From Evidence to Practice: The Growing Role of Angiography-Derived Physiology.

Angiography-derived physiology (ADP) has emerged as a validated, wire-free method for the functional assessment of coronary artery disease (CAD). By avoiding pressure-wire instrumentation and hyperemic agents, ADP reduces procedure time, radiation exposure, and cost, while maintaining strong diagnostic performance with invasive physiology. These platforms include FFRangio (CathWorks), QFR (Medis Medical Imaging), and vFFR (Pie Medical Imaging), which have undergone extensive validation and are FDA approved for use. Randomized trials, predominantly with QFR, thus far demonstrate improved outcomes of ADP-guided strategies compared with angiography alone, whereas non-inferiority to wire-based FFR guidance has not yet been established. As clinical trials continue, thoughtful integration into routine practice requires careful image acquisition, platform-specific training, and awareness of limitations. In particular, validation remains incomplete in complex subsets such as left main disease, bifurcations, and bypass grafts, though evidence is growing in the application in acute coronary syndromes, post-PCI prognostication, and surgical planning. As ongoing studies mature and ADP technology evolves, these tools are poised to reshape physiologic assessment, streamline catheterization laboratory workflow, and become integral to contemporary PCI planning and optimization. This review summarizes current evidence, clinical applications, limitations, integration into the catheterization lab, and future directions of ADP.