FAVOR III Europa Sub-Analysis: Coronary Revascularization Deferral Based On QFR vs FFR

When it comes to intermediate coronary lesion revascularization decision making, functional assessment is the recommended. At present, several indices are used, such as fractional flow reserve (FFR) and non-hyperemic coronary flow ratios. Among these, angiography based quantitative flow ratio (QFR), allows FFR estimation. Numerous studies have validated the use of QFR for coronary lesion revascularization decision making. 

However, the FAVOR III Europa randomized trial, published ad hoc, showed that QFR guided strategies do not reach non-inferiority vs FFR as regards major adverse cardiac events (MACE).

Even though revascularization deferral strategies based on physiological parameters have been shown safe for conventional indices, QFR safety has not yet been clearly established. 

Coronary Revascularization Strategies: QFR vs FFR in Intermediate Lesions

The aim of this Favor III Europa (randomized and multicenter) sub-analysis was to assess the safety of deferred revascularization based on QFR vs FFR. 

Read also: TENDERA: Comparing Conventional vs. Distal Transradial Occlusion for Coronary Interventions.

Primary end point was one-year MACE rate, defined as all-cause death, acute MI, or unplanned coronary revascularization. Secondary end point included individual primary end point components and target vessel failure (TVF).

The FAVOR III Europa trial included 2,000 patients, 1,008 assigned to QFR and 992 to FFR. Mean patient age was 66 and they were mostly men. The most frequent clinical presentation was chronic coronary syndrome.  

A total of 523 QFR patients (55.2%) and 599 FFR patients (65.3%) had at least one deferred revascularization. 433 of these QFR patients (82.8%) and 511 (85.3%) FFR patients had complete deferred revascularization of all lesions. In this subgroup, MACE rate was significantly higher among QFR patients vs FFR (24 [5.6%] vs 14 [2.8%]; HR 2.07; CI 95%: 1.07–4.03; p = 0.03). 

Read also: ROUTE TRAIL: DKCRUSH vs. DKRUSH Culotte in Non-Left Main Bifurcation Lesions.

In the subgroup of patients with at least one deferred lesion, MACE rate was 5.6% vs 3.6%, respectively (HR 1.55; CI  95%: 0.88–2.73; p = 0.13).

Conclusion: Impact of QFR vs FFR on Major Adverse Cardiac Events 

In this sub-analysis, QFR based deferred coronary revascularization was associated with higher MACE rate vs FFR. This difference was mainly related to an increase in unplanned revascularization. 

Original Title: Coronary revascularisation deferral based on quantitative flow ratio or fractional flow reserve: a post hoc analysis of the FAVOR III Europe trial.

Reference: Birgitte K. Andersen MD et al EuroIntervention 2025;21:e1-e10.