Individual Patient Data Meta-Analysis of FFR vs Conventional Angiography: Less is More?

The conventional coronary angiography has been compared against diverse invasive diagnostic methods, which has cast a shadow on the prognostic relevance of obstructions observed thereby. In consequence, there is a constant effort to find the strategies that will hone in PCI indication, especially in the context of chromic coronary syndrome (CCS) and no ST elevation acute coronary syndrome (NST-ACS). 

The PRIME group (Physiology and Revascularization for Myocardial Endpoints) presented an individual patient data meta-analysis comparing FFR vs. angiography guided revascularization. This kind of meta-analysis (patient-level) is designed to reduce the heterogeneity inherent to traditional meta-analysis (trial-level).

The study included 2,493 patients from five randomized trials (FAME, DEFER-DES, DK-CRUSH VI, FUTURE and FRAME-AMI), followed up for at least one year. It focused on intermediate coronary lesions, excluding interventions on culprit vessels in NST-ACS, and patients with STEMI or a history of CABG. 

From a clinical point of view, the use of FFR translated into lower interventions rate (30.2% vs. 45.1%) and fewer stents per patient (mean 1.5 vs. 2.0; p < 0.001). This more conservative approach did not compromise safety; instead, it was associated with significant reduction of major adverse cardiovascular events (MACE) rate the first year (HR 0.80; CI 95%: 0.64–0.99; p = 0.046), mainly driven by a lower incidence of periprocedural myocardial infarction (HR 0.71; CI 95%: 0.53–0.96; p = 0.031).

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However, when conducting a sensitivity analysis excluding periprocedural MI, the difference in MACE lost statistical significance, reinforcing the idea that FFR benefit basically lies on its capacity to prevent unnecessary interventions and their potential complications. Neither were there significant differences in all-cause or cardiac mortality, spontaneous reinfarction, or repeat revascularization. 

Upon extended 5-year analysis, FFR benefits were maintained as a favorable trend, though with no statistical significance (HR 0.85; CI 95%: 0.72–1.01; p = 0.063), which suggests its greatest impact occurs in the early phase after procedure. 

Lastly, in the subgroup of patients with high SYNTAX score, the benefit was less evident, which highlights the importance of considering both global coronary physiology and anatomy when choosing a revascularization strategy.

Conclusions

This meta-analysis reaffirms the role of a coronary physiological assessment as key to decision making during PCI, mainly for its capacity to reduce periprocedural complications with no compromise of long term safety.

Original Title: Fractional flow reserve vs angiography to guide percutaneous coronary intervention: an individual patient data meta-analysis.

Reference: Mangiacapra F, Paolucci L, De Bruyne B, Rioufol G, Hahn JY, Chen SL, Koo BK, Tonino PAL, van ‘t Veer M, Motreff P, Angoulvant D, Lee JM, Hwang D, Yang S, Pijls NHJ, Barbato E; Physiology and Revascularization for Myocardial Endpoints (PRIME) Collaboration. Fractional flow reserve vs angiography to guide percutaneous coronary intervention: an individual patient data meta-analysis. Eur Heart J. 2025 Oct 14;46(39):3851-3859. doi: 10.1093/eurheartj/ehaf504. PMID: 40831380.