Functional assessment of coronary atherosclerosis in the catheterization laboratory: the key role of fractional flow reserve

Patients with suspected coronary artery disease often undergo coronary angiography without prior non-invasive functional stress testing, mainly because of logistic reasons, shortcomings of the non-invasive tests, and a more widespread confidence in invasive techniques. The availability in the catheterization laboratory of the pressure-derived fractional flow reserve (FFR) has provided the interventional cardiologist with the ideal tool for appropriate decision-making based on the functional significance of the coronary stenosis detected at the angiogram. In fact, FFR allows a more refined and individualized understanding of the true severity of coronary artery disease, and, therefore, a more appropriate selection of the epicardial lesions to be treated, especially in patients with dubious lesions and complex disease. A clinical decision-making based on coronary pressure measurement results in a more effective strategy than placing stents on a "trial and error" basis. This is particularly true in case of drug-eluting stents where an approach based on an indiscriminate multi-stenting will annihilate the benefits of these new stents and be unacceptably expensive. In addition, many angiographically mild stenoses happen to be hemodynamically significant and, therefore, deserve revascularization, especially in the drug-eluting stent era.