Outcomes of Lesions With Discordance Between FFR and Nonhyperemic Pressure Ratios

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.

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.

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).

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.

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.