Cardiac imaging for the detection of ischemia: current status and future perspectives – When “50–60% Stenosis” Isn’t the Full Story: Can Imaging Replace the Functional FFR?
Cardiac imaging for the detection of ischemia: current status and future perspectives –
When “50–60% Stenosis” Isn’t the Full Story: Can Imaging Replace the Functional FFR?
Source: ,JACC , October 2025.
Background:
Intermediate coronary stenosis (≈50–60%) remains a daily challenge in cardiology.
Angiography shows anatomy, not ischemia, while traditional FFR and stress tests can be invasive or inconclusive.
Modern cardiac imaging now bridges anatomy and physiology — revealing perfusion, viability, and the true burden of ischemia.
Keynotes:
Imaging Spectrum – From Anatomy to Function
1. CCTA: Excellent for anatomy and plaque, limited for microvascular ischemia.
2. Stress Echocardiography: Detects wall-motion abnormalities, operator-dependent.
3. Nuclear (SPECT/PET): Assesses perfusion; PET quantifies flow but uses radiation.
4. Cardiac MRI (CMR): Combines stress perfusion, LGE, and mapping — detects ischemia, viability, and microvascular dysfunction without radiation.
CMR vs. FFR – Complement or Replacement?
• For 40–70% lesions, quantitative perfusion CMR can match or surpass invasive FFR in detecting flow limitation.
• CMR assesses the effect of stenosis, not just its degree.
• Particularly valuable in multivessel or microvascular disease where FFR may miss global ischemia.
Clinical Takeaways
1. Stress + LGE CMR is the noninvasive gold standard for diagnosing ischemia and viability.
2. It answers: Is the myocardium alive? Is it suffering?
3. Quantitative CMR perfusion = a “virtual FFR” without a wire.
4. The future lies in imaging the impact of disease, not its geometry.
