Angiography-derived index versus fractional flow reserve for intermediate coronary lesions: a meta-analysis review

Assessment and treatment of intermediate coronary lesions, defined as those which represent 30%-90% of the vessel lumen, remains a clinical challenge. Physiological evaluation techniques, such as fractional flow reserve (FFR), non-adenosine-based methods, such as instantaneous wave-free ratio or resting full-cycle ratio, and angiography-derived physiological assessment techniques (ADPAT) have transformed the diagnostic landscape. This meta-analysis aimed to systematically review and compare the diagnostic performance of ADPAT and FFR evaluating intermediate coronary lesions.

We conducted a systematic review of comparative research on FFR and ADPAT from January through February 2024.

A total of 27 studies were finally included in the meta-analysis for a total of 4818 patients and 5440 vessels. Overall, a strong correlation between the different ADPAT and FFR was observed (r = 0.83; 95%CI, 0.80-0.85), with a mean ADPAT value of 0.82; 95%CI, 0.81-0.83 and a mean FFR of 0.83; 95%CI, 0.82-0.85. The summary area under the curve for predicting significant FFR (≤ 0.80) was excellent at 0.947. The overall sensitivity rate was 85% (95%CI, 81-87) with a specificity rate of 93% (95%CI, 91-94). The positive predictive value was 86% (95%CI, 83-88) with a total negative predictive value of 92% (95%CI, 91-94).

ADPAT show good correlation and concordance with FFR for intermediate coronary lesion evaluation. However, due to unfavorable outcomes observed in the FAVOR III Europe trial¹ with quantitative flow ratio-guided revascularization, its clinical role should be reconsidered and potentially limited to scenarios where invasive assessment or adenosine use is not feasible. Further evaluation is warranted to confirm its diagnostic performance in broader clinical contexts.Registered at PROSPERO: CRD420251042828.