Real-Life Functional Assessment of Coronary Stenosis: We Are Yet to Convert to It

The use of functional assessment of coronary stenosis (following the class IA recommendation in both American and European guidelines) is below 50% in daily clinical practice. Truth be told, most operators continue having blind faith in angiography. The inclusion of coronary physiology in the decision-making process has spread widely across countries, sites, and operators.

The ERIS (Evolving Routine Standards of FFR Use) study involved 76 Italian centers and included consecutive patients during 60 days. Its aim was to assess the use of coronary physiology in daily practice and discern the reasons for its nonuse.

The study enrolled two pre-specified patient groups: 1) patients who were treated by operators who usually apply fractional flow reserve (FFR)/instantaneous wave-free ratio (iFR), and 2) patients (group 2) who were treated by operators who decided not to perform a functional assessment. Both patient groups were similar as regards their baseline characteristics.

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Overall, 1858 total cases were included (1177 in the group of patients whose operators regularly use FFR/iFR, and 681 patients whose operators use visual estimation). Physiology-based assessment was used in 7% of all angiographies and 13% of all angioplasties. Such level of use entails correspondence with European and American guidelines in only 48% of cases.

The main reason for not using FFR/iFR was that operators considered that clinical and angiographic data alone were sufficient for the decision-making process. In this analysis, the required tools were available for operators, who simply trusted in angiography. A factor that weighs on the level of use of functional assessment in other sites is health insurance coverage, among other administrative reasons. If all evidence in favor of FFR/iFR can only convince half the operators, what can we expect from those who provide funding and have to cover procedural costs?

Conclusion

The use of functional assessment of coronary stenosis in daily practice meets the current guideline recommendations in approximately 50% of cases. The main limiting factor was simply operator’s confidence in the visual assessment of lesions.

Original title: Evolving Routine Standards in Invasive Hemodynamic Assessment of Coronary Stenosis. The Nationwide Italian SICI-GISE Cross-Sectional ERIS Study.

Reference: Matteo Tebaldi et al. J Am Coll Cardiol Intv 2018. Online before print.

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