Clinical Relevance of Functionally Insignificant Moderate Coronary Artery Stenosis Assessed by 3‐Vessel Fractional Flow Reserve Measurement
Background Understanding of the risk conferred by functionally insignificant lesions in multiple coronary vessels is limited. We investigated the prognostic implications of coronary artery disease (CAD) based on 3‐vessel fractional flow reserve (FFR).
Methods and Results A total of 1,136 patients underwent FFR measurement in the 3 major epicardial arteries. We defined vessels with “Moderate CAD” as vessels with FFR, 0.81 to 0.87. Patients were classified into Group 1: No apparent CAD (FFR>0.87 in all 3‐vessels); Group 2: Single‐vessel moderate CAD; Group 3: Multivessel moderate CAD; and Group 4: Functionally significant CAD (FFR≤0.80) in any vessel. The primary end point was 2‐year major adverse cardiac events, a composite of cardiac death, myocardial infarction, and ischemia‐driven revascularization. Forty‐three percent of patients had moderate CAD (Group 2: 403/1136, 35.5%; Group 3: 84/1136, 7.4%). The 2‐year risk of major adverse cardiac events was not significantly different between patients with single‐vessel moderate CAD and no apparent CAD (2.6 versus 2.6%; HR, 1.1; 95% confidence interval, 0.4%–2.8%; P=0.89). However, patients with multivessel moderate CAD were at significantly higher risk than Group 1 (7.4 versus 2.6%; hazard ratio, 3.3; 95% confidence interval, 1.1%–9.8%; P=0.03). The risk of major adverse cardiac events in patients with multivessel moderate CAD was comparable to that of patients with functionally significant CAD (hazard ratio, 1.2; 95% confidence interval, 0.5%–3.0%; P=0.67). In a multivariable regression model, multivessel moderate CAD was an independent predictor of greater risk of 2‐year major adverse cardiac events.
Conclusions Global physiologic assessment with FFR measurement of 3 vessels can identify multivessel moderate CAD. The prognostic implication of multivessel moderate CAD appears comparable to that of functionally significant CAD.
- coronary artery disease
- fractional flow reserve
- multivessel coronary artery disease
What Is New?
Information about the risk conferred by functionally insignificant lesions in multiple coronary vessels is limited.
We investigated the prognostic implications of the severity and extent of physiologically defined coronary artery disease (CAD) by measuring fractional flow reserve in 3 vessels.
The current study focused on the prognosis of patients who have moderate CAD (fractional flow reserve 0.81–0.87), especially those with multivessel moderate CAD.
Patients with multivessel moderate CAD had a significantly higher risk of major adverse cardiac events than those with single‐vessel moderate CAD or no apparent CAD.
Patients with multivessel moderate CAD had a risk of major adverse cardiac events similar to that of patients with functionally significant CAD.
What Are the Clinical Implications?
The number of vessels with physiologically defined moderate CAD may have prognostic implications.
The physiologic index, fractional flow reserve, reflects the risk continuum of coronary atherosclerosis, and the scope of fractional flow reserve can be extended beyond an individual coronary vessel to the atherosclerotic burden of the whole coronary tree.
In the assessment of epicardial coronary stenosis, fractional flow reserve (FFR) is now regarded as a reference standard method to evaluate the functional significance of a stenosis.1, 2 Clinical outcomes of FFR‐guided percutaneous coronary intervention (PCI) were reported to be better than those of angiography‐guided PCI or medical treatment.3, 4, 5 Although a FFR>0.80 indicates that there is no ischemia caused by epicardial coronary stenosis,6 clinical events still occur in patients with high FFR and deferred revascularization.3, 7
A growing body of evidence suggests that FFR has prognostic value beyond the single cutoff value of 0.80. A recent study of deferred lesions showed a gradual trend of decreasing event rates from the FFR strata of 0.76 to 0.80 to the strata of 0.81 to 0.85.8 Studies based on angiography and coronary computed tomography angiography showed that the extent of nonobstructive disease has prognostic implications (coronary artery disease [CAD]).8, 9, 10 However, information about the influence of the extent of physiologically defined “moderate” CAD is limited.
The current study sought to explore the prognostic implication of patients with functionally insignificant CAD affecting single or multiple vessels.
The data and analytic methods that support the findings of this study are available from the corresponding author upon reasonable request.
