Background
Interpretation of instantaneous wave-Free Ratio (iFR) pressure-wire pullback data can be complex and is subjective.

Objectives
To investigate if algorithmic interpretation (AI) of iFR pressure-wire pullback data would be non-inferior to expert human interpretation.

Methods
Fifteen human experts interpreted 1008 iFR pullback traces (691 unique, 317 duplicate). For each trace, experts determined the hemodynamic appropriateness for percutaneous coronary intervention (PCI), and in such cases, the optimal physiological strategy for PCI. The Heart Team (HT) interpretation was determined by consensus of the individual expert opinions. The same 1008 pullback traces were also interpreted algorithmically. The co-primary hypotheses of this study were that AI would be non-inferior to that of the median expert human in determining 1) the hemodynamic appropriateness for PCI, and 2) the physiological strategy for PCI.

Results
Regarding the hemodynamic appropriateness for PCI, the median expert human demonstrated 89.3% agreement with the HT in comparison to 89.4% for AI (p<0.01 for non-inferiority). Across the 372 cases judged as hemodynamically appropriate for PCI according to the HT, the median expert human demonstrated 88.8% agreement with the HT in comparison to 89.7% for AI (p<0.0001 for non-inferiority). On reproducibility testing, the HT opinion itself changed 1-in-10 times for both the appropriateness for PCI and the physiological PCI strategy. In contrast, CI showed no change.

Conclusions
Algorithmic interpretation of iFR pressure-wire pullback data was non-inferior to expert human interpretation in determining both the hemodynamic appropriateness for PCI and the optimal physiological strategy for PCI.