Integrating Anatomical and Physiological Indices in Coronary Artery Stenosis Evaluation: A New Frontier

The evaluation of left main coronary artery stenosis poses a clinical challenge, particularly when choosing between anatomical and physiological indices. Contemporary guidelines suggest LM-specific IVUS thresholds (for example, a minimum lumen area around 6 mm²) and selective use of FFR/iFR when feasible, framing the anatomy–physiology balance in practice.

Assessing left main coronary artery stenosis remains fraught with challenges, especially when anatomical complexities arise, according to a recent study. Discordance between angiographic appearance, intravascular imaging, and physiological assessment can affect the perceived severity of a lesion and downstream management decisions.

The integration of anatomical and physiological indices can augment diagnostic precision and inform clinical decision-making. Physiological indices like fractional flow reserve offer functional data that can enhance intervention choices, as shown in the prospective, multicenter iLITRO-EPIC07 evaluation, where FFR complemented by imaging was associated with improved diagnostic clarity; these findings are supportive but not guideline-determinative.

From the patient lens, integrating IVUS (or other intravascular imaging) with FFR/iFR for LMCA assessment can reduce ambiguity and improve confidence in treatment plans. Clinical practice can benefit from real-world evidence drawn from large administrative datasets (US Medicare analyses), which help illuminate patterns of care and outcomes at scale. Analyses from Medicare real-world data can also inform personalization—such as using observed risk patterns to guide follow-up intensity and care coordination—without supplanting patient-level imaging and physiology.

Key predictors for heart failure risk—such as NT-proBNP and cystatin C—can support risk stratification, as illustrated by a derivation model developed in a defined cohort with clinical endpoints. When angiography is limited, pairing physiological assessment with adjunctive intravascular imaging (IVUS/OCT) can mitigate uncertainty, while acknowledging and addressing possible discordance.

Advances in imaging can improve treatment accuracy, though benefits depend on operator expertise and lesion characteristics. Therefore, the next step is leveraging this integrative diagnostic approach to enhance patient-specific treatment frameworks—drawing on insights from the iLITRO-EPIC07 findings, acknowledging LMCA IVUS thresholds and interpretive challenges, and incorporating biomarker- and RWE-informed risk stratification to tailor follow-up and therapy.

Key Takeaways:

• Integrated anatomical and physiological assessment aligns with contemporary practice for LMCA, with IVUS minimum lumen area thresholds (approximately 6 mm²) and careful use of FFR/iFR—especially in ostial disease—guiding decisions.
• Combining intravascular imaging with FFR/iFR helps reconcile anatomy–physiology discordance and supports shared, patient-centered decision-making.
• Biomarkers such as NT-proBNP and cystatin C can inform post-procedural risk stratification and follow-up planning when interpreted in clinical context.
• Insights from large real-world datasets (e.g., Medicare analyses) can complement patient-level assessments by highlighting population-level patterns that shape care pathways.