Background: Discordance between fractional flow reserve (FFR) and non-hyperemic pressure ratios (NHPRs) can occur in about 20% of clinical cases, creating treatment dilemmas in the cardiac catheterization laboratory.
Objectives: 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 versus those deferred for concordant negative results. Various NHPRs were compared to FFR. The primary endpoint varied based on the study and a composite of death (all-cause or cardiac), myocardial infarction/revascularization with several definitions. Secondary endpoint consisted of death or myocardial infarction.
Results: Six eligible trials with 9,854 intermediate lesions deferred for PCI were considered in the analysis. Compared to 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 MI) compared to concordant-negative physiology. Exploratory analysis comparing revascularization vs. deferral groups within discordant physiology demonstrated reduction in the primary endpoint in FFR+/NHPRs- group but not in FFR-/NHPRs+ group.
Conclusions: Deferral of PCI in discordant-physiology was associated with worse long-term outcomes compared to the concordant-negative physiology. There may be a benefit of revascularization in FFR+/NHPRs- lesions, which requires further investigation.
Editors
Editor-in-Chief
Harlan M. Krumholz, MD, SM, FACC
CME Editor
Ragavendra R. Baliga, MD
Authors
Yuhei Kobayashi, MD
Edward T. Ha, MD
Important Dates
Date of Release: July 14, 2025
Term of Approval/Date of CME/MOC Expiration: July 13, 2026