Study Design and Patient Selection
This study is a post hoc analysis of the 3V FFR‐FRIENDS study (3‐vessel fractional flow reserve for the assessment of total physiologic atherosclerotic burden and its clinical impact in patients with coronary artery disease, NCT01621438).11 The 3V FFR‐FRIENDS study was an observational, prospective, multinational, and multicenter study to investigate the prognostic implications of a new physiologic index, the total sum of FFR values of the 3 vessels (3V‐FFR). The current study is a post hoc analysis of that entire study population and was not prespecified in the study protocol of the 3V FFR‐FRIENDS study. The 3V FFR‐FRIENDS study included consecutive patients who underwent successful FFR measurement in all 3 major epicardial coronary arteries at 12 centers in 3 countries (Korea, China, and Japan). Patients with depressed left ventricular systolic function (ejection fraction <35%), ST‐elevation myocardial infarction within 72 hours, previous coronary artery bypass graft surgery, chronic kidney disease, abnormal epicardial coronary flow (Thrombolysis in myocardial infarction flow <3), or patients who received planned coronary artery bypass graft surgery after diagnostic angiography were excluded. The study protocol was approved by the Institutional Review Board (IRB approval number: H‐1203‐087‐402) or Ethics Committee of each participating center and all patients provided written informed consent before they were enrolled in the study. A detailed rationale for sample size calculations for the 3V FFR‐FRIENDS is presented in Data S1.
Quantitative Coronary Angiography and Angiographic Analysis
Coronary angiography was performed using standard techniques and angiographic views were obtained after intracoronary administration of nitrate (100 or 200 μg). Quantitative coronary angiography was performed at a core laboratory that was blinded to other variables. The synergy between percutaneous coronary intervention with taxus and cardiac surgery (SYNTAX) score was calculated to quantify the angiographic disease extent and severity in each patient.12, 13
FFR Measurement and Procedures
All FFR measurements were performed after diagnostic angiography. A 5−7 Fr guide catheter was used to engage the coronary artery, and a pressure sensor guide wire (St. Jude Medical, St. Paul, MN) was positioned at the distal segment of a target vessel. Continuous intravenous infusion of adenosine or ATP was used to induce hyperemia. Hyperemic proximal aortic pressure and distal coronary arterial pressure were measured during sustained hyperemia and FFR was calculated as the mean of distal coronary arterial pressure/proximal aortic pressure during hyperemia. Intracoronary nitroglycerine (100 or 200 μg) was administered before each FFR measurement. In the presence of significant drift, the study protocol required re‐equalization and re‐measurement of FFR.
For lesions with significantly low per‐vessel FFR (≤0.80), PCI was recommended based on the current guideline. When indicated, PCI was performed using current standard techniques with second‐generation drug‐eluting stents. The treating physician made decisions about PCI. In patients who underwent PCI, the study protocol required post‐PCI FFR measurement, and post‐PCI FFR was used for per‐vessel classification in the current analysis.
Definitions of Per‐Vessel and Per‐Patient Classifications
For the per‐vessel level classification based on FFR, target vessels were classified as either functionally significant (FFR ≤0.80) or insignificant (FFR >0.80) vessels. The functionally insignificant vessels were further classified as either vessels with moderate CAD (FFR 0.81–0.87) or no apparent CAD (FFR >0.87) (Figure 1) according to the lowest quartile value of FFR (0.87). Patients were classified according to extent of CAD into 4 groups as follows: Group 1: No apparent CAD (FFR >0.87 in all 3 vessels); Group 2: Moderate CAD (FFR 0.81–0.87) in a single vessel; Group 3: Moderate CAD (FFR 0.81–0.87) in multiple vessels; and Group 4: Functionally significant CAD (FFR ≤0.80) in any vessel.
Follow‐Up of Patients, Outcome Measurements, and Adjudication of Clinical Events
Clinical data were obtained at outpatient clinic visits or by telephone interview. An independent clinical event committee, which was unaware of clinical, angiographic, and physiologic data, adjudicated all events. The primary outcome was any major adverse cardiac event (MACE) by 2 years after FFR, including cardiac death, any myocardial infarction, or any ischemia‐driven revascularization. All clinical outcomes were defined according to the Academic Research Consortium, including the addendum to the definition of myocardial infarction.14 All deaths were considered cardiac unless an undisputable noncardiac cause was present. Ischemia‐driven revascularization was defined as a revascularization procedure with at least 1 of the following: (1) Recurrence of angina, (2) Positive noninvasive test, or (3) Positive invasive physiologic test.
