FFR Going FFR Going Beyond Beyond

AngiographyAngiographyByBy

Amr El NagarAmr El Nagar

•Should this lesion be stented ??

Back to the Basic Back to the Basic Coronary PhysiologyCoronary Physiology

• • Coronary blood flow = 3-5% of C.O.Coronary blood flow = 3-5% of C.O.• • Resting myocardial O2 demand isResting myocardial O2 demand isextremely high (20 x skeletal O2 demand)extremely high (20 x skeletal O2 demand)• • Myocardium extracts maximum O2Myocardium extracts maximum O2from blood (80% versus 30-40% skeletal muscle)from blood (80% versus 30-40% skeletal muscle)• • Myocardium has high capillary densityMyocardium has high capillary density(3000-4000/mm2 versus 500-2000/mm2 skeletal muscle)(3000-4000/mm2 versus 500-2000/mm2 skeletal muscle)• • Therefore, only way to meet increasingTherefore, only way to meet increasingdemand is to increase blood flowdemand is to increase blood flow

Coronary Blood Flow vs Percent Coronary Blood Flow vs Percent Diameter StenosisDiameter Stenosis

AutoregulationAutoregulation

AutoregulationAutoregulation

HyperemiaHyperemia

Hyperemia is a state of myocardial vasculature Hyperemia is a state of myocardial vasculature dilatationdilatation

Myocardial bed can be pharmacologically dilated Myocardial bed can be pharmacologically dilated with an agent eg:Adenosinewith an agent eg:Adenosine

occurs naturally in the body in small quantities occurs naturally in the body in small quantities and is produced during exercise to assist in the and is produced during exercise to assist in the dilatation of the myocardial bed.dilatation of the myocardial bed.

Physiology to Address Clinical Physiology to Address Clinical Questions in the Cath Lab…Questions in the Cath Lab…

FFRFFR What ??????????????What ?????????????? Why???????????????Why??????????????? How??????????????How?????????????? When?????????????When????????????? $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

What is FFR?What is FFR?

Maximum flow down a vessel in the presence of a stenosis…

…and

maximum flow in the hypothetical absence of the stenosis

It is aIt is a RatioRatio betweenbetween

Derivation of FFRDerivation of FFR FFR = FFR = Coronary Coronary FlowFlow(Stenosis)(Stenosis)

Coronary Coronary FlowFlow (Normal) (Normal)

Coronary Flow = Coronary Flow = PressurePressure Resistance Resistance

at maximal hyperemia at maximal hyperemia Coronary Flow ≈PressureCoronary Flow ≈Pressure

So, FFR = So, FFR = Coronary Coronary PressurePressure(Stenosis)(Stenosis) Coronary Coronary PressurePressure (Normal) (Normal)

FFR threshold for ischemiaFFR threshold for ischemia

FFR

Noischemia

Yes ischemia

1.00 0.75 0.00

FFR < 0.75 inducible ischemia (spec. 100 % )FFR > 0.75 no inducible ischemia (sens. 90 % )

Pijls, De Bruyne et al, NEJM 1996

Why FFR(is it Why FFR(is it superior)????superior)????

*Stenting of non-ischemic stenoses has no benefit *Stenting of non-ischemic stenoses has no benefit compared to medical treatment only.compared to medical treatment only.

*Stenting of ischemia-related stenoses improves *Stenting of ischemia-related stenoses improves symptoms and outcome.symptoms and outcome.

*In multivessel coronary disease (MVD), identifying *In multivessel coronary disease (MVD), identifying which stenoses cause ischemia is difficult.which stenoses cause ischemia is difficult.

*Non-invasive tests are often unreliable in MVD and *Non-invasive tests are often unreliable in MVD and coronary angiography often results in both under or coronary angiography often results in both under or overestimation of functional stenosis severity.overestimation of functional stenosis severity.

Limitations of Anatomic Limitations of Anatomic Techniques:Techniques:

- Underestimates diffuse disease

- Large Intra- and inter-observer variability

- Not designed to assesses physiologic lesion significance

Limitations of Non-Invasive StudiesLimitations of Non-Invasive StudiesSPECT ImagingSPECT Imaging

- SPECT imaging 70% - SPECT imaging 70% sensitivity for single sensitivity for single vessel diseasevessel disease

- - SPECT imaging has SPECT imaging has 85-90% sensitivity 85-90% sensitivity for detecting for detecting disease in patients disease in patients with MVD, but only with MVD, but only 50% sensitivity for 50% sensitivity for detecting MVD detecting MVD ischemia patternischemia pattern

But FFR !!!!• FFR is not influenced by changes in blood pressure, heart rate, or contractility

• FFR has a unique normal value of 1.0 in every patient and every coronary artery

• FFR incorporates the contribution of collateral flow to myocardial perfusion

How????How????Technique!!!!Technique!!!!

