Fractional flow reserve, instantaneous wave-free ratio, and resting Pd/Pa compared with [15O]H2O positron emission tomography myocardial perfusion imaging: a PACIFIC trial sub-study

Guus A de Waard, Ibrahim Danad, Ricardo Petraco, Roel S Driessen, Pieter G Raijmakers, Paul F Teunissen, Peter M van de Ven, Maarten A H van Leeuwen, Alexander Nap, Hendrik J Harms, Adriaan A Lammertsma, Justin E Davies, Paul Knaapen, Niels van Royen

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Aims: Guidelines recommend the use of fractional flow reserve (FFR) to guide percutaneous coronary intervention. For this purpose, physiological lesion assessment without adenosine may have a similar diagnostic accuracy as FFR. We aimed to investigate the performances of FFR, resting instantaneous wave-free ratio (iFR), and resting Pd/Pa compared with [15O]H2O positron emission tomography (PET) perfusion imaging.

Methods and results: [15O]H2O PET and intracoronary pressure measurements were evaluated in 320 coronary arteries (of which 136 coronary stenoses) in 129 stable patients. The primary analysis consisting of the area-under-the-receiver-operating-characteristic curve for impaired PET hyperaemic myocardial blood flow (MBF) <2.3 mL⋅min-1⋅g-1 in coronary stenoses was 0.78 [95% confidence interval (CI): 0.70-0.85] for FFR, 0.74 (95% CI: 0.66-0.81) for iFR, and 0.75 (95% CI: 0.67-0.82) for Pd/Pa. No significant differences between area-under-the-receiver-operating-characteristic curve were observed for any two indices compared. In a secondary analysis, the diagnostic accuracy compared with impaired PET hyperaemic MBF in coronary stenoses was 72% (95% CI: 64-79%, κ: 0.44) for FFR ≤0.80, 72% (95% CI: 64-80%, κ: 0.44) for iFR ≤0.89, and 70% (95% CI: 62-78%, κ: 0.40) for Pd/Pa ≤0.92. Other secondary analyses included a comparison of physiological indices with PET hyperaemic MBF in all vessels and all of the aforementioned analyses using PET myocardial perfusion reserve as comparator. Statistical testing for the secondary analyses showed results that were consistent with the results of the primary analysis.

Conclusion: Fractional flow reserve, iFR, and Pd/Pa showed a similar performance when compared with PET imaging. Our results support the validity of invasive physiological lesion assessment under resting conditions by iFR or Pd/Pa.

Trial registration: Sub-study of the PACIFIC trial with identifier: NCT01521468.

Original languageEnglish
Pages (from-to)4072-4081
JournalEuropean Heart journal
Issue number46
Publication statusPublished - 7 Dec 2018


  • CAD = coronary artery disease
  • Coronary Angiography/methods
  • Coronary circulation
  • FFR
  • Intracoronary physiology techniques
  • PET (positron emission tomography)
  • PET quantification
  • Pressure
  • Stenosis
  • coronary stenosis
  • myocardial blood flow

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