Thresholds of the Invasive Physiological Indices Associated with Anginal Symptoms and an Impaired Exercise Capacity in Patients with Chronic Coronary Syndrome

Q: What are the key findings of this study?

Fractional flow reserve and diastolic pressure ratio predicted anginal symptoms during a 6-minute walk test with an AUC of 0.68, yielding optimal cutoff values of 0.52 and 0.60, respectively.

Q: What is the clinical evidence from this study?

Study design: Observational. Population: Chronic coronary syndrome (n=174). Intervention: Fractional flow reserve (FFR) and diastolic pressure ratio (dPR). Primary outcome: Prediction of anginal symptoms during the 6-minute walk test (AUC 0.68, 95% CI 0.57-0.78, p=<0.001).

Q: What does this research mean for the field?

Fractional flow reserve and diastolic pressure ratio predict typical anginal symptoms during a 6-minute walk test with optimal cutoff values of 0.52 and 0.60, respectively, but do not predict impaired exercise capacity. Novelty: ClaimNovelty.NOVEL_FINDING. Consensus alignment: ConsensusAlignment.NEUTRAL.

Q: What question did this study set out to answer?

To identify the thresholds of invasive physiological indices, specifically fractional flow reserve and non-hyperemic pressure ratios, associated with anginal symptoms and impaired exercise capacity in patients with chronic coronary syndrome.

Natsuki Higashimoto; Yasutsugu Shiono; Daisuke Higashioka; Hiroki Emori; S Kuki; Yasushi Ino; Toshikazu Hashizume; Toshio Imanishi; Akira Taruya; Masahiro Takahata; Teruaki Wada; Y Ozaki; Hironori Kitabata; Atsushi Tanaka

doi:10.7793/jcad.32.26-00005

June 24, 2026Journal of Coronary Artery DiseaseOpen Access

Thresholds of the Invasive Physiological Indices Associated with Anginal Symptoms and an Impaired Exercise Capacity in Patients with Chronic Coronary Syndrome

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Key result

FFR and dPR predict anginal symptoms during a 6MWT with an AUC of 0.68.

AUC 0.68
95% CI 0.57-0.78
P<0.001
n=174

Why the study?

Although physiological thresholds for ischemia and revascularization are established, the values of FFR and NHPRs associated with patient symptoms remain unclear.

What are the thresholds of FFR and NHPRs associated with anginal symptoms and impaired exercise capacity in patients with chronic coronary syndrome?

Key Points

To identify the thresholds of invasive physiological indices, specifically fractional flow reserve and non-hyperemic pressure ratios, associated with anginal symptoms and impaired exercise capacity in patients with chronic coronary syndrome.
Prospective multicenter study enrolled 208 patients across five institutions in Japan between July 4, 2022, and January 25, 2025, analyzing 174 patients with chronic coronary syndrome.
Invasive physiological assessments were performed using fractional flow reserve (FFR) and the diastolic pressure ratio (dPR).
Exercise capacity and the occurrence of typical anginal symptoms were evaluated using the 6-minute walk test (6MWT) alongside patient-reported outcome measures including SAQ-7 and RDS.
Typical anginal symptoms occurred in 40 patients (23%) during the 6MWT; ROC analyses identified optimal cutoff values of 0.52 for FFR (AUC, 0.68; 95% CI, 0.57–0.78; P < 0.001) and 0.60 for dPR (AUC, 0.68; 95% CI, 0.57–0.78; P < 0.001) for predicting symptoms.
Multivariable logistic regression demonstrated that FFR per 0.10 increase (OR, 0.60; 95% CI, 0.45–0.76; P < 0.001) and dPR per 0.10 increase (OR, 0.71; 95% CI, 0.58–0.85; P < 0.001) were significantly associated with typical anginal symptoms during the 6MWT.
Neither FFR (AUC, 0.56; 95% CI, 0.46–0.65; P = 0.28) nor dPR (AUC, 0.57; 95% CI, 0.46–0.66; P = 0.09) predicted an impaired exercise capacity.

Study Design

Type

Observational (n=174)

Multicenter

Yes

Structured PICO

What are the thresholds of FFR and NHPRs associated with anginal symptoms and impaired exercise capacity in patients with chronic coronary syndrome?

P

Population

174 patients aged 20 years or older with suspected chronic coronary syndrome undergoing coronary angiography were evaluated to identify physiological thresholds associated with anginal symptoms.

E

Exposure

Measurement of fractional flow reserve (FFR) and non-hyperemic pressure ratios (NHPRs)

O

Outcome

Thresholds associated with anginal symptoms and an impaired exercise capacitypatient reported

Main Result

Effect estimate: AUC 0.68 (95% CI 0.57-0.78)

p-value: p=<0.001

This study aims to identify the specific thresholds of invasive physiological indices (FFR and NHPRs) that correlate with anginal symptoms and impaired exercise capacity in patients with chronic coronary syndrome.

Limitations

The 6-minute walk test may have had reduced sensitivity if patients voluntarily limited exertion to avoid symptom onset.
Excluded patients with low left ventricular ejection fraction, severe heart failure, prior coronary artery bypass grafting, hemodynamic instability, or severe valvular heart disease.
The observational design meant anti-anginal medications were more likely prescribed to symptomatic patients, confounding their association with symptoms.

Implication

Modest predictive performance warrants caution in symptom-based decisions; leaves open validation in larger prospective cohorts.

Abstract

Objective: The thresholds of the fractional flow reserve (FFR) and non-hyperemic pressure ratios (NHPRs) for identifying myocardial ischemia and guiding coronary revascularization are well-established (FFR ≤ 0.80 and NHPRs ≤ 0.89). However, the values associated with patient symptoms remain unclear. This study aimed to identify the thresholds associated with anginal symptoms and an impaired exercise capacity in patients with chronic coronary syndrome (CCS).

Discussion

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Cite This Study

Higashimoto et al. (2026) conducted an observational in Chronic coronary syndrome (n=174). Fractional flow reserve (FFR) and diastolic pressure ratio (dPR) was evaluated on Prediction of anginal symptoms during the 6-minute walk test (AUC 0.68, 95% CI 0.57-0.78, p=<0.001). Fractional flow reserve and diastolic pressure ratio predicted anginal symptoms during a 6-minute walk test with an AUC of 0.68, yielding optimal cutoff values of 0.52 and 0.60, respectively.

synapsesocial.com/papers/6a3f67aaaea7db3c1953f15c https://doi.org/10.7793/jcad.32.26-00005

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Thresholds of the Invasive Physiological Indices Associated with Anginal Symptoms and an Impaired Exercise Capacity in Patients with Chronic Coronary Syndrome

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

Thresholds of the Invasive Physiological Indices Associated with Anginal Symptoms and an Impaired Exercise Capacity in Patients with Chronic Coronary Syndrome

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

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