The document describes a study comparing instantaneous wave-free ratio (iFR) to fractional flow reserve (FFR) for assessing coronary stenosis. The study involved 2492 patients with intermediate coronary lesions randomized 1:1 to iFR-guided or FFR-guided percutaneous coronary intervention (PCI). The primary endpoint was a composite of death, myocardial infarction, or urgent revascularization at 30 days, 1 year, and 5 years. Results showed non-inferiority of iFR-guided PCI compared to FFR-guided PCI for the primary endpoint. An iFR cutoff of 0.89 provided comparable classification of lesions to an FFR cutoff of 0.80. iFR assessment does not require induction

1. Lorem Ipsum Dolor
performed after the angioplasty balloon had been removed, the
catheter flushed and nitrates administered again. The pressure
wire was normalised at the vessel ostium and then measure-
ments were made at the same coronary location as pre-
angioplasty.
All patients received an oral loading dose of aspirin 300 mg
and clopidogrel 600 mg, and intravenous heparin according to
weight, together with bivalirudin or GPIIbIIIa-antagonist accord-
ing to clinical indication.
Pd/Pa ratio
pressure to
cardiac cycle
FFR meas
nique,5
using
pressure dur
was induced
administered
an intracoron
Figure 1 Calculation of iFR over the resting wave-free window. Using an automated off-li
distal-to-proximal pressure ratio during the wave-free period.
2 Ni
Mario Sádaba.
Hospital Galdakao-Usansolo.
8 Junio ´18
ÍNDICES NO HIPERÉMICOS
VALIDADOS CLINICAMENTE.
NO NECESITAS MÁS.

2. ❖ FRACCIONAL FLOW RESERVE
❖ Ratio de presión media distal y presión
media de aorta en un vaso estenótico
en hiperemia.
❖ FFR = Pd/Pa.. Lo normal 1.
❖
❖ Instantaneous wave free Ratio
❖ Ratio de presión diastólica distal a la
lesión y la presión diastólica en Ao.
❖ Resistencias bajas y estables con lo
que no se necesita adenosina.
❖ iFR = Pd/Pa.. Lo normal 1.
Definición FFR
Definición iFR
assessment with the pressure wire. Repeated measurements were
performed after the angioplasty balloon had been removed, the
catheter flushed and nitrates administered again. The pressure
wire was normalised at the vessel ostium and then measure-
ments were made at the same coronary location as pre-
angioplasty.
All patients received an oral loading dose of aspirin 300 mg
and clopidogrel 600 mg, and intravenous heparin according to
weight, together with bivalirudin or GPIIbIIIa-antagonist accord-
ing to clinical indication.
tion1
(figure 1).
Pd/Pa ratio was c
pressure to proxim
cardiac cycle.
FFR measuremen
nique,5
using the r
pressure during co
was induced by ade
administered by fem
an intracoronary 60
Figure 1 Calculation of iFR over the resting wave-free window. Using an automated off-line algo
distal-to-proximal pressure ratio during the wave-free period.
DIFERENCIAS FFR-iFR
MÁS RÁPIDO, MÁS BARATO, MÁS ESTABLE, SIN CONTRAINDICACIONES

3. Estudio DEFER
Estudio FAME
Estudio FAME 2
Adenosine IV (140 μg/kg/min)
or IC (15 μg in RCA or 20 μg
in LCA).
Adenosine IV (140 μg/kg/min). If
Adenosine IV cannot be given,
Adenosine IC 50 μg and repeated
twice.
Adenosine IV, 140 μg/Kg/min
through a central vein.
CUANTO Y COMO.
DIFERENCIAS FFR-iFR. ADENOSINA

