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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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.
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