Outcomes of Lesions With Discordance Between FFR and Nonhyperemic Pressure Ratios

Edward T Ha; Takeshi Nishi; Tatsunori Takahashi; Tatsuro Yamazaki; Yuichi Saito; Shoichi Kuramitsu; Yoshiaki Kawase; Manish A Parikh; Ron Waksman; Yuhei Kobayashi

doi:10.1016/j.jcin.2025.05.032

Outcomes of Lesions With Discordance Between FFR and Nonhyperemic Pressure Ratios

JACC Cardiovasc Interv. 2025 Jul 14;18(13):1631-1642. doi: 10.1016/j.jcin.2025.05.032.

Authors

Affiliations

¹ NewYork-Presbyterian Brooklyn Methodist Hospital, Brooklyn, New York, USA.
² Smidt Heart Institute, Cedars-Sinai Medical Center, California, USA.
³ Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan.
⁴ Sapporo Cardiovascular Clinic, Sapporo Heart Center, Sapporo, Japan.
⁵ Gifu Heart Center, Gifu, Japan.
⁶ NewYork-Presbyterian Brooklyn Methodist Hospital, Brooklyn, New York, USA; Weill Cornell Medical College, New York, New York, USA.
⁷ Medstar Washington Hospital Center, Washington, DC, USA.
⁸ NewYork-Presbyterian Brooklyn Methodist Hospital, Brooklyn, New York, USA; Weill Cornell Medical College, New York, New York, USA. Electronic address: dxl9003@med.cornell.edu.

PMID: 40669964
DOI: 10.1016/j.jcin.2025.05.032

Abstract

Background: Discordance between fractional flow reserve (FFR) and nonhyperemic pressure ratios (NHPRs) can occur in about 20% of clinical cases, creating treatment dilemmas in the cardiac catheterization laboratory.

Objectives: The authors sought to perform a systematic review and meta-analyses investigating the long-term outcome of deferral strategy in patients found to have discordant physiology.

Methods: The primary comparison tested the long-term prognosis of patients who were deferred for discordant physiology vs those deferred for concordant negative results. Various NHPRs were compared with FFR. The primary endpoint was a composite of death (all-cause or cardiac) and myocardial infarction/revascularization with several definitions. Secondary endpoint consisted of death or myocardial infarction. The study is registered with PROSPERO (CRD42024628393).

Results: Six eligible trials with 9,854 intermediate lesions deferred for PCI were considered in the analysis. Compared with concordant-negative physiology (FFR^-/NHPRs^-), deferral of PCI for discordant physiology was associated with an increase in the primary endpoints (FFR^-/NHPRs⁺: HR: 2.73 [1.95-3.80]; P < 0.00001 and FFR⁺/NHPRs^-: HR: 3.29[2.33-4.64]; P < 0.00001). Secondary dichotomous analysis showed that deferral of PCI in both discordant groups was associated with an increase in the hard endpoints (death or myocardial infarction) compared with concordant-negative physiology. Exploratory analysis comparing revascularization vs deferral groups within discordant physiology demonstrated reduction in the primary endpoint in the FFR⁺/NHPRs^- group, but not in the FFR^-/NHPRs⁺ group.

Conclusions: Deferral of PCI in discordant-physiology was associated with worse long-term outcomes compared with the concordant-negative physiology. There may be a benefit of revascularization in FFR⁺/NHPRs^- lesions, which requires further investigation.

Keywords: FFR; deferral of PCI; discordant physiology; fractional flow reserve; iFR; nonhyperemic pressure ratios.

Publication types

Systematic Review
Meta-Analysis
Research Support, Non-U.S. Gov't

MeSH terms

Aged
Cardiac Catheterization*
Clinical Decision-Making
Coronary Artery Disease* / diagnosis
Coronary Artery Disease* / diagnostic imaging
Coronary Artery Disease* / mortality
Coronary Artery Disease* / physiopathology
Coronary Artery Disease* / therapy
Coronary Vessels* / physiopathology
Female
Fractional Flow Reserve, Myocardial*
Humans
Male
Middle Aged
Myocardial Infarction / etiology
Myocardial Infarction / physiopathology
Percutaneous Coronary Intervention* / adverse effects
Percutaneous Coronary Intervention* / mortality
Predictive Value of Tests
Risk Assessment
Risk Factors
Time Factors
Treatment Outcome