nov 2017. | This topic last updated: Jun 06, 2017.
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  1. White CW, Wright CB, Doty DB, et al. Does visual interpretation of the coronary arteriogram predict the physiologic importance of a coronary stenosis? N Engl J Med 1984; 310:819.
  2. Kern MJ, Samady H. Current concepts of integrated coronary physiology in the catheterization laboratory. J Am Coll Cardiol 2010; 55:173.
  3. Qian J, Ge J, Baumgart D, et al. Safety of intracoronary Doppler flow measurement. Am Heart J 2000; 140:502.
  4. Kern MJ, Donohue TJ, Aguirre FV, et al. Clinical outcome of deferring angioplasty in patients with normal translesional pressure-flow velocity measurements. J Am Coll Cardiol 1995; 25:178.
  5. Ofili EO, Kern MJ, Labovitz AJ, et al. Analysis of coronary blood flow velocity dynamics in angiographically normal and stenosed arteries before and after endolumen enlargement by angioplasty. J Am Coll Cardiol 1993; 21:308.
  6. Donohue TJ, Kern MJ, Aguirre FV, et al. Assessing the hemodynamic significance of coronary artery stenoses: analysis of translesional pressure-flow velocity relations in patients. J Am Coll Cardiol 1993; 22:449.
  7. Miller DD, Donohue TJ, Younis LT, et al. Correlation of pharmacological 99mTc-sestamibi myocardial perfusion imaging with poststenotic coronary flow reserve in patients with angiographically intermediate coronary artery stenoses. Circulation 1994; 89:2150.
  8. Joye JD, Schulman DS, Lasorda D, et al. Intracoronary Doppler guide wire versus stress single-photon emission computed tomographic thallium-201 imaging in assessment of intermediate coronary stenoses. J Am Coll Cardiol 1994; 24:940.
  9. Pijls NH, De Bruyne B, Peels K, et al. Measurement of fractional flow reserve to assess the functional severity of coronary-artery stenoses. N Engl J Med 1996; 334:1703.
  10. Echavarria-Pinto M, Escaned J, Macías E, et al. Disturbed coronary hemodynamics in vessels with intermediate stenoses evaluated with fractional flow reserve: a combined analysis of epicardial and microcirculatory involvement in ischemic heart disease. Circulation 2013; 128:2557.
  11. Sen S, Escaned J, Malik IS, et al. Development and validation of a new adenosine-independent index of stenosis severity from coronary wave-intensity analysis: results of the ADVISE (ADenosine Vasodilator Independent Stenosis Evaluation) study. J Am Coll Cardiol 2012; 59:1392.
  12. Escaned J, Echavarría-Pinto M, Garcia-Garcia HM, et al. Prospective Assessment of the Diagnostic Accuracy of Instantaneous Wave-Free Ratio to Assess Coronary Stenosis Relevance: Results of ADVISE II International, Multicenter Study (ADenosine Vasodilator Independent Stenosis Evaluation II). JACC Cardiovasc Interv 2015; 8:824.
  13. Götberg M, Christiansen EH, Gudmundsdottir IJ, et al. Instantaneous Wave-free Ratio versus Fractional Flow Reserve to Guide PCI. N Engl J Med 2017; 376:1813.
  14. Davies JE, Sen S, Dehbi HM, et al. Use of the Instantaneous Wave-free Ratio or Fractional Flow Reserve in PCI. N Engl J Med 2017; 376:1824.
  15. Watkins S, McGeoch R, Lyne J, et al. Validation of magnetic resonance myocardial perfusion imaging with fractional flow reserve for the detection of significant coronary heart disease. Circulation 2009; 120:2207.
  16. Melikian N, De Bondt P, Tonino P, et al. Fractional flow reserve and myocardial perfusion imaging in patients with angiographic multivessel coronary artery disease. JACC Cardiovasc Interv 2010; 3:307.
  17. Waksman R, Legutko J, Singh J, et al. FIRST: Fractional Flow Reserve and Intravascular Ultrasound Relationship Study. J Am Coll Cardiol 2013; 61:917.
  18. Johnson NP, Kirkeeide RL, Gould KL. Coronary anatomy to predict physiology: fundamental limits. Circ Cardiovasc Imaging 2013; 6:817.
  19. Gonzalo N, Escaned J, Alfonso F, et al. Morphometric assessment of coronary stenosis relevance with optical coherence tomography: a comparison with fractional flow reserve and intravascular ultrasound. J Am Coll Cardiol 2012; 59:1080.
  20. Chamuleau SA, Tio RA, de Cock CC, et al. Prognostic value of coronary blood flow velocity and myocardial perfusion in intermediate coronary narrowings and multivessel disease. J Am Coll Cardiol 2002; 39:852.
  21. Leesar MA, Abdul-Baki T, Akkus NI, et al. Use of fractional flow reserve versus stress perfusion scintigraphy after unstable angina. Effect on duration of hospitalization, cost, procedural characteristics, and clinical outcome. J Am Coll Cardiol 2003; 41:1115.
  22. Ragosta M, Bishop AH, Lipson LC, et al. Comparison between angiography and fractional flow reserve versus single-photon emission computed tomographic myocardial perfusion imaging for determining lesion significance in patients with multivessel coronary disease. Am J Cardiol 2007; 99:896.
  23. Ntalianis A, Sels JW, Davidavicius G, et al. Fractional flow reserve for the assessment of nonculprit coronary artery stenoses in patients with acute myocardial infarction. JACC Cardiovasc Interv 2010; 3:1274.