The primary hypothesis of this study was that the presence of moderate CAD (FFR 0.81–0.87) and its extent would significantly affect the risk of 2‐year MACE. For this, the analysis was performed for 3 groups of vessels classified with the per‐vessel FFR value (functionally significant, moderate CAD, and no apparent CAD) and for 4 groups of patients classified according to the severity and extent of CAD. Event rates were calculated based on Kaplan–Meier censored estimates, and survival curves between groups were compared using the log‐rank test.
Cox proportional hazards regression analysis was used to examine the associations between covariables and the 4 patient groups described above and MACE. Previously known risk factors and variables that were distributed significantly differently among the 4 groups were included in univariable Cox regression analyses (Table S1). For continuous variables, the linearity assumption was assessed graphically using Martingale residuals. SYNTAX score and age were converted to categorical values because they did not fulfill the linearity assumption. Crude and multivariable adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) were computed by univariable and multivariable Cox regression analyses. Variables associated with time to MACE in the univariable Cox regression analyses (Wald test P<0.10) were included in a multivariable Cox regression model. The multivariable Cox regression model included age, male sex, smoking status, presentation with acute coronary syndrome, high SYNTAX score (≥8), and the 4‐group categorical variable based on FFR measurement of 3 vessels. C‐statistics with 95% CI were calculated to validate the discriminant function of the model.
Categorical variables were presented as numbers and relative frequencies (percentages), and continuous variables as means and SDs. All probability values were 2‐sided, and P values <0.05 were considered statistically significant. The SPSS version 20.0 (SPSS Inc, Chicago, IL), STATA version 12 (SAS Institute, Inc, Cary, NC), and R 3.2.3 (R Foundation for Statistical Computing, Vienna, Austria) statistical packages were used for statistical analyses.
Patient Characteristics of 4 Groups According to the Extent of CAD
In the parent study, 1136 patients were admitted for coronary angiography and underwent FFR measurements of all 3 major coronary arteries. Baseline characteristics and treatment strategies are presented in Table 1. The mean age of the study cohort was 61.9±9.8 years and 73.5% of the patients were male. Hypertension was diagnosed in 60.7% of the patients, 32% had diabetes mellitus, and 22.4% of patients were admitted because of acute coronary syndrome. Among the 3298 interrogated vessels, 572 vessels were revascularized and 2726 vessels were deferred. Among the deferred vessels, 314 vessels (11.5%) were deferred despite vessel‐specific FFR ≤0.80. Among these 314 vessels, PCI was deferred because of insignificant angiographic stenosis (reverse mismatch) (185 vessels, 58.9%), diffuse disease without focal stenosis (48 vessels, 15.3%), no angiographic progression since previous angiography (31 vessels, 9.9%), negative results of noninvasive tests (17 vessels, 5.4%), small myocardial territory (15 vessels, 4.8%), or for other reasons (17 vessels, 5.4%).
Among the 1136 patients, 26.6% (302/1136) were classified as no apparent CAD (Group 1), 35.5% (403/1136) as moderate CAD (FFR 0.81–0.87) in a single vessel (Group 2), 7.4% (84/1136) as multivessel moderate CAD (FFR 0.81–0.87) (Group 3), and 30.5% (347/1136) as functionally significant disease in any of the 3 major epicardial arteries (Group 4). Table 1 summarizes the comparison of baseline characteristics among the 4 patient groups. More patients in Groups 3 and 4 were prescribed anti‐platelet therapy at discharge. During the 2‐year follow‐up, the use of antiplatelet therapy decreased among the whole study population. At discharge, 87.9% were prescribed a statin. The frequency of statin use did not change significantly during the 2‐year follow‐up (Table S2). Otherwise, clinical characteristics among the 4 groups did not differ significantly.
