Background: Atherosclerotic coronary heart disease (CHD) is the commonest non-communicable disease worldwide and contributes to more than 1.2 million myocardial infarctions and nearly 500,000 deaths each year. The aim of the study was to assess FFR in patients with coronary lesions of intermediate/uncertain severity after conventional CAG and derive revascularization decision thereby. To assess how often FFR changes revascularization decisions in such patients and to analyse inter observer variability in angiographic decision making between experienced operators in coronary lesions of intermediate/uncertain severity.

Methods: We enrolled 40 patients with coronary lesions of intermediate/uncertain severity whose revascularization decision remained ambiguous as assessed by the primary operator after clinical and non-invasive data (TMT, DSE, stress MIBI) and coronary angiography.

Results: A total of 40 patients were enrolled for the study among which 79.3% were males and 20.7% females. The Mean age (± SD) in female group was 64.5± 6.097 years and that in male group was 59.3± 11.02 years. Eight coronary lesions were found to be of intermediate/ uncertain severity and were subjected to FFR. All lesions having FFR ≤ 0.8 underwent intervention while none of the lesion having FFR value of ≥ 0.8 were intervened. So there was significant association found between FFR value and decision changed.

Conclusion: FFR provides a reliable and objective assessment of intermediate/uncertain lesions leading to better revascularization decisions.

Keywords: Coronary Revascularization, coronary artery disease, Fractional Flow Reserve, FFR.

