Real-time use of instantaneous wave–free ratio: Results of the ADVISE in-practice: An international, multicenter evaluation of instantaneous wave–free ratio in clinical practice

Objectives To evaluate the first experience of real-time instantaneous wave–free ratio(iFR) measurement by clinicians. Background The iFR is a new vasodilator-free index of coronary stenosis severity, calculated as a trans-lesion pressure ratio during a specific period of baseline diastole, when distal resistance is lowest and stable. Because all previous studies have calculated iFR offline, the feasibility of real-time iFR measurement has never been assessed. Methods Three hundred ninety-two stenoses with angiographically intermediate stenoses were included in this multicenter international analysis. Instantaneous wave–free ratioand fractional flow reserve(FFR) were performed in real time on commercially available consoles. The classification agreement of coronary stenoses between iFR and FFR was calculated. Results Instantaneous wave–free ratioand FFR maintain a close level of diagnostic agreement when both are measured by clinicians in real time (for a clinical 0.80 FFR cutoff: area under the receiver operating characteristic curve [ROC AUC ] 0.87, classification match 80%, and optimal iFR cutoff0.90; for a ischemic 0.75 FFR cutoff: iFR ROC AUC 0.90, classification match 88%, and optimal iFR cutoff0.85; if the FFR 0.75-0.80 gray zone is accounted for: ROC AUC 0.93, classification match 92%). When iFR and FFR are evaluated together in a hybrid decision-making strategy, 61% of the population is spared from vasodilator while maintaining a 94% overall agreement with FFR lesion classification. Conclusion When measured in real time, iFR maintains the close relationship to FFR reported in offline studies. These findings confirm the feasibility and reliability of real-time iFR calculation by clinicians.