4. Ramón López-Palop et al. Am J Cardiol 2013;111:1277-1283
FFR <0.80
CUANTO Y COMO.
DIFERENCIAS FFR-iFR. ADENOSINA

5. Valor dicotómico, discordancia entre FFR e iFR
FFR 0,80. VALOR DICOTOMICO??
Petraco R et al. JACC Cardiol Intv 2013

6. FFR. EVIDENCIA
Estudio DEFER. 325 pac
Aleatorización:
lesiones con FFR>0.75
Pronóstico lesiones estables FFR>0,75 sin isquemia documentada (Sin test
isquemia, test negativo o no concluyente)
ACTP
TT médico
Bech et al. Circulation 2001;103:2928-2934
5-Year Follow-Up of the DEFER Study
PCI vs. OMT of Func1onally Non-significant Stenoses

7. Bech et al. Circulation 2001;103:2928-2934
FFR. EVIDENCIA
Estudio FAME 1005 pac
Angiography-guided PCI FFR-guided PCI
Measure FFR in all
indicated stenoses
Stent all indicated
stenoses
Stent only those
stenoses with FFR ≤ 0.80
Randomization
Indicate all stenoses ≥ 50%
considered for stenting
Patient with stenoses ≥ 50%
in at least 2 of the 3 major
epicardial vessels
1-year follow-up
FLOW CHART
FFR-guided
30 days
2.9% 90 days
3.8% 180 days
4.9% 360 days
5.3%
Angio-guided
absolute difference in MACE-free survival
FAME study: Event-free Survival
ANGIO-group
N=496
FFR-group
N=509
P-value
Events at 1 year, No (%)
Death, MI, CABG, or repeat-PCI 91 (18.4) 67 (13.2) 0.02
Death 15 (3.0) 9 (1.8) 0.19
Death or myocardial infarction 55 (11.1) 37 (7.3) 0.04
CABG or repeat PCI 47 (9.5) 33 (6.5) 0.08
Total no. of MACE 113 76 0.02
Myocardial infarction, specified
All myocardial infarctions 43 (8.7) 29 (5.7) 0.07
Small periprocedural CK-MB 3-5 x N 16 12
Other infarctions (“late or large”) 27 17
FAME study: Adverse Events at 1 year
Mejor ICP guiada
Tonino et al, N Engl J Med 2009; 360:213-224

8. FFR. EVIDENCIA
De Bruyne et al, N Engl J Med 2012; 367:991-1001
Estudio FAME 2 888 pac
Fractional Flow Reserve in Stable C
CumulativeIncidence(%)
35
30
20
25
15
10
5
0
0 2 4 6 8 10 121 3 5 7 9 11
Months since Randomization
A Primary End Point
PCI vs. medical therapy:
Hazard ratio, 0.32 (95% CI, 0.19–0.53); P<0.001
PCI vs. registry:
Hazard ratio, 1.29 (95% CI, 0.49–3.39); P=0.61
Medical therapy vs. registry:
Hazard ratio, 4.32 (95% CI, 1.75–10.70); P<0.001
No. at Risk
Medical
therapy
PCI
Registry
441
447
166
370
388
145
414
414
156
322
351
133
283
308
117
253
277
106
220
243
93
192
212
74
162
175
64
127
155
52
100
117
41
70
92
25
37
53
13
Medical
therapy
PCI
Registry
nce(%)
35
30
25
C Myocardial Infarction
PCI vs. medical therapy:
Hazard ratio, 1.05 (95% CI, 0.51–2.19); P=0.89
PCI vs. registry:
Hazard ratio, 1.61 (95% CI, 0.48–5.37); P=0.41
Medical therapy vs. registry:
D
12,7%
4,3%
End point primario muerte, IAM o
revascularización urgente

9. iFR. EVIDENCIA. ADVISE
Figure 1 Calculation of iFR over the resting wave-free window. Using an automated off-lin
distal-to-proximal pressure ratio during the wave-free period.
2 Ni
La resistencia intracoronaria es constante y mínima de
forma natural durante el periodo libre de ondas (wave
free period). El ratio de presión durante este periodo
libre de ondas da un indice de la severidad de la
estenosis, sin farmacos, similar al FFR.
Sen et al. J Am Coll Cardiol 2012;59: 1392-402