Pressure WirePressure Wire

Pressure sensorTipGuide wire - 0.014

straight or ‘J’ tip

pressure sensor - 3 cm proximal to the end of the wire

RADI ANALYZERRADI ANALYZER PRESSURE PRESSURE WIREWIRE

EquipmentsEquipments

Aorta coronaryartery

Myocardium

100 0

Normal perfusion pressure

Pa

100 Pd0

Stenotic perfusion pressure

Pa

Qnormal

Qstenosis

Qstenosis Stenotic perfusion press. Pd

FFR = = = Qnormal Normal perfusion press. Pa

Max. hyperemia

Pd

blood pressure distal to the lesion being blood pressure distal to the lesion being assessed - assessed - Pressure distal (Pd)Pressure distal (Pd)

conventional pressure transducer - measures conventional pressure transducer - measures arterial/aortic pressure - arterial/aortic pressure - Pressure arterial (Pa)Pressure arterial (Pa)

mean pressuresmean pressures of Pd and Pa are used of Pd and Pa are used assuming there is assuming there is no lesionno lesion present = present = no no

differencedifference in pressure in pressure The difference between these two The difference between these two

pressures pressures taken at resttaken at rest determines if there determines if there is a is a resting gradient across a lesionresting gradient across a lesion

Gradient calculation = Gradient calculation = Pd/Pa.Pd/Pa.

no lesion, the pressures will be the same no lesion, the pressures will be the same and therefore the gradient value will be 1and therefore the gradient value will be 1

  e.g. Pa = 150 mmHge.g. Pa = 150 mmHg Pd = 150mmHgPd = 150mmHg

   So, So, Pd/Pa = 1 Pd/Pa = 1

  

Dilation of Dilation of micro-vasculaturemicro-vasculature increases increases oxygen demandoxygen demand

a flow limiting lesion will cause the blood a flow limiting lesion will cause the blood pressure distalpressure distal to the lesion to fall to the lesion to fall

FFRFFR will fall  will fall  The extent of this reduction gives an The extent of this reduction gives an

indication as to the degree of flow indication as to the degree of flow limitation and hence degree of severity of limitation and hence degree of severity of stenosisstenosis

Vasodilatory Agents for Vasodilatory Agents for HyperemiaHyperemia

Where to Administer Where to Administer Adenosine?Adenosine?

Examples of coronary Examples of coronary pressure gradient pressure gradient

Coronary pressure Coronary pressure measuremntsmeasuremnts

Pitfalls and Pitfalls and ArtifactsArtifacts

Technical:Technical: loose connectionloose connection

leak in guide connectionsleak in guide connections

improper zeroimproper zero

Inadequate hyperemiaInadequate hyperemia

Anatomic/Theoretical:Anatomic/Theoretical: Ostial, diffuse diseaseOstial, diffuse disease

microvascular diseasemicrovascular disease

Extreme tortuosityExtreme tortuosity

Serial lesionsSerial lesions

Mechanical/Hemodynamic:Mechanical/Hemodynamic: Guide catheter obstructionGuide catheter obstruction

Low drug deliveryLow drug delivery

Insufficient HyperemiaInsufficient Hyperemia

IV Adenosine:-IV Adenosine:- Check infusion, pump system and linesCheck infusion, pump system and lines Infuse through central veinInfuse through central vein Avoid Valsalva maneuver during infusionAvoid Valsalva maneuver during infusion

For Intracoronary route:-For Intracoronary route:- Guiding catheter failure to seat Guiding catheter failure to seat flow obstruction-incorrect dose mix or flow obstruction-incorrect dose mix or

dilutiondilution incorrect dose mix or dilutionincorrect dose mix or dilution

Reasons of Non-ischemic FFR Reasons of Non-ischemic FFR Despite an Apparently Tight Despite an Apparently Tight

StenosisStenosis

Physiologic explanations:Physiologic explanations: Stenosis hemodynamically nonsignificant Stenosis hemodynamically nonsignificant

despite angiographic appearancedespite angiographic appearance Small perfusion territory, old MI, little viable Small perfusion territory, old MI, little viable

tissue, small vesseltissue, small vessel Abundant collateralsAbundant collaterals Severe microvascular disease (rarely affecting Severe microvascular disease (rarely affecting

