Expanding physiology beyond the wire: will 2026 be the defining year?

The assessment of coronary lesion functional significance remains central to contemporary percutaneous coronary intervention (PCI). Although wire-based fractional flow reserve (FFR) is supported by strong evidence, its global adoption remains limited by cost, procedural complexity, hyperaemia, and operator preference1. Angiography-derived physiological indices such as quantitative flow ratio (QFR) have therefore emerged as attractive alternatives. Beyond eliminating the pressure wire and pharmacological hyperaemia, angiography-derived FFR enables virtual pullback analysis, allowing discrimination between focal and diffuse disease and supporting PCI planning without intracoronary instrumentation2. If rigorously validated, this technology could expand the use of physiology-guided revascularisation, particularly in laboratories where pressure wire adoption is low. Its evaluation is thus not merely a device comparison but a test of whether physiology can be made more accessible without compromising outcomes.

In this issue of EuroIntervention, Andersen et al report the outcomes of the 2-year follow-up of the FAVOR (Functional Assessment by Virtual Online Reconstruction) III Europe trial, which provides important data in this regard3. After the 1-year analysis failed to demonstrate the non-inferiority of QFR-guided versus FFR-guided revascularisation4, largely due to...