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Background: Invasive fractional flow reserve (FFR) has emerged as an important tool to identify a subset of patients in whom coronary revascularization may be beneficial. Our objective was to evaluate temporal trends in FFR utilization.Methods: In this population-based study, we identified all coronary angiograms in the CorHealth Ontario Cardiac Registry between January 1st, 2010 to December 31st, 2015. The primary and secondary outcomes were the age-sex adjusted monthly rate of FFR per 100,000 population and per 100 angiograms respectively. Piecewise regression analysis was used to evaluate the temporal trends in FFR utilization, for the entire cohort, and then stratified by indication (stable coronary disease (SCAD) versus acute coronary syndrome (ACS)).Results: The study cohort included 379,688 angiograms, of which 122,571 were for SCAD (32%), and 134,769 were for ACS (35%). FFR was performed in 3.2% of all angiograms (4.6% in SCAD; 2.7% in ACS). Monthly age-sex adjusted FFR utilization rates increased significantly over the study period, from 0.4 to 2.1 per 1000,000 people/month. The monthly FFR utilization rate per 100 angiograms increased from 1.3 to 4.8 per 100 angiograms/month; however, the proportion of positive FFR results was relatively constant at 27%. There was a more dramatic increase in the use of FFR in the SCAD (1.4 to 7.5 per 100 angiograms/month) compared to the ACS population (1.3 to 3.4 per 100 angiograms/month).Conclusions: Over time, there was a 5-fold increase in the use of FFR in patients across Ontario, which was predominantly driven by use in patients with SCAD. Case selection for FFR use was relatively unchanged with approximately a quarter of FFR cases being positive over time.