Current Use of Fractional Flow Reserve: A Nationwide Survey

Abstract

Major medical society guidelines recommend the measurement of fractional flow reserve (FFR) C oronary angiography has been well established as the initial invasive technique for evaluating coronary stenoses in patients with stable coronary artery disease (CAD), but its ability to determine the functional significance of an angiographically intermediate lesion is quite limited. Indeed, flow through a stenotic vessel is affected by multiple factors that cannot be measured by visual evaluation alone, such as flow entrance and exit angle, orifice shape, and degree of turbulence. Guidelines have recommended noninvasive functional tests before angiography.1 Nevertheless, only 44.5% of patients undergo stress testing in the 90 days before their elective percutaneous coronary intervention (PCI).2 Therefore, in many elective cases, the decision to stent is guided mainly by standard coronary angiographic findings. Indeed, 60.6% of PCIs in the American College of Cardiology National Cardiovascular Data Registry are performed ad hoc. Fractional flow reserve (FFR), defined as the pressure distal to a stenosis relative to the pressure proximal to that stenosis, enables the determination of flow impediment during maximal hyperemia and incorporates many lesion-specific variables, such as anatomic variability and the contribution of collateral vessels. The relative ease and safety of the test, as well as its documented sensitivity and specificity 4 (88% and 100%, respectively), make it ideal as objective documentation of the appropriateness of ad hoc PCI.The frequency of FFR use in daily practice is unknown. A recent study by Orvin and colleagues 5 showed that the operator's decision to stent was in discordance with FFR measurements in nearly 20% of cases. It is important to note that 83% of patients in Orvin's study had acute coronary syndrome (ACS), in which the clinical usefulness of FFR is less well established than in patients with stable CAD; in addition, interventionalists are generally more willing to perform PCI on ACS patients than on patients with stable CAD, even if their lesions are angiographically comparable. We performed a nationwide survey to determine how FFR is being applied by interventionalists in the United States to patients with stable CAD.

Fractional flow reserve use during elective coronary angiography among elderly patients in the US

“…Recent reports suggest physiologic assessment of coronary artery disease (CAD) prior to revascularization is low despite guidelines supporting its use [1,2]. In prior work, we found <10% of Medicare beneficiaries undergoing elective percutaneous coronary intervention (PCI) received fractional flow reserve (FFR) or equivalent physiological measurements [3].…”

Temporal Trends in Fractional Flow Reserve Use in Patients Undergoing Coronary Angiography: A Population-Based Study

“…Previous studies have shown an increase in the use of FFR since the seminal FAME study, focusing on practice from 2001 to 2013. [25][26][27][28][29] Indeed, more than 70% of physicians thought that the FAME trial led to more widespread use of FFR. 25 Harle et al 29 found a very low rate of FFR; nonetheless, they observed an increasing trend in use over the course of the study period.…”

Coronary Angiography With Pressure Wire and Fractional Flow Reserve

“…A survey conducted in 2012 among 1089 interventional cardiologists identified lack of availability (47%) and problems with reimbursement (39%) as the primary reasons for the infrequent use of FFR guidance (40). In Germany, however, FFR measurement is included in the diagnosis-related group (DRG) system.…”