Journal Article

Angiogram-derived physiology: will it change the game or miss the boat?

Curzen, Nick

2024

Overview

Correspondence to Professor Nick Curzen, Coronary & Structural Heart Research Group, University Hospital Southampton NHS Foundation Trust, Southampton, Hampshire, UK; [e-mail] Ghobrial et al describe the impact that one coronary angiogram-derived physiology system, virtual fractional flow reserve (vFFR), has on diagnosis and decision-making of cardiologists when assessing patients undergoing diagnostic angiography for either chronic coronary syndrome or non-ST elevation (NSTE) myocardial infarction (MI), when compared with angiography alone.1 In 320 patients, the availability of vFFR data led to a significant reduction in the number of vessels considered to have important disease and changed the management in 22% of cases when compared with their classification using angiography alone. Reassuringly, the degree of reclassification of vessels with significant disease and overall change in management reported in VIRTU4 are remarkably similar to the results of RIPCORD (Does routine pressure wire assessment influence management strategy at coronary angiography for diagnosis of chest pain?),2 on which this methodology was based, and several other studies that employed intracoronary pressure wire assessment of all coronary arteries of a size consistent with revascularisation and compared outcomes with angiographic assessment alone.3 The vFFR results certainly therefore raise the possibility that such profound alterations in diagnosis and management could be harnessed in routine clinical practice to aid more accurate treatment for individual patients undergoing coronary angiography. Specifically, the evidence base from observational and randomised trials unequivocally demonstrates that FFRCT significantly reduces both the number of ICA and the proportion of ICA that shows no significant coronary disease.6 Furthermore, as confidence in this technology grows, Heart Team consensus will allow for patients to undergo CABG surgery based on FFRCT results without the need for ICA. [...]in the near future, the majority of patients who undergo ICA will be those with known coronary disease very likely to require PCI: those with unobstructed coronary arteries, mild disease and surgical disease will be detected and managed based on non-invasive testing and, where appropriate, Heart Team discussion. [...]in randomised trials, the value of having routine and comprehensive information on coronary physiology at the time of ICA has consistently turned out to be lower than would be predicted from data derived from initial observational testing.

• Publisher: BMJ Publishing Group Ltd and British Cardiovascular Society,BMJ Publishing Group LTD
• Subject: Cardiology / Cardiovascular disease / Catheters / Clinical medicine / Coronary Angiography / Coronary vessels / Diagnostic Imaging / Editorial / Funding / Heart attacks / Medical imaging / Patients / Physiology / Vein & artery diseases