title: Association of Coronary Stenosis and Plaque Morphology With Fractional Flow Reserve and Outcomes.
abstract: Obstructive coronary lesions with reduced luminal dimensions may result in abnormal regional myocardial blood flow as assessed by stress-induced myocardial perfusion imaging or a significant fall in distal perfusion pressure with hyperemia-induced vasodilatation (fractional flow reserve [FFR] ≤0.80). An abnormal FFR has been demonstrated to identify high-risk lesions benefitting from percutaneous coronary intervention while safely allowing revascularization to be deferred in low-risk lesions, resulting in a decrease in the number of revascularization procedures as well as substantially reduced death and myocardial infarction. While FFR identifies hemodynamically significant lesions likely to produce ischemia-related symptoms, it remains less clear as to why it might predict the risk of acute coronary syndromes, which are usually due to plaque rupture and coronary thrombosis.
  
  
  
  Although the atherosclerotic plaques with large necrotic cores (independent of the degree of luminal stenosis) are known to be associated with vulnerability to rupture and acute coronary syndromes, emerging evidence also suggests that they may induce greater rates of ischemia and reduced FFR compared with non-lipid-rich plaques also independent of the degree of luminal narrowing. It is proposed that the presence of large necrotic cores within the neointima may be associated with the inability of the vessel to dilate and may predispose to ischemia and abnormal FFR.
  
  
  
  Having a normal FFR requires unimpaired vasoregulatory ability and significant luminal stenosis. Therefore, FFR should identify lesions that are unlikely to possess large necrotic core, rendering them safe for treatment with medical therapy alone. Further studies are warranted to determine whether revascularization decisions in patients with stable coronary artery disease could be improved by assessment of both plaque composition and ischemia.
authors.affiliation: Division of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York2Division of Cardiology and Radiology, University of British Columbia, Vancouver, Canada.
authors.forename: Amir
authors.initials: A
authors.lastname: Ahmadi
authors.affiliation: Division of Cardiology, Columbia University Medical Center, Cardiovascular Research Foundation, New York, New York.
authors.forename: Gregg W
authors.initials: GW
authors.lastname: Stone
authors.affiliation: Division of Cardiology and Radiology, University of British Columbia, Vancouver, Canada.
authors.forename: Jonathon
authors.initials: J
authors.lastname: Leipsic
authors.affiliation: Division of Cardiology, Imperial College, London, England.
authors.forename: Patrick W
authors.initials: PW
authors.lastname: Serruys
authors.affiliation: Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Leslee
authors.initials: L
authors.lastname: Shaw
authors.affiliation: Division of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York.
authors.forename: Harvey
authors.initials: H
authors.lastname: Hecht
authors.affiliation: Division of Cardiology and Radiology, University of British Columbia, Vancouver, Canada.
authors.forename: Graham
authors.initials: G
authors.lastname: Wong
authors.affiliation: Division of Cardiology, Aarhus University Hospital, Skejby, Denmark.
authors.forename: Bjarne Linde
authors.initials: BL
authors.lastname: Nørgaard
authors.affiliation: Division of Cardiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
authors.forename: Patrick T
authors.initials: PT
authors.lastname: O'Gara
authors.affiliation: Division of Cardiology, University of Minnesota School of Medicine, Minneapolis9Division of Cardiology, Veterans Affairs Medical Center, Minneapolis.
authors.forename: Y
authors.initials: Y
authors.lastname: Chandrashekhar
authors.affiliation: Division of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York.
authors.forename: Jagat
authors.initials: J
authors.lastname: Narula
mesh_terms: D023921:Coronary Stenosis / Q000473:pathology* / Q000503:physiopathology*; D053805:Fractional Flow Reserve, Myocardial / Q000502:physiology*; D006801:Humans; D058226:Plaque, Atherosclerotic / Q000473:pathology* / Q000503:physiopathology