10. iFR. EVIDENCIA. ADVISE II
J Escaned et al. J Am Coll Cardiol Intv 2015; 8: 824–33
End point primario: % de estenosis
correctamente clasificadas con el iFR
values <0.85 and >0.94, y el % de
estenosis correctamente clasificadas tras
hacer un approach hibiro iFR-FFR.
sure wires were introduced. Pressure wires were normalised at
the coronary ostia before every pressure recording. If more than
one stent was used within one coronary segment, the pressure
analysis was performed for the complete segment. For post-
angioplasty measurements, all stents were optimised with postdi-
lation where angiographically indicated before further
assessment with the pressure wire. Repeated measurements were
performed after the angioplasty balloon had been removed, the
catheter flushed and nitrates administered again. The pressure
wire was normalised at the vessel ostium and then measure-
ments were made at the same coronary location as pre-
angioplasty.
All patients received an oral loading dose of aspirin 300 mg
and clopidogrel 600 mg, and intravenous heparin according to
weight, together with bivalirudin or GPIIbIIIa-antagonist accord-
ing to clinical indication.
Calculation of Pd/Pa, iFR and FFR
iFR was calculated as a ratio of the distal coronary pressure to
proximal coronary pressure at rest, using the validated auto-
mated algorithms with phase alignment acting over the diastolic
wave-free period over a minimum of five beats. iFR is measured
using pressure-only, at baseline, without adenosine administra-
tion1
(figure 1).
Pd/Pa ratio was calculated using the ratio of distal coronary
pressure to proximal coronary pressure at rest over the entire
cardiac cycle.
FFR measurements were performed using a standard tech-
nique,5
using the ratio of distal coronary pressure to proximal
pressure during conditions of stable hyperaemia. Hyperaemia
was induced by adenosine infusion at a rate of 140 mcg/kg/min,
administered by femoral venous access in 96 (80%) stenoses and
an intracoronary 60 mcg bolus in 24 (20%) stenoses.
Figure 1 Calculation of iFR over the resting wave-free window. Using an automated off-line algorithm, iFR was calculated at rest from the
distal-to-proximal pressure ratio during the wave-free period.
2 Nijjer SS, et al. Heart 2013;0:1–9. doi:10.1136/heartjnl-2013-304387

11. iFR. EVIDENCIA
the overall proportion of stenoses properly classified by iFR =<0.85 and
>=0.94 was 91.6%. the percent of stenoses properly classified by hybrid iFR-
FFR approach was 94.2%. Optimal cutoff value 0,89
Study protocol: coronary catheterisation
Coronary angiography and pressure wire assessments of coron-
ary stenoses were performed using conventional approaches.
Intracoronary nitrates were administered in all cases before pres-
sure wires were introduced. Pressure wires were normalised at
the coronary ostia before every pressure recording. If more than
one stent was used within one coronary segment, the pressure
analysis was performed for the complete segment. For post-
angioplasty measurements, all stents were optimised with postdi-
lation where angiographically indicated before further
assessment with the pressure wire. Repeated measurements were
performed after the angioplasty balloon had been removed, the
catheter flushed and nitrates administered again. The pressure
wire was normalised at the vessel ostium and then measure-
ments were made at the same coronary location as pre-
angioplasty.
All patients received an oral loading dose of aspirin 300 mg
and clopidogrel 600 mg, and intravenous heparin according to
weight, together with bivalirudin or GPIIbIIIa-antagonist accord-
ing to clinical indication.
core laboratory using a custom software package with Matlab
(Mathworks, Inc., Natick, Massachusetts).
Calculation of Pd/Pa, iFR and FFR
iFR was calculated as a ratio of the distal coronary pressure to
proximal coronary pressure at rest, using the validated auto-
mated algorithms with phase alignment acting over the diastolic
wave-free period over a minimum of five beats. iFR is measured
using pressure-only, at baseline, without adenosine administra-
tion1
(figure 1).
Pd/Pa ratio was calculated using the ratio of distal coronary
pressure to proximal coronary pressure at rest over the entire
cardiac cycle.
FFR measurements were performed using a standard tech-
nique,5
using the ratio of distal coronary pressure to proximal
pressure during conditions of stable hyperaemia. Hyperaemia
was induced by adenosine infusion at a rate of 140 mcg/kg/min,
administered by femoral venous access in 96 (80%) stenoses and
an intracoronary 60 mcg bolus in 24 (20%) stenoses.
Figure 1 Calculation of iFR over the resting wave-free window. Using an automated off-line algorithm, iFR was calculated at rest from the
distal-to-proximal pressure ratio during the wave-free period.
2 Nijjer SS, et al. Heart 2013;0:1–9. doi:10.1136/heartjnl-2013-304387
J Escaned et al. J Am Coll Cardiol Intv 2015; 8: 824–33