A significant trend of increasing SYNTAX score (P<0.001 for trend) was observed from Group 1 to Group 4. Between‐group comparisons found that Group 3 had significantly higher SYNTAX scores than Group 2 (2.4±0.8, P=0.012), whereas the difference of SYNTAX score between Groups 4 and 3 was insignificant (1.1±0.8, P=0.54) (Table 1 and Figure 2)
Comparison of Clinical Outcomes Among 4 Patient Groups According to the Extent of CAD
Figure 3 presents the comparison of 2‐year MACE rates among the 4 patient groups. The risk of 2‐year MACE of Group 1 (patients with no apparent CAD) and Group 2 (patients with single‐vessel moderate CAD [FFR 0.81–0.87]) was not significantly different (2.6 versus 2.6%; HR, 1.1; 95% CI, 0.4%–2.8%; P=0.89). However, Group 3 (patients with multivessel moderate CAD [FFR 0.81–0.87]) had a significantly higher risk of MACE than Group 1 (7.4 versus 2.6%; HR, 3.3; 95% CI, 1.1%–9.8%; P=0.032). The 2‐year MACE risk of Group 3 was similar to Group 4 (patients with any functionally significant CAD) (7.4 versus 8.0%; HR, 1.0; 95% CI, 0.4%–2.4%; P=0.98) (Table 2 and Figure 3). Between‐group differences in MACE risk were mainly driven by significant differences in the rates of ischemia‐driven revascularization events (Table 2). Among patients with ischemia‐driven revascularization, 25 patients (62.5%) presented with acute coronary syndrome: 9 patients had aggravated angina with progression of the coronary stenosis, and the remaining 6 underwent revascularization because of positive noninvasive tests during follow‐up.
Table 3 presents the independent predictors of 2‐year MACE according to multivariable regression analysis. The independent predictors included age (>70 years), SYNTAX score (>8), presentation with acute coronary syndrome, and patient group based on FFR measurements of the 3 vessels. The relatively higher risk of MACE in Groups 3 and 4 than in Group 1 was consistently observed in multivariable‐adjusted regression models. Moderate CAD (FFR 0.81–0.87) in multiple vessels (Group 3) was independently associated with greater risk of 2‐year MACE (HR, 3.3; 95% CI, 1.0%–10%; P=0.043) than in Group 1. The 2‐year risk of MACE in patients with multivessel moderate CAD (FFR 0.81–0.87) (Group 3) was comparable to that of patients with functionally significant CAD (Group 4) (HR, 1.2; 95% CI, 0.5%–3.0%; P=0.67). When 3V FFR was added to the multivariable Cox regression model, the high‐risk patient group with multivessel moderate CAD (FFR 0.81–0.87) or any functionally significant CAD (FFR ≤0.80) was still associated with increased risk of 2‐year MACE (HR, 2.3; 95% CI, 1.0%–5.3%; P=0.043) (Table 4).
Vessels with functionally significant stenosis (FFR ≤0.80) had the highest risk of 2‐year ischemia‐driven revascularization relative to vessels with no apparent CAD (HR, 9.5; 95% CI, 4.0%–22%; P<0.001), or moderate CAD (FFR 0.81–0.87) (HR, 3.2; 95% CI, 1.4%–7.7%; P=0.008). Vessels with moderate CAD (FFR 0.81–0.87) were associated with moderately greater risk of ischemia‐driven revascularization than vessels with no apparent CAD (HR, 2.9; 95% CI, 1.1%–7.8%; P=0.031) (Figure S1).
Clinical Outcomes in High‐Risk Subgroups and Anatomically Nonobstructive CAD
In patients with diabetes mellitus, the 2‐year risk of MACE was higher in patients with moderate CAD (FFR 0.81–0.87) in multivessels (Group 3) (HR, 11.7; 95% CI, 0.4%–2.5%; P=0.028) than in Group 1; the risk of patients in Group 2 was similar to that of Group 1 (HR, 1.1; 95% CI, 0.1%–11.7%; P=0.96). In patients with acute coronary syndrome, the pattern of 2‐year risk of MACE was similar to that of the whole study population. In the high‐risk subgroups of diabetes mellitus or acute coronary syndrome, Group 3 had significantly higher risk of MACE than Group 1 (HR, 4.8; 95% CI, 1.2%–20.2%; P=0.031), and those risks were comparable to those of Group 4 (HR, 1.2; 95% CI, 0.5%–3.3%; P=0.68) (Figure 4). In a subgroup of patients without anatomically obstructive CAD (% DS in all coronary vessels <50%), the 2‐year risk of MACE was higher in patients with multivessel moderate CAD (FFR 0.81–0.87) (Group 3) than in Group 1 (HR, 12.0; 95% CI, 2.2%–65.5%; P=0.004) (Figure 4).
