Fractional flow reserve versus solely angiography-guided revascularisation in coronary artery disease. Systematic review and meta-analysis.

Background: Subsequent randomized controlled trials (RCTs) comparing the clinical outcomes of fractional flow reserve (FFR)-guided and angiography-guided revascularisation in patients with coronary artery disease (CAD) yielded inconsistent results.

Aims: This study aimed to assess head to head whether FFR-guided revascularisation reduces the rates of hard clinical endpoints in comparison with the angiography-guided approach alone.

Methods: This systematic review was conducted through June 2024 at Embase, Clinicaltrials.gov, Cochrane Library, and EBSCO. Only RCTs that evaluated stable and unstable CAD and acute myocardial infarction (MI) were included. Eight RCTs involving 4713 patients were included in the meta-analysis.

Results: FFR guidance was associated with a reduction of MI (risk ratio (RR), 0.75 [95% confidence interval (Cl), 0.58-0.96], p=0.02) and lower rate of revascularisation (standardised mean difference - 0.12, [95% Cl, -0.14-0.09], p<00001). There were no differences between FFR-guided and angio-guided revascularisation in major adverse cardiovascular events (MACE) (RR, 0.84 [95% Cl, 0.69-1.02], p=0.08), all-cause mortality (RR, 1.00 [95% Cl, 0.58-1.74], p=0.99), and unplanned revascularisation (RR, 0.89 [95% Cl, 0.72-1.10], p=0.28).

Conclusions: FFR-driven revascularisation was associated with a significantly lower rate of MI for entire population and also in the acute coronary syndrome (ACS) subset. These results were achieved with a substantially less revascularisations compared with solely angiographic guidance.