Does Coronary Flow Trump Coronary Anatomy?

Coronary function versus anatomy, flow versus stenosis: which optimizes coronary artery disease (CAD) management? In patients, coronary flow is poorly related to stenosis severity, and revascularization fails to improve mortality over medical treatment in randomized trials. Yet percutaneous intervention (PCI) guided by fractional flow reserve reduces coronary events more than PCI guided by arteriographic stenosis. These paradoxes are explained by the poor relation between coronary flow reserve (CFR) and stenosis severity due to diffuse CAD, with surprising clinical implications. Should the concept of anatomically critical coronary stenosis be replaced by the concept of critical CFR reduction for managing CAD? (J Am Coll Cardiol Img 2009;2:1009-23) (C) 2009 by the American College of Cardiology Foundation