This study focused on the prognostic implications of the severity and extent of physiologically defined CAD based on FFR measurements of all 3 major coronary arteries. The main findings can be summarized as follows. Patients with multivessel moderate CAD (FFR 0.81–0.87) had a significantly higher risk of MACE than those with single‐vessel moderate CAD (FFR 0.81–0.87) or no apparent CAD. Patients with multivessel moderate CAD (FFR 0.81–0.87) had a risk of MACE similar to patients with functionally significant CAD. These findings persisted in a multivariable regression model and were more prominent in the clinically high‐risk subsets and in patients without anatomically obstructive CAD.
Risk Beyond Per‐Vessel FFR Value 0.8
The risk of CAD extends beyond the FFR cutoff value of 0.80, and moderate CAD can contribute to the risk of an individual patient. In the FAME (Fractional Flow Reserve versus Angiography for Multivessel Evaluation)‐2 substudy by Barbato et al,15 the per‐vessel 2‐year MACE rate was significantly higher in vessels with moderate CAD (FFR value of 0.78–0.86, defined by the second quartile) than in those with FFR closer to normal (FFR value of 0.87–1.00, defined by the highest quartile) (HR, 3.4; 95% CI, 1.9%–6.2%, P<0.001). In the current study, moderate CAD was defined as the vessels within the lowest quartile of FFR values (0.81–0.87) among functionally insignificant coronary vessels. The risk of 2‐year per‐vessel ischemia‐driven revascularization was higher in vessels with moderate CAD (FFR 0.81–0.87) than in vessels with no apparent CAD (FFR 0.87–1.0) (HR, 3.0; 95% CI, 1.4%–6.4%; P=0.006). When the criteria of Barbato et al15 were applied to our study, the risk of 2‐year ischemia‐driven revascularization was also greater in vessels with FFR of 0.78 to 0.86 than in those with a FFR of 0.87 to 1.00 (HR, 3.3; 95% CI, 1.7%–6.7%, P=0.001). We observed a continuous association between the risk of ischemia‐driven revascularization and lower FFR value in coronary arteries with FFR >0.80 (Table S3). In addition, the continuous association between the risk of 2‐year MACE in patients with lower 3‐vessel FFR measurements was consistently observed in patients without any coronary artery with functionally significant CAD (FFR ≤0.80) (Table S4). Considered together, these findings indicate that coronary arteries with moderate CAD could have prognostic implications.
Per‐Vessel Versus Per‐Patient Risk Assessment
To comprehensively evaluate the long‐term risk of CAD in an individual patient, the risk of all 3 epicardial coronary arteries needs to be taken into consideration. Previous studies16, 17 demonstrate that a substantial proportion of late events occur in nontarget lesions and that CAD burden confers a significant risk for plaque progression. In the BASKET‐PRO (Basel Stent Kosten‐Effektivitäts Trial ‐Progression of CAD) study,18 37.1% of late clinical events occurred in the nontarget vessels.
The current study focused on the outcomes of patients with multivessel moderate CAD (FFR 0.81–0.87) because FFR measurement in all 3 epicardial coronary arteries enabled the evaluation of the aggregated risk of CAD. Based on per‐patient risk assessment, patients with moderate CAD (FFR 0.81–0.87) in a single vessel (Group 2) and multivessel (Group 3) experienced substantially different outcomes. The patients with multivessel moderate CAD (FFR 0.81–0.87) had significantly higher per‐patient indices of disease burden, such as 3V‐FFR and SYNTAX score. Because pathological progression of CAD involves incremental expansion of the total atherosclerotic volume that occurs in 2 dimensions (both the extent and the stenotic severity),19 Group 3 may represent patients at a more advanced stage of atherosclerosis in terms of disease extent, compared with Group 2. It was interesting in our study that despite the incremental difference in per‐patient anatomical and physiologic disease burden between Groups 1 and 2, clinical outcomes of these 2 groups did not differ. This result suggests that a certain anatomical or physiologic threshold determines clinical outcomes.
