Physiological assessment of intermediate coronary lesions remains a cornerstone in decision-making for coronary revascularization. Although FFR continues to be one of the guideline-recommended references, its adoption in daily practice is limited due to the need for an invasive pressure wire, hyperemia, longer procedural time, patient discomfort, and reimbursement-related issues. In this context, vesselFFR (vFFR), an angiography-based method using three-dimensional reconstruction that does not require a pressure wire or hyperemia, has emerged as a simpler alternative.
The aim of the FAST III trial was to evaluate whether a vFFR-guided revascularization strategy is non-inferior to an FFR-guided strategy in patients with intermediate coronary lesions.
A 1:1 randomized trial was conducted including adult patients with chronic coronary syndrome (CCS), unstable angina, or NSTEMI, with at least one intermediate lesion (30–80%) in a native vessel ≥2.5 mm suitable for physiological assessment. The primary endpoint was a composite of all-cause death, myocardial infarction (MI), or any revascularization at one year. Among 2,235 patients enrolled across 37 centers in 7 countries (Europe and the United Kingdom), 1,116 were assigned to vFFR-guided revascularization and 1,095 to FFR-guided revascularization.
The mean age was 67.6 years, and 81% of cases were indicated for CCS. The primary endpoint occurred in 7.5% of the vFFR-guided group and 7.5% of the FFR-guided group, with a risk difference of -0.02% (95% CI -2.25 to 2.21; non-inferiority p = 0.004). Per-protocol analysis yielded consistent results (7.0% vs 7.4%; difference -0.40%; 95% CI -2.65 to 1.86).
Regarding secondary endpoints, vessel failure occurred in 4.0% vs 4.6% in the FFR group (risk difference -0.62%; 95% CI -2.35% to 1.10%). No relevant differences were observed in all-cause death (2.2% vs 2.3%), cardiac death (1.0% vs 1.5%), or any MI (2.9% vs 2.4%).
Revascularization of at least one study lesion was more frequent in the vFFR group (45.0% vs 36.0%), with a similar number of stents per patient (0.92 ± 1.13 vs 0.80 ± 1.06) and shorter procedural time in patients undergoing PCI in the vFFR arm (55.8 ± 26.8 min vs 60.9 ± 28.5 min).
Conclusions: vFFR demonstrates non-inferiority compared to FFR in the revascularization of intermediate coronary lesions
In patients with intermediate coronary lesions, a vFFR-guided revascularization strategy was non-inferior to an FFR-guided strategy regarding the composite endpoint of death, myocardial infarction, or revascularization at one year.
Presented by Joost Daemen at Late-Breaking Clinical Trials, ACC.26, March 28–30, New Orleans, USA.
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