  24. Sels JW, Tonino PA, Siebert U, et al. Fractional flow reserve in unstable angina and non-ST-segment elevation myocardial infarction experience from the FAME (Fractional flow reserve versus Angiography for Multivessel Evaluation) study. JACC Cardiovasc Interv 2011; 4:1183.
  25. Tobis J, Azarbal B, Slavin L. Assessment of intermediate severity coronary lesions in the catheterization laboratory. J Am Coll Cardiol 2007; 49:839.
  26. Bech GJ, De Bruyne B, Bonnier HJ, et al. Long-term follow-up after deferral of percutaneous transluminal coronary angioplasty of intermediate stenosis on the basis of coronary pressure measurement. J Am Coll Cardiol 1998; 31:841.
  27. Bech GJ, De Bruyne B, Pijls NH, et al. Fractional flow reserve to determine the appropriateness of angioplasty in moderate coronary stenosis: a randomized trial. Circulation 2001; 103:2928.
  28. Pijls NH, van Schaardenburgh P, Manoharan G, et al. Percutaneous coronary intervention of functionally nonsignificant stenosis: 5-year follow-up of the DEFER Study. J Am Coll Cardiol 2007; 49:2105.
  29. Ahn JM, Park DW, Shin ES, et al. Fractional Flow Reserve and Cardiac Events in Coronary Artery Disease: Data From a Prospective IRIS-FFR Registry (Interventional Cardiology Research Incooperation Society Fractional Flow Reserve). Circulation 2017; 135:2241.
  30. Chamuleau SA, Meuwissen M, Koch KT, et al. Usefulness of fractional flow reserve for risk stratification of patients with multivessel coronary artery disease and an intermediate stenosis. Am J Cardiol 2002; 89:377.
  31. Tonino PA, De Bruyne B, Pijls NH, et al. Fractional flow reserve versus angiography for guiding percutaneous coronary intervention. N Engl J Med 2009; 360:213.
  32. Van Belle E, Rioufol G, Pouillot C, et al. Outcome impact of coronary revascularization strategy reclassification with fractional flow reserve at time of diagnostic angiography: insights from a large French multicenter fractional flow reserve registry. Circulation 2014; 129:173.
  33. Li J, Elrashidi MY, Flammer AJ, et al. Long-term outcomes of fractional flow reserve-guided vs. angiography-guided percutaneous coronary intervention in contemporary practice. Eur Heart J 2013; 34:1375.
  34. Toth G, De Bruyne B, Casselman F, et al. Fractional flow reserve-guided versus angiography-guided coronary artery bypass graft surgery. Circulation 2013; 128:1405.
  35. Botman CJ, Schonberger J, Koolen S, et al. Does stenosis severity of native vessels influence bypass graft patency? A prospective fractional flow reserve-guided study. Ann Thorac Surg 2007; 83:2093.
  36. Pijls NH, De Bruyne B, Bech GJ, et al. Coronary pressure measurement to assess the hemodynamic significance of serial stenoses within one coronary artery: validation in humans. Circulation 2000; 102:2371.
  37. De Bruyne B, Pijls NH, Heyndrickx GR, et al. Pressure-derived fractional flow reserve to assess serial epicardial stenoses: theoretical basis and animal validation. Circulation 2000; 101:1840.
  38. Koo BK, Kang HJ, Youn TJ, et al. Physiologic assessment of jailed side branch lesions using fractional flow reserve. J Am Coll Cardiol 2005; 46:633.
  39. Pijls NH, Fearon WF, Tonino PA, et al. Fractional flow reserve versus angiography for guiding percutaneous coronary intervention in patients with multivessel coronary artery disease: 2-year follow-up of the FAME (Fractional Flow Reserve Versus Angiography for Multivessel Evaluation) study. J Am Coll Cardiol 2010; 56:177.
  40. van Nunen LX, Zimmermann FM, Tonino PA, et al. Fractional flow reserve versus angiography for guidance of PCI in patients with multivessel coronary artery disease (FAME): 5-year follow-up of a randomised controlled trial. Lancet 2015; 386:1853.
  41. Bech GJ, Droste H, Pijls NH, et al. Value of fractional flow reserve in making decisions about bypass surgery for equivocal left main coronary artery disease. Heart 2001; 86:547.
  42. Courtis J, Rodés-Cabau J, Larose E, et al. Usefulness of coronary fractional flow reserve measurements in guiding clinical decisions in intermediate or equivocal left main coronary stenoses. Am J Cardiol 2009; 103:943.
  43. Hamilos M, Muller O, Cuisset T, et al. Long-term clinical outcome after fractional flow reserve-guided treatment in patients with angiographically equivocal left main coronary artery stenosis. Circulation 2009; 120:1505.
  44. Fearon WF, Yong AS, Lenders G, et al. The impact of downstream coronary stenosis on fractional flow reserve assessment of intermediate left main coronary artery disease: human validation. JACC Cardiovasc Interv 2015; 8:398.
  45. Pijls NH, Klauss V, Siebert U, et al. Coronary pressure measurement after stenting predicts adverse events at follow-up: a multicenter registry. Circulation 2002; 105:2950.
  46. Fihn SD, Gardin JM, Abrams J, et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2012; 126:e354.
  47. Authors/Task Force members, Windecker S, Kolh P, et al. 2014 ESC/EACTS Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J 2014; 35:2541.