Coronary Flow Reserve in Patients with Intermediate FFR: Should We Use This Tool to Define When to Perform Coronary Angioplasty?

Current guidelines recommend using fractional flow reserve (FFR) to guide coronary angioplasty. However, intermediate FFR values (0.75-0.80) generate uncertainty about the prognostic value of performing coronary angioplasty over optimal medical treatment.

reserva fraccional de flujo sindrome coronario agudo

The use of coronary flow reserve (CFR) together with FFR provides further insight into coronary circulation because CFR is an index that also includes microcirculation assessment.

The aim of this retrospective study was to evaluate the prognosis between deferring vs. performing coronary angioplasty according to CFR score in patients with intermediate FFR.

The endpoint was treated vessel failure (TVF), defined as a composite of cardiovascular death, treated-vessel-related infarction, and clinically driven repeat vascularization of the treated vessel.

Out of the 2322 patients in the ILIAS Registry (Inclusive Invasive Physiological Assessment in Angina Syndromes Registry), 400 had intermediate FFR stenosis and were included in this study. Coronary angioplasty was differed in 210 patients (deferred group) and it was performed in 190 patients (performed group). They were further stratified according to CFR value into preserved CFR (>2) and decreased CFR (≤2).

Mean patient age was 60 years old. The most frequent clinical presentation was unstable angina. The most frequently treated artery was the anterior descending artery. According to CRF, angioplasty was performed in 38% of the preserved CFR cohort, and in 61% of the decreased CRF cohort.

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There were no significant differences in TVF between groups at 5 years of follow-up. However, when performed in decreased CRF patients, the risk of TVF was higher for the deferred group when compared with the performed group (17.2% vs. 14.2%, hazard ratio: 4.932; 95% confidence interval: 1.312 to 18.53; p = 0.018). This difference was at the expense of a higher rate of revascularization of the treated vessel (12.1% vs. 8.3%; p = 0.025).


In patients with an intermediate FFR of 0.75-0.80, the prognostic value of the therapeutic strategy differed according to CFR value. Coronary angioplasty was associated with a lower rate of TVF when the CFR was decreased. However, there were no differences in TVF in patients with preserved CFR.

CFR can be used to stratify risk in patients with intermediate FFR to determine therapeutic strategy.

Dr. Andrés Rodríguez
Member of the Editorial Board of .

Original Title: Differential Prognostic Value of Revascularization for Coronary Stenosis With Intermediate FFR by Coronary Flow Reserve.

Reference: Juwon Kim, MD et al J Am Coll Cardiol Intv 2022.

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