Fractional Flow Reserve versus Angiography–Guided Management of Coronary Artery Disease: A Meta–Analysis of Contemporary Randomised Controlled Trials

Abstract

Background and Aims: Randomised controlled trials (RCTs) comparing outcomes after fractional flow reserve (FFR)-guided versus angiography-guided management for obstructive coronary artery disease (CAD) have produced conflicting results. We investigated the efficacy and safety of an FFR-guided versus angiography-guided management strategy among patients with obstructive CAD. Methods: A systematic electronic search of the major databases was performed from inception to September 2022. We included studies of patients presenting with angina or myocardial infarction (MI), managed with medications, percutaneous coronary intervention, or bypass graft surgery. A meta-analysis was performed by pooling the risk ratio (RR) using a random-effects model. The endpoints of interest were all-cause mortality, MI and unplanned revascularisation. Results: Eight RCTs, with outcome data from 5077 patients, were included. The weighted mean follow up was 22 months. When FFR-guided management was compared to angiography-guided management, there was no difference in all-cause mortality [3.5% vs. 3.7%, RR: 0.99 (95% confidence interval (CI) 0.62–1.60), p = 0.98, heterogeneity (I2) 43%], MI [5.3% vs. 5.9%, RR: 0.93 (95%CI 0.66–1.32), p = 0.69, I2 42%], or unplanned revascularisation [7.4% vs. 7.9%, RR: 0.92 (95%CI 0.76–1.11), p = 0.37, I2 0%]. However, the number patients undergoing planned revascularisation by either stent or surgery was significantly lower with an FFR-guided strategy [weighted mean difference: 14 (95% CI 3 to 25)%, p =< 0.001]. Conclusion: In patients with obstructive CAD, an FFR-guided management strategy did not impact on all-cause mortality, MI and unplanned revascularisation, when compared to an angiography-guided management strategy, but led to up to a quarter less patients needing revascularisation.

Cardiovascular Computed Tomography in the Diagnosis of Cardiovascular Disease: Beyond Lumen Assessment

“…The clinical value of FFR-guided patient management strategies has been well studied, with beneficial effects being reported in many studies [66,[163][164][165][166][167][168][169][170]. Maznyczka et al, in their recent meta-analysis, analyzed eight randomized controlled trials to compare outcomes between FFR-guided versus ICA-guided management strategies for patients with obstructive CAD [171]. Their analysis did not show significant differences in all-cause mortality (3.5% vs. 3.7%, p = 0.98), myocardial infarction (5.3% vs. 5.9%, p = 0.69), and unplanned revascularization (7.4% vs. 7.9%, p = 0.37).…”

Impact of assessment of fractional flow reserve and instantaneous wave-free ratio on clinical outcomes of percutaneous coronary intervention: a systematic review, meta-analysis and meta-regression analysis

“…В систематическом обзоре и метаанализе, опубликованном в декабре 2022г [22], авторами не было обнаружено различий в отношении смертности от всех причин, ИМ или незапланированной реваскуляризации миокарда. Тем не менее число пациентов, перенесших плановую реваскуляризацию с помощью ЧКВ со стентированием КА или коронарного шунтирования, было статистически значимо ниже при использовании стратегии под контролем ФРК по сравнению со стратегией под контролем КАГ (p<0,001).…”

“…Однако в данный анализ были включены 8 РКИ, из которых в двух исследованиях реваскуля-ризация миокарда проводилась исключительно с помощью коронарного шунтирования [23,24]. Кроме того, были включены и два РКИ с участием пациентов с ОКС с подъемом сегмента ST и многососудистым поражением КА, перенесших успешное ЧКВ инфаркт-связанной артерии, которым проводилась полная реваскуляризация миокарда под контролем ФРК, либо КАГ [22,25]. Возможно, вышеуказанными факторами обусловлены различия результатов данного метаанализа с результатами нашего исследования.…”

Comparison of Fractional Flow Reserve with Resting Non-Hyperemic Indices in Patients with Coronary Artery Disease

“…Thus, invasive functional assessment should complement coronary angiography, particularly in patients with 50–90% coronary stenosis or multivessel disease [ 1 ]. Fractional flow reserve (FFR) is the most commonly used method for this purpose, and measurements are acquired during drug-induced hyperemia [ 3 , 4 , 5 , 6 , 7 ]. Nevertheless, the need to administer hyperemic agents increases procedural costs and may cause discomfort to patients [ 8 , 9 , 10 ].…”