Implication of the Extent of Nonobstructive CAD
Several studies investigated the prognostic impact of the extent of anatomical nonobstructive disease evaluated by coronary angiography9, 20 or coronary computed tomography angiography.8, 21, 22 In the CONFIRM (coronary CT angiography evaluation for clinical outcomes: an international multicenter registry) registry,22 patients with 2‐ or 3‐vessel involvement of nonobstructive (1–49% diameter stenosis) CAD on coronary computed tomography angiography had a 3‐fold higher risk of all‐cause mortality than normal subjects. Conversely, the risk of patients with 1‐vessel involvement was similar to that of normal subjects.
Our study demonstrated that the extent of physiologically defined moderate CAD (FFR 0.81–0.87) may have prognostic implications. Although CAD of the individual coronary vessel was functionally insignificant, the risk associated with multivessel moderate CAD (FFR 0.81–0.87) was as high as the risk of patients who had functionally significant CAD. The prognostic implication of the high‐risk group of multivessel moderate CAD or any functionally significant CAD was still observed in a multivariable regression model that included 3V‐FFR as a continuous predictor (Table 4). This finding further supports the concept that the extent of disease can be a predictor of clinical outcome and opens the possibility of practical risk stratification of a patient for whom the measurement of FFR in all 3 vessels is not available.
This finding was more prominent in a subgroup of high‐risk patients and in those without anatomically obstructive CAD. The risk of patients with single‐vessel moderate CAD (FFR 0.81–0.87) was not significantly different from those without apparent CAD. These findings suggest that the physiologic index, FFR, reflects the risk continuum of coronary atherosclerosis, and further extends the scope of FFR beyond an individual coronary vessel to the atherosclerotic burden of the whole coronary tree.
Some limitations of the current study should be considered. First, the patient group with multivessel moderate CAD (FFR 0.81–0.87) comprised a relatively small (84 of 1136 patients) portion of the study population and the difference of 2‐year MACE rates among the 4 groups was primarily driven by ischemia‐driven revascularization. Second, we did not apply differential weights to the FFR values of different coronary arteries based on the volume of myocardium supplied by each vessel. Therefore, individual variance in coronary anatomy and subsequent difference in the prognostic impact between coronary arteries were not taken into account. Third, total plaque burden assessed by invasive imaging modalities was not available in this study.
The prognostic implication of multivessel moderate CAD (FFR 0.81–0.87) might be comparable to that of functionally significant CAD. Global physiologic assessment with FFR measurement in 3 vessels enables the identification of patients with multivessel moderate CAD (FFR 0.81–0.87) who might be at greater risk of long‐term complications.
Sources of Funding
This study was supported by an unrestricted research grant from St. Jude Medical Foundation. The foundation had no role in study design, conduct, data analysis, or preparation of the manuscript.
Dr Koo received an institutional research grant from St. Jude Medical Foundation. The remaining authors have no disclosures to report.
Data S1. Supplemental Methods.
Table S1. Univariable Cox Regression Analysis of Association of Variables with 2‐Year MACE
Table S2. Medication Changes During Follow‐Up*
Table S3. Univariable Cox Regression Analysis of Association of FFR With Per‐Vessel Ischemia‐Driven Revascularization Incidence
Table S4. Independent Predictors of 2‐Year Major Adverse Cardiac Events in Multivariable Cox Regression Analysis With 3V‐FFR as a Continuous Variable
Figure S1. Comparison of per‐vessel ischemia‐driven revascularization incidence among vessel groups stratified by FFR.
- ↵Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, Chambers CE, Ellis SG, Guyton RA, Hollenberg SM, Khot UN, Lange RA, Mauri L, Mehran R, Moussa ID, Mukherjee D, Nallamothu BK, Ting HH, Jacobs AK, Albert N, Creager MA, Ettinger SM, Halperin JL, Hochman JS, Kushner FG, Magnus Ohman E, Stevenson W, Yancy CW. ACCF/AHA/SCAI guideline for percutaneous coronary intervention a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. Circulation. 2011;2011:124.