FFR)FFR)

Interpretable explanations:Interpretable explanations: Other culprit lesion, diffuse disease not focal Other culprit lesion, diffuse disease not focal

stenosisstenosis Chest pain of noncardiac originChest pain of noncardiac origin

Technical explanations:Technical explanations: Insufficient hyperemiaInsufficient hyperemia Guiding catheter related pitfall (deep Guiding catheter related pitfall (deep

engagement, small ostium,sideholes)engagement, small ostium,sideholes) Electrical driftElectrical drift

Actual false negative FFR:Actual false negative FFR: Acute phase of ST elevation myocardial Acute phase of ST elevation myocardial

infarctioninfarction Severe left ventricular hypertrophySevere left ventricular hypertrophy Exercise-induced spasmExercise-induced spasm

When FFR???(value)When FFR???(value)

Borderline lesionsBorderline lesions Evaluation of PCIEvaluation of PCI

FFR after coronary intervention FFR after coronary intervention should preferably be higher than should preferably be higher than 0.900.90

Multicenter registry Europe-Multicenter registry Europe-USAUSA-Asia-Asia

750 pat. post-STENT FFR 750 pat. post-STENT FFR

0.96-1.000.86-0.90 0.91-0.950.81-0.850.76-0.800%

10%

20%

30%

40%

% death, infarction, or re-intervention at 6 mnths.

4%

7%

19%

28%

37%

Post-STENT FFR

After stenting: Inverse correlation between FFR and event rate.

How does FFR works How does FFR works in complex coronary in complex coronary

disease?disease?

• difficult anatomy, poorly visible lesions, overlapdifficult anatomy, poorly visible lesions, overlap

• multiple stenoses within one arterymultiple stenoses within one artery

• diffuse diseasediffuse disease• left main diseaseleft main disease• multivessel diseasemultivessel disease

LAD D 1D 2

Male, 67, stable angina, positive exercise test

RCA

LCX

2 intermediate stenoses mid RCA Complex lesion proximal LAD

0

100

FFR = 92/98 = 0.94

Pa

Pd

Pa

Pd

LAD, hyperemia

FFR = 87/97 = 0.890

100

Pa

Pd

Pa

Pd

DIAG 2, hyperemia

FFR = 87/96 = 0.900

100

Pa

Pd

Pa

Pd

DIAG 1, hyperemia

0

100Pa

PdFFR = 38/92 = 0.41

RCA, hyperemia

Balloon 3.0 mm

FFR = 55/82 = 0.67

100

0

Pa

Pd

After balloon inflation3.0 balloon 12 atm

Stent 3.5 mm(mid-RCA)

Stent 3.5 mm(mid-RCA)

FFR = 76/95 = 0.80

100

0

Pa

Pd

Pull back pressure wire

Pressure drop

Additional Stent 3.5 mm (prox-RCA)

Stent 3.5 mm(mid-RCA) +Stent 3.5 mm(prox-RCA)

FFR = 88/94 = 0.94

100

0

Pa

Pd

In this patient with complex coronary artery disease,coronary pressure measurement:

• confirmed the appropriateness of stenting the RCA while avoiding a riskful intervention of the LAD or bypass surgery

• Selected the correct spots in the RCA where to stent

• evaluated the result of stenting.

How does FFR works How does FFR works in complex in complex

coronary coronary disease?disease?

• difficult anatomy, poorly visible lesions, overlapdifficult anatomy, poorly visible lesions, overlap

• multiple stenoses within one arterymultiple stenoses within one artery

• diffuse diseasediffuse disease• left main diseaseleft main disease• multi vessel diseasemulti vessel disease

AB

Coronary Pressure & FFR: Pull-Back CurveCoronary Pressure & FFR: Pull-Back Curve

Focal disease: sudden changes in pressure

Coronary Pressure & FFR: Pull-Back CurveCoronary Pressure & FFR: Pull-Back Curve

Diffuse coronary disease: gradual increase of pressure.

• By slowly retrieving the pressure wire under By slowly retrieving the pressure wire under fluoroscopy and sustained hyperemia fluoroscopy and sustained hyperemia

• the individual contribution of every segment the individual contribution of every segment of the of the coronary system coronary system to the extent of disease can be to the extent of disease can be studied and such spatial information cannot be studied and such spatial information cannot be obtained by any other methodobtained by any other method

FFR: The Pressure Pull-back CurveFFR: The Pressure Pull-back Curve

How does FFR works How does FFR works in complex coronary in complex coronary

disease?disease?

