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Original research
Fractional flow reserve versus angiography alone in guiding myocardial revascularisation: a systematic review and meta-analysis of randomised trials
  1. Ayman Elbadawi1,
  2. Ramy Sedhom2,
  3. Alexander T Dang3,
  4. Mohamed M Gad4,
  5. Faisal Rahman1,
  6. Emmanouil S Brilakis5,
  7. Islam Y Elgendy6,
  8. Hani Jneid1
  1. 1Cardiology, Baylor College of Medicine, Houston, Texas, USA
  2. 2Internal Medicine, Albert Einstein Medical Center, Philadelphia, Pennsylvania, USA
  3. 3Internal Medicine, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
  4. 4Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
  5. 5Cardiology, Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA
  6. 6Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar
  1. Correspondence to Dr Hani Jneid, Cardiology, Baylor College of Medicine, Houston, Texas, USA; jneid{at}bcm.edu

Abstract

Background Randomised trials evaluating the efficacy and safety of fractional flow reserve (FFR)-guided versus angiography-guided revascularisation among patients with obstructive coronary artery disease (CAD) have yielded mixed results.

Aims To examine the comparative efficacy and safety of FFR-guided versus angiography-guided revascularisation among patients with obstructive CAD.

Methods An electronic search of MEDLINE, SCOPUS and Cochrane databases without language restrictions was performed through November 2021 for randomised controlled trials that evaluated the outcomes of FFR-guided versus angiography-guided revascularisation. The primary outcome was major adverse cardiac events (MACE). Data were pooled using a random-effects model.

Results The final analysis included seven trials with 5094 patients. The weighted mean follow-up duration was 38 months. Compared with angiography guidance, FFR guidance was associated with fewer number of stents during revascularisation (standardised mean difference=−0.80; 95% CI −1.33 to −0.27), but no difference in total hospital cost. There was no difference between FFR-guided and angiography-guided revascularisation in long-term MACE (13.6% vs 13.9%; risk ratio (RR) 0.97, 95% CI 0.85 to 1.11). Meta-regression analyses did not reveal any evidence of effect modification for MACE with acute coronary syndrome (p=0.36), proportion of three-vessel disease (p=0.88) or left main disease (p=0.50). There were no differences between FFR-guided and angiography-guided revascularisation in the outcomes all-cause mortality (RR 1.16, 95% CI 0.80 to 1.68), cardiovascular mortality (RR 1.27, 95% CI 0.50 to 3.26), repeat revascularisation (RR 0.99, 95% CI 0.81 to 1.21), recurrent myocardial infarction (RR 0.92, 95% CI 0.74 to 1.14) or stent thrombosis (RR 0.61, 95% CI 0.31 to 1.21).

Conclusion Among patients with obstructive CAD, FFR-guided revascularisation did not reduce the risk of long-term adverse cardiac events or the individual outcomes. However, FFR-guided revascularisation was associated with fewer number of stents.

PROSPERO registration number CRD42021291596.

  • percutaneous coronary intervention
  • coronary artery disease

Data availability statement

Data are available upon reasonable request.

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Data availability statement

Data are available upon reasonable request.

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Footnotes

  • Twitter @AYMAN_ELBADAWI_, @RamySedhomMD, @islamelgendy83

  • IYE and HJ contributed equally.

  • Contributors AE: conception and design, analysis and interpretation of data, drafting of the manuscript, revision of the manuscript and final approval. RS: analysis and interpretation of data, drafting of the manuscript, revision of the manuscript and final approval. MMG: conception and design, drafting of the manuscript, revision of the manuscript and final approval. ESB: conception and design, interpretation of data, drafting of the manuscript, revision of the manuscript and final approval. ATD: interpretation of data, revision of the manuscript and final approval. FR: drafting of the manuscript, revision of the manuscript and final approval. IYE: conception and design, interpretation of data, revision of the manuscript, final approval and is responsible for the overall content as guarantor. HJ: conception and design, interpretation of data, revision of the manuscript, final approval and is responsible for the overall content as guarantor.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests IYE has disclosures unrelated to this manuscript content, including receiving research grants from Caladrius Biosciences. ESB: consulting/speaker honoraria from Abbott Vascular, American Heart Association (Associate Editor, Circulation), Amgen, Asahi Intecc, Biotronik, Boston Scientific, Cardiovascular Innovations Foundation (Board of Directors), ControlRad, CSI, Elsevier, GE Healthcare, IMDS, InfraRedx, Medicure, Medtronic, Opsens, Siemens and Teleflex; research support: Boston Scientific and GE Healthcare; owner: Hippocrates; shareholder: MHI Ventures, Cleerly Health and Stallion Medical.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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