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Review
. 2022 Nov 30;11(23):7092.
doi: 10.3390/jcm11237092.

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

Annette M Maznyczka  1 , Connor J Matthews  1 , Jonathan M Blaxill  1   2 , John P Greenwood  1   2 , Abdul M Mozid  1   2 , Jennifer A Rossington  1   2 , Murugapathy Veerasamy  1   2 , Stephen B Wheatcroft  1   2 , Nick Curzen  3   4 , Heerajnarain Bulluck  1   2
Affiliations
Review

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

Annette M Maznyczka et al. J Clin Med. .

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.

Keywords: angiography; coronary artery bypass graft surgery; coronary artery disease; fractional flow reserve; percutaneous coronary intervention.

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Conflict of interest statement

NC reports receiving unrestricted research grants from Boston Scientific (RIPCORD2) and HeartFlow (FORECAST).

Figures

Figure 1
Figure 1
Risk of bias summary for the individual studies, by Cochrane risk assessment tool. + = low risk of bias, − = risk of bias, ? = unclear.
Figure 2
Figure 2
PRISMA diagram of the trial selection process.
Figure 3
Figure 3
Forest plot of the trial-defined composite endpoint stratified by stable CAD and ACS.
Figure 4
Figure 4
Forest plots of (a) all-cause mortality; (b) non-fatal myocardial infarction; and (c) unplanned revascularisation.
Figure 5
Figure 5
Forest plots of (a) average number of stented implanted; and (b) percentage of patients undergoing planned revascularisation as per their randomisation group.
See this image and copyright information in PMC

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