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Fractional flow reserve, intravascular ultrasound, and optical coherence tomography all likely have a place in the interventional cardiologist's armamentarium, according to a consensus statement from the Society for Cardiovascular Angiography and Interventions (SCAI).

"Fractional flow reserve (FFR) is used to determine the functional significance of a coronary stenosis. Intravascular ultrasound (IVUS) offers excellent visualization of intraluminal and transmural coronary anatomy. Optical coherence tomography (OCT) further improves vascular visualization," stated the guidance, which was published online in Catheterization and Cardiovascular Interventions.

The 2011 guidelines on percutaneous coronary intervention (PCI) released by the American College of Cardiology, American Heart Association, and SCAI included information on all of these technologies, although none of the recommendations was stronger than Class IIa for either FFR or IVUS and there were no specific recommendations made for OCT.

"The angioplasty guidelines take some time to revise and the use of these adjunctive technologies -- particularly fractional flow reserve -- needed to be updated," , of the University of Colorado at Denver and one of the statement authors, said in an interview. "The consensus document from SCAI is intended to inform the next revision of [the guidelines] to include FFR in a much more prominent role in the evaluation of stable ischemic heart disease."

The members of the writing group reviewed the evidence and made several recommendations regarding the usefulness -- or lack of utility -- of the three technologies:

Fractional Flow Reserve

In patients with stable ischemic heart disease, when noninvasive stress imaging is either not available or does not resolve clinical uncertainty, FFR should be performed to determine the functional significance of intermediate stenoses of 50% to 70% and more severe stenoses less than 90%. "That is very important in 2013 where appropriate use criteria for PCI are completely dependent on the identification of ischemia at the time of the cath lab visit in patients who haven't had a prior stress test," Messenger said.

In patients with multivessel coronary disease, FFR guidance of PCI has been shown to improve outcomes in randomized trials, including FAME. FFR also can help determine whether a patient's disease is best suited for PCI, surgery, or medical therapy alone.

Because of a lack of proven benefit, FFR should not be used to assess the culprit vessel in patients with an acute ST-segment elevation myocardial infarction or any unstable acute coronary syndrome.

Intravascular Ultrasound

IVUS is "definitely beneficial" for determining optimal stent placement and the size of the vessel undergoing PCI, and is "probably beneficial" for determining the significance of a stenosis of the left main coronary artery to help guide the need for revascularization. It "can be useful" for assessing plaque morphology.

IVUS should not be used to assess the severity of nonleft main coronary artery disease when deciding on the need for revascularization.

Optical Coherence Tomography

OCT is "probably beneficial" for assessing optimal stent placement, with improved visualization compared with IVUS, and is "possibly beneficial" for evaluating plaque morphology.

OCT should not be used to determine the functional significance of stenoses, and no studies have evaluated whether using OCR improves patient outcomes. "As a result," the authors wrote, "this imaging modality remains investigational in terms of improving clinical outcomes associated with the performance of PCI."

"The writing group concurs with current guidelines that these modalities are not indicated when noninvasive imaging and angiographic data are concordant or when the result of the additional procedure will not alter the planned treatment strategy or optimization of stent implantation," the authors wrote.

From the American Heart Association:

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