• Coronary Angiography
• Percutaneous Coronary Intervention
• Coronary Stenosis
• Coronary Artery Disease

The need for percutaneous coronary intervention (PCI) following an invasive coronary angiogram may be determined by angiographic appearance alone or with invasive coronary physiologic guidance using fractional flow reserve (FFR). The two key objectives of PCI are to alleviate symptoms of myocardial ischaemia and to reduce major adverse cardiac events (MACE). Historically, the sole determinant of the need for revascularisation at the time of invasive coronary angiography was percent diameter stenosis of a diseased artery. A recognition of the limitations of this approach prompted a shift to incorporating the functional impact of coronary stenoses. This led to the development of FFR to invasively assess the haemodynamic significance of a stenosis. It measures the pressure decline across a stenosis and expresses it as the ratio of maximum flow in a stenotic vessel compared with normal maximum flow. It was proposed that revascularisation could be safely deferred in angiographically intermediate stenoses below the threshold for haemodynamic significance by FFR.1 Early outcome data suggested a reduction in MACE with the use of FFR to guide PCI compared with angiography alone.2 As a result, the uptake of FFR increased markedly over the last two decades. Today, FFR is the standard of care in guiding decision-making regarding revascularisation. Modern-day clinicians rely heavily on FFR measurements when challenged by ambiguity in either the patient’s symptoms or angiographic appearances. It provides an objective basis for discussions with patients and sound decision-making.

In this issue, Elbadawi et al present a literature-based meta-analysis of randomised controlled trials that studied the outcome of FFR-guided compared with angiography-guided PCI.3 They include more recent trials, longer …