Fractional Flow Reserve to Guide Treatment of Patients With Multivessel Coronary Artery Disease

J Am Coll Cardiol. 2021 Nov 9;78(19):1875-1885. doi: 10.1016/j.jacc.2021.08.061.


Background: There is limited evidence that fractional flow reserve (FFR) is effective in guiding therapeutic strategy in multivessel coronary artery disease (CAD) beyond prespecified percutaneous coronary intervention or coronary graft surgery candidates.

Objectives: The FUTURE (FUnctional Testing Underlying coronary REvascularization) trial aimed to evaluate whether a treatment strategy based on FFR was superior to a traditional strategy without FFR in the treatment of multivessel CAD.

Methods: The FUTURE trial is a prospective, randomized, open-label superiority trial. Multivessel CAD candidates were randomly assigned (1:1) to treatment strategy based on FFR in all stenotic (≥50%) coronary arteries or to a traditional strategy without FFR. In the FFR group, revascularization (percutaneous coronary intervention or surgery) was indicated for FFR ≤0.80 lesions. The primary endpoint was a composite of major adverse cardiac or cerebrovascular events at 1 year.

Results: The trial was stopped prematurely by the data safety and monitoring board after a safety analysis and 927 patients were enrolled. At 1-year follow-up, by intention to treat, there were no significant differences in major adverse cardiac or cerebrovascular events rates between groups (14.6% in the FFR group vs 14.4% in the control group; hazard ratio: 0.97; 95% confidence interval: 0.69-1.36; P = 0.85). The difference in all-cause mortality was nonsignificant, 3.7% in the FFR group versus 1.5% in the control group (hazard ratio: 2.34; 95% confidence interval: 0.97-5.18; P = 0.06), and this was confirmed with a 24 months' extended follow-up. FFR significantly reduced the proportion of revascularized patients, with more patients referred to exclusively medical treatment (P = 0.02).

Conclusions: In patients with multivessel CAD, we did not find evidence that an FFR-guided treatment strategy reduced the risk of ischemic cardiovascular events or death at 1-year follow-up. (Functional Testing Underlying Coronary Revascularisation; NCT01881555).

Keywords: coronary artery disease; coronary revascularization strategy; fractional flow reserve.

Publication types

  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Coronary Angiography / methods
  • Coronary Artery Bypass* / adverse effects
  • Coronary Artery Bypass* / methods
  • Coronary Artery Disease* / diagnosis
  • Coronary Artery Disease* / mortality
  • Coronary Artery Disease* / physiopathology
  • Coronary Artery Disease* / surgery
  • Coronary Stenosis* / diagnostic imaging
  • Coronary Stenosis* / etiology
  • Coronary Stenosis* / surgery
  • Coronary Vessels* / diagnostic imaging
  • Coronary Vessels* / physiopathology
  • Early Termination of Clinical Trials
  • Female
  • Fractional Flow Reserve, Myocardial / physiology*
  • Humans
  • Long Term Adverse Effects / mortality
  • Male
  • Percutaneous Coronary Intervention* / adverse effects
  • Percutaneous Coronary Intervention* / methods
  • Postoperative Complications / mortality*
  • Predictive Value of Tests
  • Risk Assessment / methods
  • Severity of Illness Index

Associated data