He came to my office holding the results of his coronary CT scan. His eyes went immediately to the numbers, his voice tense: “Doctor, my FFR is 0.86. Do I need a stent?”
This is not an unusual question anymore. Coronary CT angiography with fractional flow reserve (FFR-CT) is rapidly becoming a common tool in cardiology. It gives us noninvasive insight into whether a coronary lesion is functionally significant. In plain language, it helps us decide whether a narrowing is tight enough to impair blood flow and potentially cause ischemia. For patients, though, the numbers are anxiety-provoking. They see a threshold, they see decimals, and they want clarity: stent or no stent? Traditionally, invasive FFR measured in the cath lab guided those decisions. An FFR <=0.80 has long been considered hemodynamically significant. But now, with FFR-CT, patients arrive at clinic already armed with their “score.” And when the number lands in the borderline zone (say 0.82, 0.83, 0.86), the uncertainty creates real distress.
What the research shows
Studies have validated FFR-CT as a reliable diagnostic tool, correlating well with invasive FFR. Importantly, values above 0.80 are generally associated with no hemodynamically significant obstruction. Patients in this range do not benefit from stenting. Instead, they benefit most from medical management: statins, blood pressure control, diabetes care, smoking cessation, diet, and exercise. The large trials that shaped modern cardiology, COURAGE, ISCHEMIA, and FAME, consistently remind us that stents improve symptoms, but not survival, in stable coronary disease. It is optimal medical therapy that moves the needle on long-term outcomes. So, when a patient with an FFR-CT of 0.86 asks if they need a stent, the answer is clear: not based on this test alone.
Where this leaves patients
But clarity for the physician doesn’t always mean clarity for the patient. Patients equate “plaque” with “blockage” and “blockage” with “heart attack.” They want something done, something fixed. Explaining that not intervening is actually the safer, evidence-based path can feel counterintuitive to them. This is where our role as physicians extends beyond data interpretation. We have to reassure, educate, and contextualize. A stent is not a cure for atherosclerosis. It is a treatment for symptoms when medical therapy isn’t enough. And sometimes, the bravest course is not to intervene, but to prevent progression through lifestyle and medication.
My advice to patients
- Don’t chase the number: An FFR-CT above 0.80 means your flow is preserved. That’s good news.
- Focus on risk factors: Cholesterol, blood pressure, blood sugar, weight, and smoking matter far more for your long-term outcome than a single borderline FFR value.
- Take your medications seriously: Statins, antihypertensives, and aspirin (when indicated) are not “optional.” They are your best defense.
- Listen to your symptoms: If chest pain persists despite therapy, then further evaluation, and sometimes a stent, may be warranted.
The patient with the 0.86 FFR-CT left reassured. No stent. No cath lab. Just a clear plan: optimize risk factors, take medications, and return for close follow-up.
Technology gives us numbers, but medicine requires wisdom. As cardiologists, we must bridge the gap between what the research shows and what our patients fear. Because often, the best care we can offer is not the stent; it’s the conversation.
Monzur Morshed is a cardiologist. Kaysan Morshed is a medical student.
