In Reply: Drs Kostis and Shulman point out that FFR is a reasonable alternative for the assessment of ischemia in the absence of a noninvasive functional study. We concur that FFR is useful when physicians are confronted with coronary anatomy of uncertain physiologic significance to help determine the need for PCI.1
However, it is difficult to argue in favor of an approach that requires a diagnostic cardiac catheterization for patients who might not have needed one had they had a negative noninvasive test. Furthermore, FFR is an invasive procedure that carries small but significant additional risks beyond those associated with diagnostic coronary angiography, and the technology is available only in a minority of US catheterization laboratories. Finally, noninvasive testing with selective cardiac catheterization has been shown to be more cost-effective than routine cardiac catheterization for patients with stable coronary artery disease,2 so there are likely few situations where routine cardiac catheterization plus FFR would be more cost-effective than a strategy of initial stress testing.
Lin GA, Malenka DJ, Redberg RF. Documenting Ischemia Prior to Elective Percutaneous Coronary Intervention—Reply. JAMA. 2009;301(10):1018-1019. doi:10.1001/jama.2009.259