Practical Application of Coronary Physiologic Assessment

Figure 1. Physiologic Approach for Coronary Bifurcation Lesions Based on the previous evidence, treatment strategy flow of coronary bifurcation intervention based on angiographic, physiologic, and imaging assessments is suggested. Reprinted with permission from the Central Illustration in J Am Coll Cardiol Intv. 2022;15(13):1297-1309. FFR = fractional flow reserve; IVUS = intravascular ultrasound; MV = main vessel; NHPR = nonhyperemic pressure ratio; OCT = optical coherence topography; SB = side branch.

Figure 2. Discordance Between Anatomic and Physiologic Severity in Coronary Bifurcation Lesions Discordance between angiographic and physiologic severities has been reported in about 30% to 40% of coronary stenosis. The distribution of mismatch (angiographic diameter stenosis >50% and FFR ≥0.80, orange) and reverse mismatch (diameter stenosis ≤50% and FFR <0.80, gray) is different between left main disease and non-left main disease. The reverse mismatch was more frequently observed in left main disease than in non-left main disease. DS = diameter stenosis; FFR = fractional flow reserve.

Figure 3. Physiologic Assessment of Nonculprit Lesion in Patients With ACS Based on the previous evidence, treatment strategy flow of nonculprit lesion treatment in patients with acute coronary syndrome based on invasive physiologic assessment is suggested. ACS = acute coronary syndrome; FFR = fractional flow reserve; NSTEMI = non–ST-segment elevation myocardial infarction; NHPR = nonhyperemic pressure ratio; PCI = percutaneous coronary intervention; STEMI = ST-segment elevation myocardial infarction.

Figure 4. FFR-Guided Drug-Coated Balloon Treatment for De Novo Coronary Artery Disease Based on the previous evidence, drug-coated balloon treatment can be performed safely and effectively after successful balloon angioplasty with physiology guidance. DCB = drug-coated balloon; DES = drug-eluting stent(s); FFR = fractional flow reserve.

Figure 5. Diagnosis and Management of INOCA INOCA can be suspected when a coronary angiogram shows no obstructive epicardial arteries and FFR or NHPR is negative in patients with chest pain. Coronary flow is determined by CFR and microvascular resistance, such as IMR. If either the CFR or IMR is abnormal, MVA is diagnosed. VSA is diagnosed based on the response to acetylcholine provocation. INOCA includes patients with MVA, VSA, or both. ACEi = angiotensin-converting enzyme inhibitor; CFR = coronary flow reserve; ECG = electrocardiogram; FFR = fractional flow reserve; INOCA = ischemia with no obstructive coronary artery; IMR = index of microvascular resistance; MVA = microvascular angina; NHPR = nonhyperemic pressure ratio; VSA = vasospastic angina.