EuroIntervention. 2026 Aug 17;22(16):847-863. doi: 10.4244/EIJ-D-25-01315.
ABSTRACT
The assessment of myocardial ischaemia is entering a new computational era. Beyond the traditional boundaries of anatomical imaging and invasive fractional flow reserve (FFR), emerging techniques based on coronary computed tomography (CT) angiography and invasive coronary artery angiography now allow the derivation of physiological information without pressure wires, hyperaemic agents, or additional procedures. These image-based indices, commonly referred to as FFR-CT and angiography-derived FFR, are reshaping both diagnostic and interventional cardiology. This review provides an updated synthesis of the latest evidence on their clinical integration. FFR-CT has demonstrated its ability to refine diagnostic pathways, reduce unnecessary invasive angiography, and safely guide management decisions within precision diagnostic strategies. In parallel, angiography-derived FFR has matured into a real-time wire-free solution within the catheterisation laboratory. Randomised studies confirm that physiology-guided revascularisation improves procedural efficiency and optimises outcomes compared with angiography alone. Beyond ischaemia detection, these technologies now extend to virtual stenting, procedural simulation, and the identification of vulnerable plaques through haemodynamic indices such as endothelial shear stress and perivascular inflammation mapping. Together, these developments mark a paradigm shift: from anatomy-based to physiology-driven and, ultimately, prediction-guided coronary intervention. By merging artificial intelligence, computational modelling, and advanced imaging, CT- and angiography-derived physiology offer the prospect of fully integrated real-time functional assessment. This convergence defines a new frontier in coronary medicine, where precision, automation, and clinical impact coalesce to transform everyday cardiovascular practice.
PMID:42610337 | DOI:10.4244/EIJ-D-25-01315