How to manage an asymptomatic 45 year old man with 90 % mid LAD lesion , with FFR .9 who is stress test positive at 9 Mets ?
Six cardiologists and six responses . . . and the elusive seventh sense
- FFR is most scientific test to assess physiology of coronary stenosis . I will go with that and put this patient under medical management.
- I agree with FFR, still the patient has no symptoms , but why the hell is EST + ve ? I am confused .
- I would definitely stent the lesion irrespective of the symptoms .
- I would order a stress thallium . I do not believe in FFR
- The data provided is insufficient. I would like to this patient in my clinic , and if necessary may order a fresh CAG.
- For a 90 % LAD lesion FFR should not have been done in the first place .That is the root of the confusion. He should have received a stent long back .
Final message
FFR is a terrible concept for two reasons . One , it never bothers about flow across a lesion. It simply relies upon pressure drop. we all know there is an intricate relationship between pressure and flow . Simple pressure drop can never be expected to translate into incremental flow in biological systems .The second major limitation is it ignores the morphology of the lesion . We know an eccentric soft lesion with a good distal FFR is live coronary explosive .
Dr.S.Venkatesan MD 
Dear Dr Venkatesan
I believe that this concept is like the ‘severe asymptomatic” stenosis concept which tantalizes cardiology practice for half a century… AS Severity beeing graded on the sole basis of transaortic gradient and ignoring the pathophysiology of PRESSURE RECOVERY taking place DISTAL to the stenosis.
Thus the presence of PRESSURE RECOVERY explains the asymptomatic status of the patient because the LV where the symptoms originate from DOES NOT face the heavy load suggested by the high gradient but a significantly (25-35%) less load.
In other words velocity(or its derivative gradient) across a stenotic lesion is not synonymous to the severity of the lesion.
Analogous effect to the morphology of the coronary plaque has the morphology of the stenosed AoV (flat,funnel or doming shape) on transaortic velocity …
best hellenic regards