From SYNTAX to FAME, a paradigm shift in revascularization strategies: the key role of fractional flow reserve in guiding myocardial revascularization.

In patients with chest pain, noninvasive functional assessment prior to cardiac catheterization is often missing or it is inadequate to guide percutaneous coronary revascularization. This is particularly frequent in patients with complex coronary atherosclerotic disease, such as left main stenosis or multivessel disease. Interventional cardiologists are therefore often confronted with diagnostic dilemmas as to which revascularization strategy should be adopted in these patients. A revascularization strategy based on drug-eluting stent (DES) implantation of all the lesions deemed anatomically significant has been increasingly adopted, thanks to the availability of DESs. The down side of this strategy is that DESs are being liberally used even to treat lesions that are not responsible for patients' symptoms (e.g. not ischemic), just on the basis of their angiographic appearance. An alternative approach consists in limiting DES implantation to only the lesions that are indeed responsible for patients' symptoms, like those inducing ischemia, on the basis of fractional flow reserve (FFR). Following the results of important randomized clinical trials, this article discusses the pros and cons of both strategies, underscoring the key role of functional assessment of coronary stenosis severity by FFR.