Outcomes associated with fractional flow-guided revascularization: A meta-analysis

Background: Deferral of revascularization for abnormal but nonischemic lesions is usually recommended; however, the long-term outcome of this approach is not well known.

Hypothesis: Deferral of nonischemic lesions will be associated with a low frequency of adverse events.

Methods: A PubMed search of the MEDLINE database identified studies that reported clinical outcomes among patients who had fractional flow reserve-guided revascularization. We further categorized studies into 2 subgroups: left main and non-left main coronary artery lesions. Baseline demographics and clinical outcome data were extracted by 3 independent reviewers. Fixed and random effects summary risk ratios were constructed using Mantel-Haenszel and DerSimonian-Laird models, respectively. The primary outcome was the composite of death, myocardial infarction, and revascularization.

Results: From 741 potential studies, 17 were included in the meta-analysis (n=2975 participants), 8 in the left main subgroup (n=595) and 9 studies (n=2380) in non-left main subgroup. In the left main subgroup, the incidence of the composite outcome was 15.3% in the no-ischemia/deferral group vs 14.3% in the ischemia/revascularization group (risk ratio [RR]=1.13, 95% confidence interval [CI]: 0.76-1.68, P =0.54, I2 =3.7%). In the non-left main subgroup, the incidence of the composite outcome was 9.2% in the no-ischemia/deferral group vs 18.8% in the ischemia/revascularization group (RR=0.42, 95% CI: 0.34-0.52, P < 0.0001, I2 =20.7%).

Conclusions: Patients with left main coronary disease had a relatively high incidence of adverse cardiovascular events, which was similar in both the deferral and revascularization groups. In patients with non-left main disease, ischemia was associated with worse outcomes despite revascularization.