• difficult anatomy, poorly visible lesions, overlapdifficult anatomy, poorly visible lesions, overlap

• multiple stenoses within one arterymultiple stenoses within one artery

• diffuse diseasediffuse disease• long and ostial lesionslong and ostial lesions• left main diseaseleft main disease

• mmultiultivessel diseasevessel disease

Decision making in equivocal left main coronary artery

disease by Fractional Flow Reserve

Bech et al, Heart 2001

•The presence of angiographic clearly significant LMCA stenosis is often decisive in the choice for invasive strategy.

•However, often patients are encountered with angiographically an intermediate LMCA stenosis of unclear physiological significance.

•It is unclear whether bypass surgery should be performed.

Aim of the study

•To investigate the usefulness of pressure derived FFRto decide between medical versus surgical therapy in patients with equivocal LMCA disease.

follow-up54 patients

FFR > 0.75N=24

Medical Group

FFR < 0.75N=30

Surgical Group

Mean follow-up (mths) 28 15 2914

Death 0 1

MI 0 1

Early re-operation -- 3

CABG 3 0

PTCA 2 0

Total 5 (21%) 5 (17%)

Conclusion

•FFR is useful in equivocal left main coronary artery disease.

•If LM FFR 0.75, a conservative medical of the LM lesion approach seems to be safe.

•If LM FFR < 0.75, the stenosis bears physiologic significance which justifies bypass surgery of the LM lesion.

How does FFR works How does FFR works in complex coronary in complex coronary

disease?disease?

• difficult anatomy, poorly visible lesions, overlapdifficult anatomy, poorly visible lesions, overlap

• multiple stenoses within one arterymultiple stenoses within one artery

• diffuse diseasediffuse disease• long and ostial lesionslong and ostial lesions• left main diseaseleft main disease

• mmultiultivessel diseasevessel disease (FAME Study) (FAME Study)

Evidence BasedEvidence BasedDEFER STUDY:DEFER STUDY:

A Multicenter Randomized Study A Multicenter Randomized Study to Compare Deferral Versus to Compare Deferral Versus Performance of PCI of Non-Performance of PCI of Non-Ischemia-Producing StenosesIschemia-Producing Stenoses

The DEFER Study: DesignThe DEFER Study: Design

prospective randomized multicentric trial prospective randomized multicentric trial (14 centers) in 325 patients with stable (14 centers) in 325 patients with stable chest pain and an intermediate stenosis chest pain and an intermediate stenosis without objective evidence of ischemiawithout objective evidence of ischemia

AalstAmsterdamEindhoven Essen Gothenborg Hamburg Liège

Maastricht Madrid Osaka Rotterdam Seoul Utrecht Zwolle

The DEFER Study: The DEFER Study: ObjectivesObjectives

• to test to test safetysafety of deferring PCI of stenoses of deferring PCI of stenoses not responsible for inducible ischemia as not responsible for inducible ischemia as indicated by FFR > 0.75 ( indicated by FFR > 0.75 ( ““outcomeoutcome”” ))

Secondary objectiveSecondary objective

• to compare to compare quality of lifequality of life in such patients, in such patients, whether or not treated by PCI whether or not treated by PCI (CCS-class, need for anti-anginal drugs)(CCS-class, need for anti-anginal drugs) (“symptoms”)(“symptoms”)

Primary objective

DEFER Group

REFERENCE Group PERFORM Group

The DEFER Study: Flow ChartPatients scheduled for PCI without Proof of Ischemia

(n=325)

performance of PTCA (158)

deferral of PTCA (167)

FFR 0.75 (91)

No PTCA

FFR 0.75(90)

PTCA

FFR < 0.75(76)

PTCA

FFR < 0.75(68)

PTCA

RandomizationRandomization

performance of PTCA (158)

deferral of PTCA (167)

No. at riskNo. at risk

Defer groupDefer group 9090 8585 8282 7474 7373

7272

Perform groupPerform group 8888 7878 7373 7070 6767

6565

Reference grReference gr 135135 105105 103103 9696

9090

8888

78.8

72.7

64.4

0 1 2 3 4 50

25

50

75

100

Defer

Perform

Reference(FFR < 0.75)

p=0.52

p=0.17p=0.03

Years of Follow-up

event – free survival (%)

