Comparing the Clinical Outcomes of Fractional Flow Reserve and Intravascular Imaging in Guiding Percutaneous Coronary Intervention: A Systematic Review and Meta-analysis.
Abstract
Background
Fractional flow reserve (FFR) and intravascular imaging (IVI) are both used to guide management of intermediate coronary stenoses, but comparative outcome data remain limited.
Methods
We systematically searched MEDLINE/PubMed and the Cochrane Central Register of Controlled Trials from inception through September 1, 2025, for randomized controlled trials and comparative observational studies directly comparing physiology-guided versus intravascular imaging-guided strategies for angiographically intermediate coronary stenoses. Outcomes included major adverse cardiovascular events (MACE), all-cause mortality, cardiac mortality, myocardial infarction (MI), target-vessel revascularization (TVR), and PCI rate. Risk ratios (RRs) with 95% confidence intervals (CIs) were pooled using random-effects models. Risk of bias was assessed with RoB 2 for randomized trials and ROBINS-I for observational studies. A sensitivity analysis excluded FLAVOUR II because it used angiography-derived rather than pressure-wire FFR.
Results
Six comparative studies including 5,047 participants were included: four randomized trials and two observational studies. No statistically significant differences were detected in all-cause mortality (RR 0.87, 95% CI 0.53-1.42; p=0.58), cardiac mortality (RR 1.11, 95% CI 0.63-1.96; p=0.72), MACE (RR 1.09, 95% CI 0.88-1.35; p=0.42), nonfatal MI (RR 1.45, 95% CI 0.80-2.64; p=0.22), or TVR (RR 1.27, 95% CI 0.85-1.90; p=0.24). Physiology guidance was associated with lower PCI utilization (RR 0.60, 95% CI 0.48-0.75; p<0.001), with substantial heterogeneity (I²=93.6%). Exclusion of FLAVOUR II did not materially alter the findings, including PCI utilization (RR 0.55, 95% CI 0.45-0.67; I²=76.7%).
Conclusions
Among patients with intermediate coronary stenoses, FFR- and IVI-guided strategies were associated with similar clinical outcomes, while FFR guidance reduced PCI utilization.