Key result
Visual prediction of FFR from angiography shows limited intra-operator reproducibility among interventional cardiologists.
Why the study?
The accuracy and intra-operator reproducibility of ischemia assessments from coronary angiography by interventional cardiologists, and its influence on treatment strategies, needed assessment.
Does visual prediction of ischemia from coronary angiography accurately and reproducibly estimate fractional flow reserve and guide appropriate treatment strategies?
Observational (n=194)
Blinded to clinical data and duplicate cases
Yes
Does visual prediction of ischemia from coronary angiography accurately and reproducibly estimate fractional flow reserve and guide appropriate treatment strategies?
Visual prediction of ischemia from coronary angiography has limited accuracy and reproducibility, underscoring the necessity of objective physiological assessments like FFR to guide appropriate revascularization decisions.
Supports caution with visual FFR estimates for decisions; leaves open whether training or tools improve reproducibility.
Background: This study aimed to assess the accuracy and intra-operator reproducibility of ischemia assessments from coronary angiography, as performed by interventional cardiologists, and its influence on treatment strategies. Methods and Results: Twenty-two interventionalists predicted fractional flow reserve (predFFR) from 194 angiograms obtained from patients with single-vessel disease in the Objective Randomized Blinded Investigation with Optimal Medical Therapy of Angioplasty in Stable Angina (ORBITA) study. For each case, respondents selected either angio-guided percutaneous coronary intervention (PCI), medication, or a physiology-guided approach. Respondents were divided into high- and low-physiology-use groups based on the frequency of selecting physiology-guided treatment. Physiological strategies were chosen for 60.3% and 23.9% of the cases in the high and low groups, respectively. Correlations between predFFR and measured FFR values were weak (r=0.451; P<0.001), with 84.7% agreement for fractional flow reserve ≤0.80 and 75.0% for severity classification. Intra-operator agreement for treatment strategy in duplicate cases was 76.9%. Bland-Altman analysis showed considerable variability in repeated predFFR estimations (limits of agreement -0.16 to +0.15), exceeding thresholds considered acceptable in clinical practice. Although the diagnostic concordance was similar, the low group made more inappropriate treatment decisions, notably selecting PCIs for non-ischemic lesions, and more often opted for medication in truly ischemic patients compared with the high group (P<0.001). Conclusions: Visual prediction of ischemia from angiography is limited in accuracy and reproducibility. Physiological assessment remains essential for determining the appropriate treatment.
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Nakayama et al. (2025) conducted an observational in Stable angina with single-vessel disease (n=194). Visual prediction of fractional flow reserve (predFFR) from coronary angiography vs. Measured fractional flow reserve (measFFR) was evaluated on Intra-operator reproducibility of predicted FFR (predFFR) (Mean difference -0.005, 95% CI -0.16 to +0.15). Visual prediction of fractional flow reserve from coronary angiography by interventional cardiologists showed limited intra-operator reproducibility, with limits of agreement from -0.16 to +0.15.
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