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Fractional flow reserve: conundrums, controversies and challenges
N Briceno, M Lumley & D PereraFractional flow reserve (FFR) is an important invasive physiological tool that has had a great impact on the management of coronary artery disease in the catheterization laboratory. It has been proven in several large randomized trials to be superior to angiography-guided percutaneous coronary intervention, paving the way for an era of ischemia-guided revascularization. Albeit straightforward to measure, the physiological derivation of FFR and its inherent assumptions are poorly understood, which can lead to its misinterpretation in routine clinical practice. The aim is, therefore, to discuss the key physiological principles of FFR, review clinical scenarios in which its application may challenge its evidence base and discuss future perspectives with respect to alternative physiological indices and the noninvasive measurement of FFR through CT.