An individual patient data (IPD) meta-analysis has found that using fractional flow reserve (FFR) to guide percutaneous coronary intervention (PCI) is associated with a significant reduction in major adverse events compared to a standard angiography-guided strategy. The benefit appears to be driven primarily by a reduction in peri-procedural myocardial infarction (MI).¹

The PRIME Collaboration conducted an IPD meta-analysis of five randomised controlled trials (FAME, DEFER-DES, DK-CRUSH VI, FUTURE, and FRAME AMI) comparing FFR-guided versus angiography-guided PCI. The analysis included 2,493 patients with either chronic coronary syndrome (CCS) or non-ST-elevation acute coronary syndromes (NSTE-ACS) who had intermediate coronary lesions or non-culprit stenotic vessels.¹

Patients were randomised to either an FFR-guided PCI strategy or an angiography-guided PCI strategy. The primary outcome was the 1-year rate of major adverse cardiac events (MACE), a composite of all-cause death, MI, and repeat revascularisation. Secondary outcomes included the individual components of the primary endpoint and a composite of all-cause death and MI.

The analysis revealed that significantly fewer vessels underwent PCI in the FFR-guided group compared to the angiography-guided group (30.2% vs 45.1%; p<0.001), and fewer stents were implanted per patient (median 1.5 vs 2.0; p<0.001).¹

At the 1-year follow-up, the primary outcome of MACE occurred in 12.1% of patients in the FFR group versus 14.7% in the angiography group (hazard ratio [HR] 0.80; 95% confidence interval [CI] 0.64–0.99; p=0.046). The risk of MI was also significantly lower in the FFR-guided group (5.9% vs 8.0%; HR 0.71; 95% CI 0.53–0.96; p=0.031).¹

However, these outcomes were mainly driven by a reduction in peri-procedural MI. There were no significant differences between the groups in the rates of spontaneous MI, repeat revascularisation, all-cause mortality, or MACE occurring between 30 days and 1 year.

These findings suggest that an FFR-guided strategy for PCI in patients with CCS and NSTE-ACS reduces adverse events by minimising unnecessary stenting, thereby lowering the risk of peri-procedural complications. The PRIME Collaboration investigators concluded that “Fractional flow reserve–guided PCI was associated with reduced major adverse events in patients with CCS and NSTE-ACS due mainly to fewer peri-procedural MIs, with no differences in mortality or MACE beyond 30 days.”¹ This approach aligns with current guideline recommendations for using coronary physiology to guide revascularisation.²

The authors noted that further dedicated investigations are needed to confirm the safety of FFR guidance across different endpoints, particularly in the NSTE-ACS setting where achieving maximal hyperaemia can be challenging.¹

References

1. Mangiacapra F, Paolucci L, De Bruyne B, et al. Fractional flow reserve vs angiography to guide percutaneous coronary intervention: an individual patient data meta-analysis. Eur Heart J 2025;46(39):3851–3859. https://doi.org/10.1093/eurheartj/ehaf504

2. Vrints C, Andreotti F, Koskinas KC, et al. 2024 ESC guidelines for the management of chronic coronary syndromes. Eur Heart J 2024;45:3415–537. https://doi.org/10.1093/eurheartj/ehae177

This study received no funding.

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