12. iFR. iFR esperado pre-ICP
Nijjer et al, J Am Coll Cardiol Intv 2014;7: 1386–96
iFR measurements during continuous resting
pressure wire pullback provide a physiological
map of the entire coronary vessel. Before a PCI,
the iFR pullback can predict the hemodynamic
consequences of stenting specific stenoses.
Figure 1 Calculation of iFR over the resting wave-free window. Using an automated off-lin
distal-to-proximal pressure ratio during the wave-free period.
2 Nijje

13. iFR. Valoración post-ICP
Nijjer SS, et al. Heart 2013;99:1740–1748
El cambio en el iFR tras la ICP es equivalente a la observada con
FFR.Pre-PCI, mean FFR was 0.66±0.14, mean iFR was 0.75±0.21 The
change in iFR after intervention (0.20±0.21) was similar to ∆FFR
0.22±0.15 (p=0.25).
Figure 1 Calculation of iFR over the resting wave-free window. Using an automated off-lin
distal-to-proximal pressure ratio during the wave-free period.
2 Nijje

14. iFR. EVIDENCIA CLINICA
FFR>0.8'
Defer'PCI'
FFR≤0.8'
Perform'PCI'
FFR##
guided#PCI#
iFR<0.9'
Perform'PCI'
iFR≥0.9'
Defer'PCI'
Intermediate'lesion'requiring'physiological'assessment'
In'ACS':'intermediate'non#culprit+lesion'
N=2500,'1:1'RandomisaLon'
iFR##
guided#PCI#
30'day,'1,'2'and'5yr'followOup'
Func.onal#Lesion#Assessment#of#Intermediate#stenosis#to#guide#Revascularisa.on'
'
PI:'Davies'J,'Escaned'J.'Chairmen:'Serruys'P,'Patel'M'
Davies et al, N Engl J Med 2017; 376:1824-1834
2492 pac
FFR 0,80.
iFR 0,89
No inferioridad
Figure 1 Calculation of iFR over the resting wave-free window. Using an automated off-lin
distal-to-proximal pressure ratio during the wave-free period.
2 Nijje

15. iFR. EVIDENCIA CLINICA
Davies et al, N Engl J Med 2017; 376:1824-1834
FFR (7.02%)
0.000.050.10
CumulativeEventRate
0 1 2 3 4 5 6 7 8 9 10 11 12
Months since randomization
Hazard Ratio,
0.95 (95% CI, 0.68 to 1.33); p=0.78
iFR (6.79%)
Primary endpoint (MACE)
iFR equivalent to FFR with less PCI and CABGFFR>0.8'
Defer'PCI'
FFR≤0.8'
Perform'PCI'
FFR##
guided#PCI#
iFR<0.9'
Perform'PCI'
iFR≥0.9'
Defer'PCI'
Intermediate'lesion'requiring'physiological'assessment'
In'ACS':'intermediate'non#culprit+lesion'
N=2500,'1:1'RandomisaLon'
iFR##
guided#PCI#
30'day,'1,'2'and'5yr'followOup'
Func.onal#Lesion#Assessment#of#Intermediate#stenosis#to#guide#Revascularisa.on'
'
PI:'Davies'J,'Escaned'J.'Chairmen:'Serruys'P,'Patel'M'
End point 1º muerte,
IAM o revascularización
al año
CONCLUSIÓN: La
revascularización
guiada por iFR fué no
inferior a la guiada por
FFR respecto a los
MACEs al año.
Figure 1 Calculation of iFR over the resting wave-free window. Using an automated off-lin
distal-to-proximal pressure ratio during the wave-free period.
2 Nijje

