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Invasive coronary physiology techniques have an increasing role in the clinical assessment of stenosis-induced myocardial ischaemia.

The most widely adopted invasive approach to pathophysiology is (myocardial) FFR, which is calculated as the ratio of mean distal coronary pressure to mean aortic pressure during pharmacologically induced coronary vasodilatation (Fig. 8a).

Second, the prognostic value of FFR in patients with stenoses and an abnormal FFR is limited, with 27% of patients who are managed by medical therapy alone having a cardiovascular event within 5 years39.

iFR is defined as the ratio of distal coronary pressure to aortic pressure at a distinct time in cardiac diastole, termed the wave-free period (Fig. 8a), in resting, non-vasodilated conditions177.

Moreover, an iFR-guided revascularization strategy has been documented to provide equivalent clinical outcomes to those of an FFR-guided strategy in two large randomized clinical trials, where fewer coronary revascularization procedures were indicated in the iFR-guided treatment groups178,179.

CFR is defined as the ratio of coronary flow during pharmacological vasodilatation to flow at rest (Fig. 8a), representing the reserve capacity of the coronary circulation to increase flow in response to increased demand.

Coronary wedge pressure, which is the distal coronary pressure obtained during occlusion of the epicardial coronary artery to prevent antegrade coronary flow, is a simple marker of collateral function.

CFI and CFIp are the most applicable techniques, and values of >0.30 are generally considered to indicate adequate collateral artery function, substantiated by the absence of angina or electrocardiogram changes during balloon occlusion181.

In patients with a high likelihood of invasive treatment being required, invasive coronary flow and pressure measurement is well suited to guide treatment decision-making, with FFR having achieved greatest acceptance but limited clinical uptake38.

Considering the limitations of coronary pressure-based techniques, the decision to revascularize should optimally be on the basis of the combination of imaging ischaemia tests and coronary pressure measurement, the results of which should be interpreted in relation to the symptoms of the individual patient to determine the risk–benefit ratio of a coronary intervention.

Artificial intelligence, mainly in the form of machine learning and intelligent algorithms, is increasingly being recognized as a tool to aid invasive diagnostics184 and to improve the safety and accuracy of invasive physiology techniques.

VIDEO: PET vs. SPECT in Nuclear Cardiology and Recent Advances in Technology

James Carr, M.D., chair of the Department of Radiology, Northwestern University, and incoming 2020 President of the Society of Cardiac Magnetic Resonance (SCMR), explains why MRI is an ideal cardiac imaging modality, at the 2019 Radiological Society of North America (RSNA) meeting.

Heart MRI offers advantages over computed tomography (CT) and echocardiography because of its excellent soft tissue delineation and its ability to offer information beyond anatomical imaging, such as perfusion, morphology and metabolism.

While heart MRI is well known in large hospital centers, Carr said it still needs to develop and expand to community hospitals and rural hospitals outside major population centers.  Artificial intelligence is playing a significant role in cardiac MRI automation of speeding workflow and quantification.

VIDEO: PET vs. SPECT in Nuclear Cardiology and Recent Advances in Technology

Karen Ordovas, M.D., MAS, professor of radiology and cardiology at the University of California San Francisco (UCFS) School of Medicine and a Society of Cardiac Magnetic Resonance (SCMR) board member, explains how cardiac MRI can help in women's heart disease and to better define complex congenital heart anatomy.

She spoke at the 2019 Radiological Society of North America (RSNA) meeting.  She specializes in cardiac and pulmonary imaging, and has particular expertise in using CT and MRI techniques in cardiovascular imaging and the differences of presentation in imaging between male and female cardiac patients.

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