- ↵Kolh P, Windecker S, Alfonso F, Collet J‐P, Cremer J, Falk V, Filippatos G, Hamm C, Head SJ, Jüni P, Kappetein AP, Kastrati A, Knuuti J, Landmesser U, Laufer G, Neumann F‐J, Richter DJ, Schauerte P, Sousa Uva M, Stefanini GG, Taggart DP, Torracca L, Valgimigli M, Wijns W, Witkowski A; European Society of Cardiology Committee for Practice Guidelines , Zamorano JL, Achenbach S, Baumgartner H, Bax JJ, Bueno H, Dean V, Deaton C, Erol Ç, Fagard R, Ferrari R, Hasdai D, Hoes AW, Kirchhof P, Knuuti J, Kolh P, Lancellotti P, Linhart A, Nihoyannopoulos P, Piepoli MF, Ponikowski P, Sirnes PA, Tamargo JL, Tendera M, Torbicki A, Wijns W, Windecker S; EACTS Clinical Guidelines Committee , Sousa Uva M, Achenbach S, Pepper J, Anyanwu A, Badimon L, Bauersachs J, Baumbach A, Beygui F, Bonaros N, De Carlo M, Deaton C, Dobrev D, Dunning J, Eeckhout E, Gielen S, Hasdai D, Kirchhof P, Luckraz H, Mahrholdt H, Montalescot G, Paparella D, Rastan AJ, Sanmartin M, Sergeant P, Silber S, Tamargo J, ten Berg J, Thiele H, van Geuns R‐J, Wagner H‐O, Wassmann S, Wendler O, Zamorano JL; Task Force on Myocardial Revascularization of the European Society of Cardiology and the European Association for Cardio‐Thoracic Surgery, European Association of Percutaneous Cardiovascular Interventions . 2014 ESC/EACTS 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). Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur J Cardiothorac Surg. 2014;46:517–592.
- ↵De Bruyne B, Fearon WF, Pijls NHJ, Barbato E, Tonino P, Piroth Z, Jagic N, Mobius‐Winckler S, Rioufol G, Witt N, Kala P, MacCarthy P, Engström T, Oldroyd K, Mavromatis K, Manoharan G, Verlee P, Frobert O, Curzen N, Johnson JB, Limacher A, Nüesch E, Jüni P; FAME 2 Trial Investigators . Fractional flow reserve‐guided PCI for stable coronary artery disease. N Engl J Med. 2014;371:1208–1217.
- ↵Pijls NHJ, Fearon WF, Tonino PAL, Siebert U, Ikeno F, Bornschein B, van't Veer M, Klauss V, Manoharan G, Engstrøm T, Oldroyd KG, Ver Lee PN, MacCarthy PA, De Bruyne B. Fractional flow reserve versus angiography for guiding percutaneous coronary intervention in patients with multivessel coronary artery disease. J Am Coll Cardiol. 2010;56:177–184.
- ↵Shaw LJ, Berman DS, Maron DJ, Mancini GBJ, Hayes SW, Hartigan PM, Weintraub WS, O'Rourke RA, Dada M, Spertus JA, Chaitman BR, Friedman J, Slomka P, Heller GV, Germano G, Gosselin G, Berger P, Kostuk WJ, Schwartz RG, Knudtson M, Veledar E, Bates ER, McCallister B, Teo KK, Boden WE; COURAGE Investigators . Optimal medical therapy with or without percutaneous coronary intervention to reduce ischemic burden: results from the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial nuclear substudy. Circulation. 2008;117:1283–1291.
- ↵Jiménez‐Navarro M, Alonso‐Briales JH, Hernández García MJ, Rodríguez Bailón I, Gómez‐Doblas JJ, de Teresa Galván E. Measurement of fractional flow reserve to assess moderately severe coronary lesions: correlation with dobutamine stress echocardiography. J Interv Cardiol. 2001;14:499–504.
- ↵Lee JM, Jung J‐H, Hwang D, Park J, Fan Y, Na S‐H, Doh J‐H, Nam C‐W, Shin E‐S, Koo B‐K. Coronary flow reserve and microcirculatory resistance in patients with intermediate coronary stenosis. J Am Coll Cardiol. 2016;67:1158–1169.
- ↵Adjedj J, De Bruyne B, Floré V, Di Gioia G, Ferrara A, Pellicano M, Toth GG, Bartunek J, Vanderheyden M, Heyndrickx GR, Wijns W, Barbato E. Significance of intermediate values of fractional flow reserve in patients with coronary artery disease. Circulation. 2016;133:502–508.
