Implications of Fractional Flow Reserve After Coronary Stenting

Quick Takes

  • Low post-PCI FFR is common and demonstrated a significant inverse association with target vessel failure.
  • The cumulative incidence of target vessel failure at 2 years was significantly higher in patients with post-PCI FFR of ≤0.86 than with post-PCI FFR >0.86 (9.1% vs. 6.1%; adjusted HR, 1.58; 95% CI, 1.24-2.00; p < 0.001).
  • Optimal management of residual ischemia measured by post-PCI FFR remains to be determined.

Study Questions:

What is the clinical relevance of post–percutaneous coronary intervention (PCI) fractional flow reserve (FFR) measurement after drug-eluting stent (DES) implantation?


Patient-level data were collected from 17 cohorts using a standardized spreadsheet. Meta-estimates for primary and secondary outcomes were analyzed per patient and using mixed-effects Cox proportional hazard regression with registry identifiers included as a random effect. The primary outcome was target vessel failure (TVF) at 2 years, a composite of cardiac death, target vessel myocardial infarction (TVMI), and target vessel revascularization (TVR). The secondary outcome was a composite of cardiac death or TVMI at 2 years.


Of 2,268 articles identified, 29 studies met selection criteria. Of these, 28 articles from 17 cohorts provided data, including a total of 5,277 patients with 5,869 vessels who underwent FFR measurement after DES implantation. Mean (SD) age was 64.4 (10.1) years and 4,141 patients (78.5%) were men. Median (interquartile range) post-PCI FFR was 0.89 (0.84-0.94) and 690 vessels (11.8%) had a post-PCI FFR of ≤0.80. The cumulative incidence of TVF was 340 patients (7.2%), with cardiac death or TVMI occurring in 111 patients (2.4%) at 2 years. Lower post-PCI FFR significantly increased the risk of TVF (adjusted hazard ratio [HR] per 0.01 FFR decrease, 1.04; 95% confidence interval [CI], 1.02-1.05; p < 0.001). The risk of cardiac death or MI also increased inversely with post-PCI FFR (adjusted HR, 1.03; 95% CI, 1.00-1.07; p = 0.049). These associations were consistent regardless of age, sex, the presence of hypertension or diabetes, and clinical diagnosis.


Reduced FFR after DES implantation was common and associated with the risks of TVF and of cardiac death or TVMI. These results indicate the prognostic value of post-PCI physiologic assessment after DES implantation.


Findings from this large, predominantly male patient-level meta-analysis suggest that low FFR post-DES PCI is common and associated with increased risk of TVF and cardiac death over 2 years. FFR <0.86 was associated with a 3% absolute increase in TVF (adjusted HR, 1.58; 95% CI, 1.24-2.00; p < 0.001). Ongoing studies should help provide additional understanding of mechanisms and optimal management of residual ischemia post-PCI.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Prevention, Aortic Surgery, Cardiac Surgery and Arrhythmias, Hypertension

Keywords: Diabetes Mellitus, Drug-Eluting Stents, Fractional Flow Reserve, Myocardial, Hypertension, Myocardial Infarction, Myocardial Ischemia, Myocardial Revascularization, Percutaneous Coronary Intervention, Risk, Secondary Prevention

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