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PARIS -- Functional assessment of multivessel disease led to changes in treatment strategy for almost half of lesions encountered in the DEFINE REAL registry study.

Decisions between surgery, percutaneous coronary intervention, or optimal medical therapy -- initially based on coronary angiography and/or stress testing -- changed for 27% of patients after physiological evaluation with instantaneous wave-free ratio (iFR) and fractional flow reserve (FFR) assessment.

But when taking into account any strategy change for any lesion in multi-vessel disease, 44% of patients were actually reclassified after physiological assessment, according to , of University Hospital in Lille, France, in his presentation at the annual .

What's more, he reported that the more vessels assessed, the more likely it was for clinicians to switch strategies.

The time added to evaluate a second vessel was less than 5 minutes; to evaluate a third, it took 8 minutes. This is "a reasonable cost of extra time," Van Belle said.

Panel member , of University of Southampton in England, said: "I think the observation that the more physiology assessment undertaken, the more difference there is, is an important one." He commented that the difference can be even greater when considering ischemic versus non-ischemic lesions.

Van Belle's registry study included 484 patients. Three-quarters of patients had two-vessel disease, with the remaining quarter starting out with three-vessel disease. Patients had lesion stenoses greater than 40%.

Of the 1,107 vessels in the study, 75% required physiological assessment to develop a revascularization strategy. Lesions that did receive evaluation mostly got both FFR and iFR (97%), while a small minority only received FFR (3%). A sizable one-third of patients had their treatment decisions driven mainly by iFR, according to Van Belle.

Curzen noted that his group's upcoming randomized trial will mandate FFR assessment in all vessels in addition to coronary angiography, notably in an acute coronary syndrome population. Still, "the method we use for assessing physiology is going to change in the future," he said, suggestive of the growing prominence of iFR.

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