The Anatomic-Functional Duality of So-called 'Significant' Atherosclerotic Stenosis - Update on Invasive Diagnostic Strategies in Coronaropathy

So-called 'significant' atherosclerotic coronary stenosis is defined by a simple binary morphological index of tightness - percent diameter stenosis (%DS >50 %). Invasive diagnosis of atherosclerotic coronary lesions classically comprises two consecutive stages, which can be fairly accurately described as angiographic visual perception and functional deduction. This anatomic-functional duality should be seen as not so much antithetic as causal and finally quite complex. The present update seeks to: define the ambiguous relationship between functional impact and morphology in atherosclerotic coronary stenosis; to specify the means of invasive diagnosis complementing coronary angiography to compensate the anatomic and functional limitations intrinsic to the latter (cross-sectional intravascular ultrasound [IVUS] and optical coherence tomography [OCT] imaging and fractional flow reserve [FFR] determined by pressure guide); and to bring these preliminary considerations to bear on the design of algorithms to guide the use of complementary invasive diagnostic exploration and draw up a novel diagnostic strategy in interventional cardiology (first-line coronary angiography).