Ghobrial et al describe the impact that one coronary angiogram-derived physiology system, virtual fractional flow reserve (vFFR), has on diagnosis and decision-making of cardiologists when assessing patients undergoing diagnostic angiography for either chronic coronary syndrome or non-ST elevation (NSTE) myocardial infarction (MI), when compared with angiography alone.1 In 320 patients, the availability of vFFR data led to a significant reduction in the number of vessels considered to have important disease and changed the management in 22% of cases when compared with their classification using angiography alone. The authors logically suggest that the data, taken in the context of promising clinical results from this and other angiogram-derived physiology systems, indicate that vFFR should be used more routinely in clinical practice to improve the precision of patient diagnosis and management.

The paper indeed highlights the considerable clinical potential of angiogram-derived physiology systems. Reassuringly, the degree of reclassification of vessels with significant disease and overall change in management reported in VIRTU4 are remarkably similar to the results of RIPCORD (Does routine pressure wire assessment influence management strategy at coronary angiography for diagnosis of chest pain?),2 on which this methodology was based, and several other studies that employed intracoronary pressure wire assessment of all coronary arteries of a size consistent with revascularisation and compared outcomes with angiographic assessment alone.3 The vFFR results certainly therefore raise the possibility that such profound alterations in diagnosis and management could be …