title: Real-time use of instantaneous wave-free ratio: results of the ADVISE in-practice: an international, multicenter evaluation of instantaneous wave-free ratio in clinical practice.
abstract: OBJECTIVE
  To evaluate the first experience of real-time instantaneous wave-free ratio (iFR) measurement by clinicians.
  
  
  BACKGROUND
  The iFR is a new vasodilator-free index of coronary stenosis severity, calculated as a trans-lesion pressure ratio during a specific period of baseline diastole, when distal resistance is lowest and stable. Because all previous studies have calculated iFR offline, the feasibility of real-time iFR measurement has never been assessed.
  
  
  METHODS
  Three hundred ninety-two stenoses with angiographically intermediate stenoses were included in this multicenter international analysis. Instantaneous wave-free ratio and fractional flow reserve (FFR) were performed in real time on commercially available consoles. The classification agreement of coronary stenoses between iFR and FFR was calculated.
  
  
  RESULTS
  Instantaneous wave-free ratio and FFR maintain a close level of diagnostic agreement when both are measured by clinicians in real time (for a clinical 0.80 FFR cutoff: area under the receiver operating characteristic curve [ROC(AUC)] 0.87, classification match 80%, and optimal iFR cutoff 0.90; for a ischemic 0.75 FFR cutoff: iFR ROC(AUC) 0.90, classification match 88%, and optimal iFR cutoff 0.85; if the FFR 0.75-0.80 gray zone is accounted for: ROC(AUC) 0.93, classification match 92%). When iFR and FFR are evaluated together in a hybrid decision-making strategy, 61% of the population is spared from vasodilator while maintaining a 94% overall agreement with FFR lesion classification.
  
  
  CONCLUSIONS
  When measured in real time, iFR maintains the close relationship to FFR reported in offline studies. These findings confirm the feasibility and reliability of real-time iFR calculation by clinicians.
authors.affiliation: International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London and Imperial College Healthcare NHS Trust, London, United Kingdom.
authors.forename: Ricardo
authors.initials: R
authors.lastname: Petraco
authors.affiliation: International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London and Imperial College Healthcare NHS Trust, London, United Kingdom.
authors.forename: Rasha
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authors.lastname: Al-Lamee
authors.affiliation: Lund University, Lund, Sweden.
authors.forename: Matthias
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authors.affiliation: International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London and Imperial College Healthcare NHS Trust, London, United Kingdom.
authors.forename: Sukhjinder S
authors.initials: SS
authors.lastname: Nijjer
authors.affiliation: Cardiovascular Institute, Hospital Clinico San Carlos, Madrid, Spain.
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authors.affiliation: Academic Medical Centre, Amsterdam, the Netherlands.
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authors.lastname: van de Hoef
authors.affiliation: International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London and Imperial College Healthcare NHS Trust, London, United Kingdom.
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authors.affiliation: Tokyo University Hospital, Tokyo, Japan.
authors.forename: Nobuhiro
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authors.forename: Eric
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authors.affiliation: Koblenz-Mayen Hospital, Koblenz, Germany.
authors.forename: Waldemar
authors.initials: W
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authors.affiliation: St Luke's international hospital, Tokyo, Japan.
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authors.affiliation: Na Homolce Hospital, Prague, Czech Republic.
authors.forename: Martin
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authors.lastname: Mates
authors.affiliation: University Magna Graecia, Catanzaro, Italy.
authors.forename: Ciro
authors.initials: C
authors.lastname: Indolfi
authors.affiliation: University Magna Graecia, Catanzaro, Italy.
authors.forename: Salvatore
authors.initials: S
authors.lastname: De Rosa
authors.affiliation: Antwerp University Hospital, Antwerp, Belgium.
authors.forename: Christian J
authors.initials: CJ
authors.lastname: Vrints
authors.affiliation: Antwerp University Hospital, Antwerp, Belgium.
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authors.initials: S
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authors.affiliation: Kokura Memorial Hospital, Kitakyushu, Japan.
authors.forename: Hiroyoshi
authors.initials: H
authors.lastname: Yokoi
authors.affiliation: Università di Verona, Verona, Italy.
authors.forename: Flavio L
authors.initials: FL
authors.lastname: Ribichini
authors.affiliation: Amphia Hospital, Breda, the Netherlands.
authors.forename: Martjin
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authors.lastname: Meuwissen
authors.affiliation: Gifu Heart Center, Gifu, Japan.
authors.forename: Hitoshi
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authors.lastname: Matsuo
authors.affiliation: Imelda Hospital Bonheiden, Antwerp, Belgium.
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authors.lastname: Janssens
authors.affiliation: Gifu Heart Center, Gifu, Japan.
authors.forename: Ueno
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authors.lastname: Katsumi
authors.affiliation: Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, United Kingdom.
authors.forename: Carlo
authors.initials: C
authors.lastname: Di Mario
authors.affiliation: Cardiovascular Institute, Hospital Clinico San Carlos, Madrid, Spain.
authors.forename: Javier
authors.initials: J
authors.lastname: Escaned
authors.affiliation: Academic Medical Centre, Amsterdam, the Netherlands.
authors.forename: Jan
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authors.affiliation: International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London and Imperial College Healthcare NHS Trust, London, United Kingdom. Electronic address: justin.davies@imperial.ac.uk.
authors.forename: Justin E
authors.initials: JE
authors.lastname: Davies
mesh_terms: D000368:Aged; D019540:Area Under Curve; D006328:Cardiac Catheterization / Q000379:methods; D016022:Case-Control Studies; D017023:Coronary Angiography / Q000379:methods; D003326:Coronary Circulation; D023921:Coronary Stenosis / Q000175:diagnosis*; D005260:Female; D053805:Fractional Flow Reserve, Myocardial; D006801:Humans; D008297:Male; D008875:Middle Aged; D012372:ROC Curve; D012680:Sensitivity and Specificity; D012720:Severity of Illness Index