1. Lloyd-Jones, Adams R, Carnation M, et al. Heart Disease and Stroke Statistics--2009 update. A report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee.2009; 119: 480 – 486.
2. Baller GA, Zaret BL. Contributions of Nuclear Cardiology to diagnosis and prognosis of patients with Coronary Artery Disease. Circulation 2000; 101:1465-78.
3. Shaw LJ, Iskandrian AE. Prognostic value of Gated Myocardial Perfusion SPECT. Journal of Nuclear CardiologyMarch-April 2004; 11:171-85.
4. Shaw LJ, Berman DS, Maron DJ, et al. Optimal Medical Therapy with or without Percutaneous Coronary Intervention to reduce ischemic burden. Circulation 2008; 117:1283-9
5. Davies RF, Goldberg AD, Forman S, et al. Asymptomatic Cardiac Ischemia Pilot (ACIP) Study Two-Year Follow-up. Outcomes of patients randomized to initial strategies of Medical Therapy versus Revascularization. Circulation 1997; 95:2037-43.
6. Erne P, Schoenenberger AW, Burckhardt D, et al. Effects of Percutaneous Coronary Interventions in silent ischemia after Myocardial Infarction: The SWISSI II Randomized Controlled Trial. JAMA. 2007;297(18):1985-1991
7. Boden WE, O Rourke RA, Teo KK, et al. Optimal Medical Therapy with or without PCI for Stable Coronary Disease. N Engl J Med 2007; 356:1503-16.
8. Pijls NH, Van Schaardenburgh P, Manoharan G, et al. Percutaneous Coronary Intervention of functionally non-significant stenosis. 5 – Year follow-up of the DEFER Study. J Am CollCardiol 2007; 49:2105-11.
9. Moses JW, Stone GW, Nikosky E, et al. Drug-Eluting Stents in the treatment of intermediate lesions. Pooled analysis from four randomized trials J Am CollCardiol 2006; 47:2164-71.
10. Ong AT, Van Domburg RT, Aoki J, et al. Sirolimus-Eluting Stents remain superior to Bare-Metal Stents at two years: Medium-term results from the Rapamycin-Eluting Stent Evaluated at Rotterdam Cardiology Hospital (RESEARCH) Registry. J Am CollCardiol 2006; 47:1356-60.
11. Pijls NH, Van Gelder B, Van der Voort P, et al. Fractional Flow Reserve: A useful index to evaluate the influence of an Epicardial Coronary Stenosis on Myocardial Blood Flow. Circulation. 1995; 92:3183–3193.
12. De Bruyne, B, Pijls NH, VanGelder B, et al. Relation between Myocardial Fractional Flow Reserve calculated from Coronary Pressure Measurements and exercise-induced Myocardial Ischemia. Circulation. 1995; 92:39–46.
13. Pijls NH, De Bruyne B, Peels K, et al. Measurement of Fractional Flow Reserve to assess the functional severity of Coronary Artery Stenosis. N Engl. J Med 1996; 334:1703-8.
14. De Bruyne B, Bartunek J, Sys Su, et al. Relation between Myocardial Fractional Flow Reserve calculated from Coronary Pressure Measurements and exercise-induced Myocardial Ischemia. Circulation 199; 92:39-46.
15. De Bruyne B, Bartunek J, Sys S, et al. Simultaneous Coronary Pressure and Flow Velocity measurements in humans. Feasibility, reproducibility, and hemo-dynamic dependence of Coronary Flow Velocity Reserve, Hyperemia Flow versus Pressure Slope Index and Fractional Flow Reserve. Circulation 1996; 94:1842-9.
16. Frye RL, August P, Brooks MM, et al. A randomized trial of therapies for type 2 Diabetes and Coronary Artery Disease. N Engl J Med. 2009; 360:2503–2515.
17. Boden WE, O Rourke RA, Teo KK, Hartigan PM, et al. Optimal Medical Therapy with or without PCI for Stable Coronary Disease. N Engl J Med. 2007; 356:1503–1516.
18. Moses JW, Stone GW, Nikolsky E, et al. Drug-Eluting Stents in the treatment of intermediate lesions: Pooled analysis from four randomized trials. J Am CollCardiol. 2006; 47:2164–2171.
19. Botman CJ, Schonberger J, Koolen S et al: Does stenosis severity of  Native Vessels influence bypass graft patency? A prospective Fractional Flow Reserve-guided study. Ann Thorac Surg. 2007; 83:2093–2097.
20. Wijns W, Kolh P, Danchin N et al. Guidelines on Myocardial Revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2010; 31:2501–2555.
21. Kushner FG, Hand M, Smith SC Jr, et al. 2009 Focused Updates: ACC/AHA guidelines for the management of patients with ST-Elevation Myocardial Infarction (updating the 2004 guideline and 2007 focused update) and ACC/AHA/SCAI guidelines on Percutaneous Coronary Intervention (updating the 2005 guideline and 2007 focused update): A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2009; 120:2271–2306.
22. Upendra K, Vineet B: Perspective on Coronary Interventions and Cardiac Surgeries in India. Indian J Med Res 2010; 132:543–548.
23. Varghese PJ, Arumugam B, Cherian K, et al. Atheromatous plaque reflects serum total Cholesterol levels: A comparative morphologic study of Endarterectomy Coronary Atherosclerotic Plaques removed from patients from the southern part of India and Caucasians from Ottawa, Canada. Clin Cadiol 1998; 2:135–340.
24. Bernard De Bruyne, William F. Fearon, Nico H.J. Pijls, et al. Fractional Flow Reserve–Guided PCI for Stable Coronary Artery Disease. FAME 2 Trial Investi-gators. N Engl J Med. September 1, 2014.
25. Pim A.L. Tonino, Bernard De Bruyne, Nico H.J. Pijls, et al. Fractional Flow Reserve versus Angiography for Guiding Percutaneous Coronary Intervention. N Engl J Med 2009; 360:213-224January 15, 2009.
26. Bernard De Bruyne, Nico H.J. Pijls, BinduKalesan, et al. Fractional Flow Reserve–Guided PCI versus Medical Therapy in Stable Coronary Disease. N Engl J Med 2012; 367:991-1001September 13, 2012.
27. Leslee J. Shaw, Daniel S. Berman, David J. Maron, et al. Optimal Medical Therapy with or without Percutaneous Coronary Intervention to reduce ischemic burden. Circulation. 2008; 117: 1283-129.
28. Sun LJ, Mi L, Cui M, et al. Association between Fractional Flow Reserve and Quantitative Coronary Angiography Parameters in Intermediate Coronary Artery Stenosis. Zhonghua Xin Xue Guan Bing ZaZhi. 2012 Sep; 40:742-6.
29. Sengottuvelu, Babu Chakravarthy, Ravindran Rajendran, et al. Clinical usefulness and cost effectiveness of Fractional Flow Reserve among Indian patients. Catheterization and Cardiovascular Interventions 00:00–00 (2014).

Sheikh Mohamad Tahir

Consultant Cardiologist, Super Speciality Hospital, Government Medical College, J&K, India