Described by Pijls et al., in 1993, and based on extensive validation and robust clinical data, fractional flow reserve (FFR) was incorporated into the guidelines of myocardial revascularization to guide the need for revascularization of angiographically intermediate stenosis in patients with stable coronary artery disease (CAD).^– The broadest arguments for this decision were: (1) by depicting a complex tridimensional structure as a planar silhouette coronary angiography suffers from well-known limitations, it presents large variability in estimating coronary stenosis severity, and it has low ability in predicting the functional significance of epicardial coronary stenoses, and (2) revascularization in stable coronary artery disease based solely on the severity of luminal narrowing, as determined by coronary angiography, does not improve clinical outcomes as compared to optimized medical treatment or versus revascularization of only physiologically significant lesions.^–

The central premise of invasive assessment of coronary physiology is to identify myocardial ischemia with superior spatial resolution (per vessel) compared to non-invasive methods (per territory), aiding in the identification of lesions (and, therefore, patients) that are more likely to benefit from revascularization. However, despite the clinical benefits and guideline recommendations, the FFR uptake in clinical practice remains low (< 10%) in most catheterization laboratories around the globe. Costs, time added to procedures, patient discomfort to hyperemic stimulus or contraindications to adenosine use, as well as difficulties in interpretation of physiological traces in certain anatomic situations (e.g., serial/diffuse stenosis), are some of the reasons for FFR underutilization.

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