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Peer-reviewedCC BY-NC 4.0Catheterization and Cardiovascular Interventions

Diagnostic Accuracy and Feasibility of Quantitative Flow Ratio at Low Frame Rate Angiography: The Prospective Multicentre Australian AVALON Study

  • Joseph M. O'Brien1,2
  • Michael Zhang1,2
  • Thomas J. Ford3,4
  • Peter J. Psaltis5,6
  • Jessica A. Marathe5,6
  • Jayant Ravindran7
  • Rajan Rehan7,8
  • Vidushi Tripathi2
  • Eleanor Redwood3
  • Kelly Easey3
  • Adam J. Brown1,2
  • Derek P. Chew1,2
2 more authors
  • Andy Yong7,8
  • Dennis T. L. Wong1,2
8 affiliations
  1. 1Victorian Heart Hospital, Monash Health Melbourne Victoria Australia
  2. 2Victorian Heart Institute Monash University Melbourne Victoria Australia
  3. 3Department of Cardiology Gosford Hospital Gosford New South Wales Australia
  4. 4University of Newcastle Newcastle New South Wales Australia
  5. 5Department of Cardiology Royal Adelaide Hospital Adelaide South Australia Australia
  6. 6University of Adelaide Adelaide South Australia Australia
  7. 7Department of Cardiology Concord Hospital Sydney New South Wales Australia
  8. 8University of Sydney Darlington New South Wales Australia
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Abstract

Background: Quantitative Flow Ratio (QFR) is a well‐established, non‐hyperemic, angiographic, wire‐free predictor of ischemia when compared to Fractional Flow Reserve (FFR). However, its diagnostic accuracy at low frame rates (< 10 frames/second), commonly used in contemporary practice to minimize radiation exposure, has not been evaluated.

Aims: To assess the diagnostic accuracy of QFR when acquired at lower frame rates in line with contemporary practice.

Methods: The AVALON trial—a prospective, multi‐center, Australian study—included patients undergoing invasive coronary angiography (ICA) and FFR assessment for stable coronary artery disease (CAD). QFR analysis was performed using Medis QAngio XA QFR 2.2.2.4 software. Significant QFR and FFR were defined as < 0.80.

Results: Among 1054 patients (66.8 ± 10.4 years, 585 males, 797 vessels), the mean FFR was 0.81 ± 0.10, with 312 vessels (39%) classified as FFR significant. The mean QFR was 0.81 ± 0.10, and 352 vessels (44%) were QFR significant. QFR demonstrated strong diagnostic performance in predicting significant FFR with AUC of 0.92 (p < 0.001). It exhibited sensitivity of 85%, specificity 89%, positive predictive value (PPV) 83%, negative predictive value (NPV) 90%, and diagnostic accuracy 87%. Interobserver reliability for QFR was excellent (ICC = 0.92, p < 0.001). Using the established QFR‐FFR hybrid approach, where FFR was performed only if QFR ranged between 0.77 and 0.87, FFR could be safely deferred in 58% of cases, achieving a diagnostic accuracy of 93.8%.

Conclusion: QFR remains highly accurate in predicting significant FFR, even when angiography is acquired at low frame rates. The QFR‐FFR hybrid approach effectively minimizes the need for invasive FFR measurements, with the potential to enhance clinical efficiency while maintaining high diagnostic precision.

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Cite

BibTeXRIS
BibTeX
@article{obrien2026diagnostic,
  title = {{Diagnostic Accuracy and Feasibility of Quantitative Flow Ratio at Low Frame Rate Angiography: The Prospective Multicentre Australian AVALON Study}},
  author = {Joseph M. O'Brien and Michael Zhang and Thomas J. Ford and Peter J. Psaltis and Jessica A. Marathe and Jayant Ravindran and Rajan Rehan and Vidushi Tripathi and Eleanor Redwood and Kelly Easey and Adam J. Brown and Derek P. Chew and Andy Yong and Dennis T. L. Wong},
  journal = {Catheterization and Cardiovascular Interventions},
  year = {2026},
  month = sep,
  doi = {10.1002/ccd.70813},
  url = {https://doi.org/10.1002/ccd.70813},
  note = {CC BY-NC 4.0},
}
RIS
TY  - JOUR
TI  - Diagnostic Accuracy and Feasibility of Quantitative Flow Ratio at Low Frame Rate Angiography: The Prospective Multicentre Australian AVALON Study
AU  - Joseph M. O'Brien
AU  - Michael Zhang
AU  - Thomas J. Ford
AU  - Peter J. Psaltis
AU  - Jessica A. Marathe
AU  - Jayant Ravindran
AU  - Rajan Rehan
AU  - Vidushi Tripathi
AU  - Eleanor Redwood
AU  - Kelly Easey
AU  - Adam J. Brown
AU  - Derek P. Chew
AU  - Andy Yong
AU  - Dennis T. L. Wong
PY  - 2026
DA  - 2026/09/09
JO  - Catheterization and Cardiovascular Interventions
DO  - 10.1002/ccd.70813
UR  - https://doi.org/10.1002/ccd.70813
AB  - Background: Quantitative Flow Ratio (QFR) is a well‐established, non‐hyperemic, angiographic, wire‐free predictor of ischemia when compared to Fractional Flow Reserve (FFR). However, its diagnostic accuracy at low frame rates (< 10 frames/second), commonly used in contemporary practice to minimize radiation exposure, has not been evaluated.  Aims: To assess the diagnostic accuracy of QFR when acquired at lower frame rates in line with contemporary practice.  Methods: The AVALON trial—a prospective, multi‐center, Australian study—included patients undergoing invasive coronary angiography (ICA) and FFR assessment for stable coronary artery disease (CAD). QFR analysis was performed using Medis QAngio XA QFR 2.2.2.4 software. Significant QFR and FFR were defined as < 0.80.  Results: Among 1054 patients (66.8 ± 10.4 years, 585 males, 797 vessels), the mean FFR was 0.81 ± 0.10, with 312 vessels (39%) classified as FFR significant. The mean QFR was 0.81 ± 0.10, and 352 vessels (44%) were QFR significant. QFR demonstrated strong diagnostic performance in predicting significant FFR with AUC of 0.92 (p < 0.001). It exhibited sensitivity of 85%, specificity 89%, positive predictive value (PPV) 83%, negative predictive value (NPV) 90%, and diagnostic accuracy 87%. Interobserver reliability for QFR was excellent (ICC = 0.92, p < 0.001). Using the established QFR‐FFR hybrid approach, where FFR was performed only if QFR ranged between 0.77 and 0.87, FFR could be safely deferred in 58% of cases, achieving a diagnostic accuracy of 93.8%.  Conclusion: QFR remains highly accurate in predicting significant FFR, even when angiography is acquired at low frame rates. The QFR‐FFR hybrid approach effectively minimizes the need for invasive FFR measurements, with the potential to enhance clinical efficiency while maintaining high diagnostic precision.
SN  - 1522-1946
SN  - 1522-726X
ER  -