Fundamentals in clinical coronary physiology: why coronary flow is more important than coronary pressure

Wide attention for the appropriateness of coronary stenting in stable ischaemic heart disease (IHD) has increased interest in coronary physiology to guide decision making. For many, coronary physiology equals the measurement of coronary pressure to calculate the fractional flow reserve (FFR). While accumulating evidence supports the contention that FFR-guided revascularization is superior to revascularization based on coronary angiography, it is frequently overlooked that FFR is a coronary pressure-derived estimate of coronary flow impairment. It is not the same as the direct measures of coronary flow from which it was derived, and which are critical determinants of myocardial ischaemia. This review describes why coronary flow is physiologically and clinically more important than coronary pressure, details the resulting limitations and clinical consequences of FFR-guided clinical decision making, describes the scientific consequences of using FFR as a gold standard reference test, and discusses the potential of coronary flow to improve risk stratification and decision making in IHD.