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

Background: Randomized controlled trials (RCTs) comparing the clinical outcomes offractional flow reserve (FFR)-guided and angiography-guided revascularization in patients with coronary artery disease yielded inconsistent results. Aims: This study aimed to assess whether FFR-guided revascularization reduces the rates of hard clinical endpoints in comparison with the angiography-guided approach alone. Methods: This systematic review was conducted in June 2024 using Embase, Clinicaltrials.gov, Cochrane Library, and EBSCO databases. Only RCTs that evaluated stable and unstable coronary artery disease 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 in MI (risk ratio [RR], 0.75 [95% confidence interval [CI], 0.58-0.96]; P = 0.02) and a lower rate of revascularization (standardized mean difference - 0.12 [95% CI, -0.14 to 0.09]; P <00001). There were no differences between FFR-guided and angio-guided revascularization in major adverse cardiovascular events (RR, 0.84 [95% CI, 0.69-1.02]; P = 0.08), all-cause mortality (RR, 1.00 [95% CI, 0.58-1.74]; P = 0.99), and unplanned revascularization (RR, 0.89 [95% CI, 0.72-1.10]; P = 0.28). Conclusions: FFR-driven revascularization was associated with a significantly lower rate of MI for the entire population and also the acute coronary syndrome subset. These results were achieved with substantiallyfewer revascularization procedures compared with angiographic guidance alone.