The role of angiography-derived physiological assessment techniques in the post-FAVOR III Europe era?

Currently, invasive coronary angiography is still the main technique to identify obstructive coronary artery disease. However, its diagnostic yield is limited by its inability to assess the functional relevance of intermediate stenoses.1 The introduction of pressure guidewire-based physiological assessment was first enabled by the development of fractional flow reserve (FFR).2 Within the following decade, a large body of evidence supported the benefit of FFR in revascularization decision-making, leading to its endorsement by clinical practice guidelines.3-5 Still, a low penetrance of FFR was observed, due to scepticism in coronary physiology, the need for coronary instrumentation, adenosine infusion, and increased procedural time and costs.6 These challenges led to the development of several non-hyperemic indices, avoiding the need for hyperemic agents, as well as angiography-derived physiological assessment techniques (ADPAT), which avoid both the use of adenosine and coronary guidewires. Over the past few years, several ADPAT modalities have emerged with the objective of estimating FFR by combining fluid dynamic equations, 3D models of the coronary tree and certain predefined boundary flow conditions.7 Most ADPAT have pivotal validation studies that compare them to FFR showing good diagnostic accuracy. Among these methods, quantitative flow ratio (QFR) has been evaluated in the largest number of studies and,...