Angiography-derived physiology versus pressure wire-based fractional flow reserve for coronary revascularization...

Pressure-wire-based fractional flow reserve (FFR) is the gold standard for physiological assessment of intermediate coronary stenoses but remains underutilized owing to procedural complexity, cost, and the need for hyperemic agents. Angiography-derived physiology (ADP) platforms offer a wire-free, adenosine-free alternative. This systematic review and meta-analysis compared the clinical outcomes of ADP-guided versus FFR-guided revascularization in patients with coronary artery disease.

Comprehensive searches were performed in PubMed, Embase, ScienceDirect, and Cochrane CENTRAL from inception to April 2026. Dichotomous outcomes were pooled as risk ratios (RRs) with 95% confidence intervals using random-effects models and robustness was checked with trial sequential analysis (TSA).

Three multicenter randomized controlled trials involving 6165 patients were included. There was no significant difference in the primary composite endpoint (RR: 1.14, 95% CI: 0.85-1.54; p = 0.37; I ² = 57%), all-cause mortality (RR: 1.08, 95% CI: 0.75-1.56; p = .68), cardiac death (RR: 0.89, 95% CI: 0.53-1.49; p = .66), and any myocardial infarction (RR: 1.14, 95% CI: 0.66-1.98; p = .64) between ADP-guided and pressure-wire-based FFR-guided strategies. Clinically indicated revascularization was significantly higher with ADP (RR: 1.12, 95% CI: 1.05-1.20; p = .005; I ² = 0%). Trial sequential analysis confirmed that the accumulated evidence was sufficient to conclude no clinically meaningful difference in composite outcome.

ADP-guided revascularization achieves broadly comparable clinical outcomes to pressure-wire-based FFR. Although ADP offers procedural advantages, certain platforms were associated with modestly higher revascularization rates. These findings support ADP as a practical alternative to conventional FFR in selected patients.