16. iFR. EVIDENCIA CLINICA
!"#$#%#&'()
!!"#$%&
'()(*+,-.
!!"/$%&
,(*)0*1+,-.
!!"#
$%&'('#)*+
2!"3$%4
,(*)0*1+,-.
2!"5$%4
'()(*+,-.
.67(*1(8297(+:(;206+*(<=2*26>+?@A;20:0>2B9:+9;;(;;1(67
.6+C-D+E+267(*1(8297(+!"!#$%&'()*+:(;206
FGH$$$I+JEJ+"968012;97206
&!"#
$%&'('#)*+
K$+89AI+JI+H+968+LA*+)0::0MN=?
PI:$$$$Ma'hias$Gotberg$
$Ole$Frobert$
Götberg et al, N Engl J Med 2017; 376:1813-1823
!"#$#%#&'()
!!"#$%&
'()(*+,-.
!!"/$%&
,(*)0*1+,-.
!!"#
$%&'('#)*+
2!"3$%4
,(*)0*1+,-.
2!"5$%4
'()(*+,-.
.67(*1(8297(+:(;206+*(<=2*26>+?@A;20:0>2B9:+9;;(;;1(67
.6+C-D+E+267(*1(8297(+!"!#$%&'()*+:(;206
FGH$$$I+JEJ+"968012;97206
&!"#
$%&'('#)*+
K$+89AI+JI+H+968+LA*+)0::0MN=?
PI:$$$$Ma'hias$Gotberg$
$Ole$Frobert$
No inferioridad
2037 pac
FFR 0,80.
iFR 0,89
Figure 1 Calculation of iFR over the resting wave-free window. Using an automated off-lin
distal-to-proximal pressure ratio during the wave-free period.
2 Nijje

17. iFR. EVIDENCIA CLINICA
0 2 4 6 8 10 12
0
10
20
30
40
50
60
70
80
90
100
No. at Risk
Cumulativeriskofcompositeendpoint(%)
Months
Hazard ratio for primary composite end point of death, myocardial infarction
and revascularization 1.12 (95% CI, 0.79-1.58) P=0.53
iFR
FFR
HR (95% CI) =
1.12 (95% CI: 0.79, 1.58)
P=0.53
6.1%
6.7%
iFR (n=1012)
FFR (n=1007)
Götberg et al, N Engl J Med 2017; 376:1813-1823
0 2 4 6 8 10 12
0
10
20
30
40
50
60
70
80
90
100
No. at Risk
Cumulativeriskofcompositeendpoint(%)
Months
Hazard ratio for primary composite end point of death, myocardial infarction
and revascularization 1.12 (95% CI, 0.79-1.58) P=0.53
iFR
FFR
HR (95% CI) =
1.12 (95% CI: 0.79, 1.58)
P=0.53
6.1%
6.7%
iFR (n=1012)
FFR (n=1007)
0 2 4 6 8 10 12
0
10
20
30
40
50
60
70
80
90
100
No. at Risk
Cumulativeriskofcompositeendpoint(%)
Months
Hazard ratio for primary composite end point of death, myocardial infarction
and revascularization 1.12 (95% CI, 0.79-1.58) P=0.53
iFR
FFR
HR (95% CI) =
1.12 (95% CI: 0.79, 1.58)
P=0.53
6.1%
6.7%
iFR (n=1012)
FFR (n=1007)
!"#$#%#&'()
!!"#$%&
'()(*+,-.
!!"/$%&
,(*)0*1+,-.
!!"#
$%&'('#)*+
2!"3$%4
,(*)0*1+,-.
2!"5$%4
'()(*+,-.
.67(*1(8297(+:(;206+*(<=2*26>+?@A;20:0>2B9:+9;;(;;1(67
.6+C-D+E+267(*1(8297(+!"!#$%&'()*+:(;206
FGH$$$I+JEJ+"968012;97206
&!"#
$%&'('#)*+
K$+89AI+JI+H+968+LA*+)0::0MN=?
PI:$$$$Ma'hias$Gotberg$
$Ole$Frobert$
CONCLUSIÓN: La
revascularización
guiada por iFR fué no
inferior a la guiada por
FFR respecto a los
MACEs al año.
End point 1º muerte, IAM
o revascularización al año

