Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions · 2026
Head-to-Head Comparison of Quantitative Flow Ratio, Intravascular Ultrasound, and Coronary Angiography in Left Main Coronary Artery Disease.
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Zengin İskan, Polat Fuat, Elçik Deniz, Abibulaev Erlan, Ozan Ramazan, Yurt Rıdvan, Kalay Nihat, Keleşoğlu Saban, Süleymanoğlu Cuma, Düzgün İsmail, Eryol Namık Kemal
Аннотация
BACKGROUND: Intermediate left main coronary artery (LMCA) disease poses a significant diagnostic challenge. Intravascular ultrasound (IVUS) is the guideline-recommended reference standard for anatomical assessment, whereas quantitative flow ratio (QFR) provides a wire-free physiological estimate. Conventional coronary angiography (CCA) remains the most widely available assessment modality. However, a systematic three-way comparison of these modalities in LMCA disease is lacking.
AIMS: To compare the diagnostic performance, agreement, and correlations of CCA and QFR with IVUS for the assessment of intermediate LMCA disease.
METHODS: This prospective single-center study enrolled 135 patients with LMCA lesions who underwent CCA, IVUS, and offline QFR (QAngio XA 3D) between January 2024 and June 2025. IVUS-derived minimum lumen area (MLA) < 6 mm2 was defined as anatomically significant disease and served as the reference standard. QFR < 0.80 defined functional significance, while CCA diameter stenosis (DS) ≥ 50% defined angiographic significance. Diagnostic performance, inter-modality agreement, correlation, and Bland-Altman agreement were assessed.
RESULTS: The mean age was 63.4 ± 9.7 years, and 88.1% of patients were male. IVUS identified significant disease in 92 patients (68.1%), compared with 68 (50.4%) by CCA and 50 (37.0%) by QFR. Against the IVUS reference standard, CCA demonstrated 67.4% sensitivity and 86.0% specificity (κ = 0.465; AUC = 0.824; optimal threshold DS ≥ 47%), whereas QFR demonstrated 54.3% sensitivity and 100% specificity (κ = 0.426; AUC = 0.848; Youden-optimal cutoff QFR ≤ 0.49). CCA correlated moderately with IVUS-derived MLA (r = -0.384; p < 0.001) and QFR (r = -0.512; p < 0.001). Both CCA and QFR systematically underestimated vessel dimensions relative to IVUS (Bland-Altman bias: CCA - 2.50 mm2; QFR - 2.21 mm2). On multivariable analysis, CCA DS ≥ 50% (OR 2.87; p = 0.011), decreasing QFR value per 0.1-unit (OR 0.61; p = 0.019), and distal bifurcation location (OR 2.38; p = 0.045) independently predicted IVUS-defined significant disease.
CONCLUSION: QFR demonstrated perfect specificity and may serve as a rule-in tool, whereas CCA provided greater sensitivity for initial triage. Neither modality can replace IVUS for anatomical characterization and procedural planning. A multimodality approach may therefore be appropriate for the assessment of intermediate LMCA stenosis.
AIMS: To compare the diagnostic performance, agreement, and correlations of CCA and QFR with IVUS for the assessment of intermediate LMCA disease.
METHODS: This prospective single-center study enrolled 135 patients with LMCA lesions who underwent CCA, IVUS, and offline QFR (QAngio XA 3D) between January 2024 and June 2025. IVUS-derived minimum lumen area (MLA) < 6 mm2 was defined as anatomically significant disease and served as the reference standard. QFR < 0.80 defined functional significance, while CCA diameter stenosis (DS) ≥ 50% defined angiographic significance. Diagnostic performance, inter-modality agreement, correlation, and Bland-Altman agreement were assessed.
RESULTS: The mean age was 63.4 ± 9.7 years, and 88.1% of patients were male. IVUS identified significant disease in 92 patients (68.1%), compared with 68 (50.4%) by CCA and 50 (37.0%) by QFR. Against the IVUS reference standard, CCA demonstrated 67.4% sensitivity and 86.0% specificity (κ = 0.465; AUC = 0.824; optimal threshold DS ≥ 47%), whereas QFR demonstrated 54.3% sensitivity and 100% specificity (κ = 0.426; AUC = 0.848; Youden-optimal cutoff QFR ≤ 0.49). CCA correlated moderately with IVUS-derived MLA (r = -0.384; p < 0.001) and QFR (r = -0.512; p < 0.001). Both CCA and QFR systematically underestimated vessel dimensions relative to IVUS (Bland-Altman bias: CCA - 2.50 mm2; QFR - 2.21 mm2). On multivariable analysis, CCA DS ≥ 50% (OR 2.87; p = 0.011), decreasing QFR value per 0.1-unit (OR 0.61; p = 0.019), and distal bifurcation location (OR 2.38; p = 0.045) independently predicted IVUS-defined significant disease.
CONCLUSION: QFR demonstrated perfect specificity and may serve as a rule-in tool, whereas CCA provided greater sensitivity for initial triage. Neither modality can replace IVUS for anatomical characterization and procedural planning. A multimodality approach may therefore be appropriate for the assessment of intermediate LMCA stenosis.