How Different is Invasive Coronary Physiology in the Left Anterior Descending Artery?

Given the large amount of myocardium supplied by the left anterior descending (LAD) artery, it understandably receives additional scrutiny during coronary angiography. However, these same features make the interpretation of pressure wire physiology more nuanced to avoid overtreatment. This review provides case examples to underpin an extensive literature review supporting the argument that a "positive" fractional flow reserve (FFR) in the LAD needs to be approached with caution. A large hyperemic gradient, or low FFR, can arise from either a severe and focal lesion in conjunction with low flow or diffuse disease coupled with intact or normal flow. Separating these two scenarios, and the wide continuum between them, ultimately requires upstream assessment of absolute myocardial perfusion, although a pressure wire pullback can help identify diffuse patterns unsuitable for revascularization.