Fractional flow reserve: Current evidence base in stable coronary artery disease

Ozan M. Demir, Matt Ryan, Haseeb Rahman, Divaka Perera*

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

1 Citation (Scopus)


The development of fractional flow reserve (FFR) has revolutionized interventional cardiology, leading to a physiology-based instead of anatomy-based approach to coronary revascularization. There have been three landmark FFR trials: DEFER, FAME, and FAME-2. In the DEFER trial an FFR threshold of 0.75 was used to guide revascularization; subsequently, in the FAME and FAME-2 trials the FFR threshold was increased to 0.80. All these studies demonstrated that FFR-guided revascularization resulted in improved clinical outcomes with reduction in major cardiovascular events. However, in the FAME and FAME-2 trials this reduction in major cardiovascular events has principally been driven by difference in rates of urgent revascularization. The treatment thresholds for FFR have increased from initial derivation studies where the threshold was 0.75. This has been in an empirical bid to increase the sensitivity and negative predictive value, at the inevitable cost of specificity; potentially to the detriment of hard end points. Recently, resting indices have been proposed. However, despite much interest there remain some unresolved questions including the discordance with FFR that occurs in 20% of patients. In conclusion, there is overwhelming evidence for the use of FFR in guiding percutaneous coronary intervention in stable coronary artery disease, and it has become a reference surrogate measure of ischemia. However, outcome data are principally driven by rates of urgent revascularization. It may be that a lower threshold is required, as suggested by early studies, to demonstrate a mortality benefit for FFR-guided revascularization.

Original languageEnglish
Pages (from-to)9-12
Number of pages4
JournalHeart and Metabolism
Issue number78
Publication statusPublished - 1 Jan 2019


  • Coronary physiology
  • Fractional flow reserve
  • Percutaneous coronary intervention


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