Cardiac Death And Acute MI After 5 Cardiac Death And Acute MI After 5 YearsYears

3.3

7.9

15.7

0

5

10

15

20 %

P=0.20

P< 0.03

P< 0.005

DEFER PERFORM REFERENCE

FFR > 0.75 FFR < 0.75

0%

20%

40%

60%

80%

100%

baseline 1month 1 year 2 year 5 year

Defer group Perform group Reference group

Freedom From Chest Pain

FFR > 0.75 FFR > 0.75 FFR < 0.75

* *

* *

* **

*

DEFER: SummaryDEFER: Summary

1.1. In patients with stable chest pain, the most important In patients with stable chest pain, the most important prognostic factor of a given coronary artery stenosis, prognostic factor of a given coronary artery stenosis, is its ability of inducing myocardial ischemia (as is its ability of inducing myocardial ischemia (as reflected by FFR < 0.75)reflected by FFR < 0.75)

2.2. In those patients, clinical outcome of such “ischemic” In those patients, clinical outcome of such “ischemic” stenosis, even when treated by PCI, is much worse stenosis, even when treated by PCI, is much worse than that of a functionally “non-significant” stenosis.than that of a functionally “non-significant” stenosis.

3. The prognosis of “non-ischemic” stenosis (FFR > 0.75) 3. The prognosis of “non-ischemic” stenosis (FFR > 0.75) is excellent and the risk of such “non-significant” is excellent and the risk of such “non-significant” stenosis or plaque to cause death or AMI is < 1% per stenosis or plaque to cause death or AMI is < 1% per year, year, and not decreased by stentingand not decreased by stenting

DEFER:DEFER:

Conclusion

Stenting a “non-ischemic” stenosis does not Stenting a “non-ischemic” stenosis does not benefit patients with stable chest pain, neither benefit patients with stable chest pain, neither

in prognostic nor symptomatic respect.in prognostic nor symptomatic respect.

FAME study:FAME study:

Study PopulationStudy PopulationThe FAME study was designed to reflect daily practice in The FAME study was designed to reflect daily practice in

performing PCI in patients with multivessel diseaseperforming PCI in patients with multivessel disease

Inclusion criteria:Inclusion criteria: ALL patients with multivessel diseaseALL patients with multivessel disease Stenoses ≥ 50% in 2 or 3 major epicardial Stenoses ≥ 50% in 2 or 3 major epicardial

coronary arteries, which are amenable for coronary arteries, which are amenable for stenting.stenting.

Exclusion criteria:Exclusion criteria: Left main disease or previous bypass surgeryLeft main disease or previous bypass surgery Acute STEMIAcute STEMI Extremely tortuous or calcified coronary Extremely tortuous or calcified coronary

arteriesarteries

PRIMARY ENDPOINT:PRIMARY ENDPOINT:

Composite of death, myocardial infarction, Composite of death, myocardial infarction, or repeat revascularization (“MACE”) at 1 or repeat revascularization (“MACE”) at 1 yearyear

SECONDARY ENDPOINTS:SECONDARY ENDPOINTS: Individual components of MACE at 1 yearIndividual components of MACE at 1 year Functional classFunctional class Use of anti-anginal drugsUse of anti-anginal drugs Health-related quality of life (EuroQOL-5D)Health-related quality of life (EuroQOL-5D) Procedure timeProcedure time Amount of contrast agent used during Amount of contrast agent used during

procedureprocedure Cost of the procedureCost of the procedure

CONCLUSIONS (1):CONCLUSIONS (1):

*Routine measurement of FFR during PCI with *Routine measurement of FFR during PCI with DES in patients with multivessel disease, when DES in patients with multivessel disease, when compared to current angiography guided compared to current angiography guided strategy:strategy:

Reduces the rate of the composite endpoint ofReduces the rate of the composite endpoint of

death, myocardial infarction, re-PCI and CABG at death, myocardial infarction, re-PCI and CABG at 1 year by ~ 30%1 year by ~ 30%

Reduces mortality and myocardial infarction at 1 Reduces mortality and myocardial infarction at 1 year by ~ 35 %year by ~ 35 %

CONCLUSIONS (2):CONCLUSIONS (2): Routine measurement of FFR during PCI with Routine measurement of FFR during PCI with

DES in patients with multivessel disease, when DES in patients with multivessel disease, when compared to current angiography guided compared to current angiography guided strategy:strategy:

Is cost-saving and does not prolong the Is cost-saving and does not prolong the procedure.procedure.

Reduces the number of stents used.Reduces the number of stents used. Decreases the amount of contrast agent used.Decreases the amount of contrast agent used. Results in a similar, if not better, functional Results in a similar, if not better, functional

status.status.