- ↵Lee JM, Koo B‐K, Shin E‐S, Nam C‐W, Doh J‐H, Hwang D, Park J, Kim K‐J, Zhang J, Hu X, Wang J, Ahn C, Ye F, Chen S, Yang J, Chen J, Tanaka N, Yokoi H, Matsuo H, Takashima H, Shiono Y, Akasaka T. Clinical implications of three‐vessel fractional flow reserve measurement in patients with coronary artery disease. Eur Heart J. Available at: https://academic.oup.com/eurheartj/advance-article-abstract/doi/10.1093/eurheartj/ehx458/4084242?redirectedFrom=fulltext. Accessed February 10, 2018.
- ↵Yadav M, Palmerini T, Caixeta A, Madhavan MV, Sanidas E, Kirtane AJ, Stone GW, Généreux P. Prediction of coronary risk by SYNTAX and derived scores: synergy between percutaneous coronary intervention with taxus and cardiac surgery. J Am Coll Cardiol. 2013;62:1219–1230.
- ↵Cutlip DE, Windecker S, Mehran R, Boam A, Cohen DJ, van Es G‐A, Steg PG, Morel M, Mauri L, Vranckx P, McFadden E, Lansky A, Hamon M, Krucoff MW, Serruys PW; Academic Research Consortium . Clinical end points in coronary stent trials: a case for standardized definitions. Circulation. 2007;115:2344–2351.
- ↵Barbato E, Toth GG, Johnson NP, Pijls NHJ, Fearon WF, Tonino PAL, Curzen N, Piroth Z, Rioufol G, Jüni P, De Bruyne B. A prospective natural history study of coronary atherosclerosis using fractional flow reserve. J Am Coll Cardiol. 2016;68:2247–2255.
- ↵Cutlip DE, Chhabra AG, Baim DS, Chauhan MS, Marulkar S, Massaro J, Bakhai A, Cohen DJ, Kuntz RE, Ho KKL. Beyond restenosis: five‐year clinical outcomes from second‐generation coronary stent trials. Circulation. 2004;110:1226–1230.
- ↵Glaser R, Selzer F, Faxon DP, Laskey WK, Cohen HA, Slater J, Detre KM, Wilensky RL. Clinical progression of incidental, asymptomatic lesions discovered during culprit vessel coronary intervention. Circulation. 2005;111:143–149.
- ↵Zellweger MJ, Kaiser C, Jeger R, Brunner‐La Rocca H‐P, Buser P, Bader F, Mueller‐Brand J, Pfisterer M. Coronary artery disease progression late after successful stent implantation. J Am Coll Cardiol. 2012;59:793–799.
- ↵Arbab‐Zadeh A, Fuster V. The risk continuum of atherosclerosis and its implications for defining CHD by coronary angiography. J Am Coll Cardiol. 2016;68:2467–2478.
- ↵Jespersen L, Hvelplund A, Abildstrøm SZ, Pedersen F, Galatius S, Madsen JK, Jørgensen E, Kelbæk H, Prescott E. Stable angina pectoris with no obstructive coronary artery disease is associated with increased risks of major adverse cardiovascular events. Eur Heart J. 2012;33:734–744.
- ↵Mushtaq S, De Araujo Gonçalves P, Garcia‐Garcia HM, Pontone G, Bartorelli AL, Bertella E, Campos CM, Pepi M, Serruys PW, Andreini D. Long‐term prognostic effect of coronary atherosclerotic burden: validation of the computed tomography‐Leaman score. Circ Cardiovasc Imaging. 2015;8:e002332.
- ↵Chow BJW, Small G, Yam Y, Chen L, McPherson R, Achenbach S, Al‐Mallah M, Berman DS, Budoff MJ, Cademartiri F, Callister TQ, Chang H‐J, Cheng VY, Chinnaiyan K, Cury R, Delago A, Dunning A, Feuchtner G, Hadamitzky M, Hausleiter J, Karlsberg RP, Kaufmann PA, Kim Y‐J, Leipsic J, LaBounty T, Lin F, Maffei E, Raff GL, Shaw LJ, Villines TC, Min JK; CONFIRM Investigators . Prognostic and therapeutic implications of statin and aspirin therapy in individuals with nonobstructive coronary artery disease: results from the CONFIRM (COronary CT Angiography EvaluatioN For Clinical Outcomes: An InteRnational Multicenter registry). Arterioscler Thromb Vasc Biol. 2015;35:981–989.