18. iFR/FFR-GUIDELINES
European Heart Journal doi:10.1093/eurheartj/eht296

19. iFR/FFR-GUIDELINES
European Heart Journal doi:10.1093/eurheartj/ehu278

20. iFR/FFR-GUIDELINES
Patel et al. J A C C V O L . 6 9 , N O . 1 7 , 2 0 1 7: 2 2 1 2 – 4 1

21. iFR/FFR-GUIDELINES
…
iFR & FFR to identify
haemodynamically relevant
coronary lesion(s) in stable
patients when evidence of
ischemia is not available
?
325
8881005
2492
2037
iFR
FFR

22. iFR/FFR-REGISTRO DE ACTIVIDAD

23. INDICES DIASTOLICOS DE REPOSO
van’t Veer, M. et al. J Am Coll Cardiol. 2017;70(25):3088–96.
RFR

24. INDICES DIASTOLICOS DE REPOSO
van’t Veer, M. et al. J Am Coll Cardiol. 2017;70(25):3088–96.
All diastolic resting indexes tested were identical to iFR. Cutoff values,
guidelines, and clinical recommendations for iFR can therefore be extended
to these other indexes.

25. Lorem Ipsum Dolor
INDICES NO HIPEREMICOS
VALIDADOS CLINICAMENTE.
NO NECESITAS MAS.
MAS RAPIDO, MAS BARATO, SIN CONTRAINDICACIONES
!"#$#%#&'()
!!"#$%&
'()(*+,-.
!!"/$%&
,(*)0*1+,-.
!!"#
$%&'('#)*+
2!"3$%4
,(*)0*1+,-.
2!"5$%4
'()(*+,-.
.67(*1(8297(+:(;206+*(<=2*26>+?@A;20:0>2B9:+9;;(;;1(67
.6+C-D+E+267(*1(8297(+!"!#$%&'()*+:(;206
FGH$$$I+JEJ+"968012;97206
&!"#
$%&'('#)*+
PI:$$$$Ma'hias$Gotberg$
$Ole$Frobert$
Intermediate'lesion'requiring'physiological'assessment'
In'ACS':'intermediate'non#culprit+lesion'
N=2500,'1:1'RandomisaLon'
Func.onal#Lesion#Assessment#of#Intermediate#stenosis#to#guide#Revascularisa.on'
'

26. Lorem Ipsum Dolor
INDICES NO HIPEREMICOS
VALIDADOS CLINICAMENTE.
NO NECESITAS MAS.
CFR
13
1. Press STOP to end
measurement
procedure and review
result in stop/view
mode
2. Transfer the recording
to RadiView and
review IMR
3. Alternatively IMR can
be calculated
manually on Xpress as
Pd x Tmn Hyp
6. Review Result and Calculate IMR
IMR Measurement Procedure
(108)
Pa mean
(89)
Pd mean
0.82
FFR
2.4
CFR
33
IMR
IMR

27. MEJOR GUÍAR LAS ANGIOPLASTIAS CON iFR/FFR.
LINEAS CONVERGENTES DONDE HAY LINEAS PARALELAS,
LESIONES SIGNIFICATIVAS DONDE NO LAS HAY
FFR
iFR