Routine measurement of FFR Routine measurement of FFR during PCI with DES supports during PCI with DES supports the evolving paradigm of:the evolving paradigm of:

““Functionally Complete Revascularization”Functionally Complete Revascularization”

i.e. revascularization of ischemic lesions and i.e. revascularization of ischemic lesions and medical treatment of non-ischemic ones.medical treatment of non-ischemic ones.

FFR and ViabilityFFR and Viability : :

Hibernating myocardium is defined as chronic, reversible Hibernating myocardium is defined as chronic, reversible left ventricular dysfunction due to CAD.left ventricular dysfunction due to CAD.

Several animal and human studies have shown that Several animal and human studies have shown that hibernating myocardium was characterized by a hibernating myocardium was characterized by a mismatch between flow and function: a dyssynergy in mismatch between flow and function: a dyssynergy in the presence of a normal (or near normal) myocardial the presence of a normal (or near normal) myocardial flow. Explaining the apparent paradox between severe flow. Explaining the apparent paradox between severe

contractile dysfunction in presence of normal flow.contractile dysfunction in presence of normal flow.

Lee et al,.Lee et al,. showed that dyssynergic myocardial segments with a showed that dyssynergic myocardial segments with a contractile reserve had a contractile reserve had a lower flow reservelower flow reserve than normal segments than normal segments but a but a significantly higher flow reservesignificantly higher flow reserve than dyssynergic segments than dyssynergic segments without contractile reserve.without contractile reserve.

The relationship between The relationship between hibernatinghibernating myocardium and myocardium and fraction flow fraction flow reservereserve can be summarized as follows: can be summarized as follows:

(a) resting flow is normal,(a) resting flow is normal, (b) flow reserve is reduced, (b) flow reserve is reduced,

(c) the higher flow reserve (but within the abnormal range), the (c) the higher flow reserve (but within the abnormal range), the higher the likelyhood and the higher the likelyhood and the

extent of viability.extent of viability.

Practically, in a patient with an epicardial stenosis and a Practically, in a patient with an epicardial stenosis and a dyssynergy at left ventricular angiogram, it is reasonable dyssynergy at left ventricular angiogram, it is reasonable to state that: to state that:

“ “a high FFR suggest the absence of reversible ischemia.”a high FFR suggest the absence of reversible ischemia.”

Cost-effectiveness issue:Cost-effectiveness issue: **compare the long-term costs and benefits of 3 strategies for compare the long-term costs and benefits of 3 strategies for

treating patients with an intermediate coronary lesion and no prior treating patients with an intermediate coronary lesion and no prior functional studyfunctional study::

1) deferring the decision for (PCI) to obtain a nuclear 1) deferring the decision for (PCI) to obtain a nuclear stress imaging study stress imaging study (NUC strategy)(NUC strategy)

2) measuring fractional flow reserve (FFR) at the time of 2) measuring fractional flow reserve (FFR) at the time of angiography to help guide the decision for PCI angiography to help guide the decision for PCI (FFR (FFR strategy)strategy)

3) stenting all intermediate lesions 3) stenting all intermediate lesions (STENT strategy).(STENT strategy).

*Division of Cardiovascular Medicine, Stanford University Medical Center, Stanford, Calif 94305-5406, USA. *Division of Cardiovascular Medicine, Stanford University Medical Center, Stanford, Calif 94305-5406, USA. wfearon@stanford.eduwfearon@stanford.edu

RESULTS:RESULTS:

The The FFR strategyFFR strategy saved saved 1795 $1795 $ per patient per patient compared with the compared with the NUC strategyNUC strategy and and 3830 $3830 $ compared with the compared with the STENT strategySTENT strategy. .

Quality-adjusted life expectancy was similar Quality-adjusted life expectancy was similar among the 3 strategies .among the 3 strategies .

CONCLUSION:CONCLUSION:

In patients with an intermediate coronary In patients with an intermediate coronary lesion and no prior functional study, lesion and no prior functional study,

measuring FFR to guide the decision to measuring FFR to guide the decision to perform PCI may lead toperform PCI may lead to

significant cost savingssignificant cost savings compared with performing nuclear stress compared with performing nuclear stress

imaging or with simply stenting lesions in imaging or with simply stenting lesions in all patients.all patients.

•Again.......Should this lesion be stented ??

FFRFFR

Thank Thank YouYou“If you want to treat a lesion, use IVUS;

if you want to treat it correctly, use FFR.”

IVUSIVUS