Fractional flow reserve guided percutaneous coronary intervention vs coronary artery bypass grafting for multivessel coronary artery disease: A meta-analysis

doi:10.4330/wjc.v17.i9.111044

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World Journal of Cardiology

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1949-8462

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Baishideng Publishing Group Inc, 7041 Koll Center Parkway, Suite 160, Pleasanton, CA 94566, USA

Meta-Analysis

World J Cardiol. Sep 26, 2025; 17(9): 111044
Published online Sep 26, 2025. doi: 10.4330/wjc.v17.i9.111044

Fractional flow reserve guided percutaneous coronary intervention vs coronary artery bypass grafting for multivessel coronary artery disease: A meta-analysis

Suhas Kataveni, Ezza Ellahi, Fabeha Zafar, Ihsan Noushad Karuppan Veettil, Amna Iqbal, Bhavya Dhir, Shivani Sabarish, Sai Erambalur, Meenakshi Reddy Yathindra, Moukthika Kvn, Shayan Nawaz, Satish Kumar Dudekula, Usman Ul Haq, Asraf Hussain, Muhammad Muneeb Khawar

Suhas Kataveni, Shivani Sabarish, Department of Cardiology, Gandhi Medical College, Hyderabad 500001, Telangana, India

Ezza Ellahi, Department of Cardiology, Aziz Fatimah Hospital, Faisalabad 37000, Punjab, Pakistan

Fabeha Zafar, Department of Cardiology, Dow University of Health Sciences, Karachi 75280, Sindh, Pakistan

Ihsan Noushad Karuppan Veettil, Department of Cardiology, Sree Narayana Medical College, Ernakulam 683594, Kerala, India

Amna Iqbal, Department of Cardiology, Wah Medical College, Islamabad 47010, Islamabad, Pakistan

Bhavya Dhir, Department of Cardiology, Government Medical College, Patiala 147001, Punjab, India

Sai Erambalur, Department of Cardiology, Richmond Gabriel University, St. Vincent and Grenadines VCO130, Saint Vincent and the Grenadines

Meenakshi Reddy Yathindra, Department of Cardiology, Kasturba Medical College, Mangalore 575001, Karnataka, India

Moukthika Kvn, Department of Cardiology, Sri Venkateshwara Institute of Medical Sciences, Tirupati 517501, Andhra Pradesh, India

Shayan Nawaz, Department of Cardiology, University College of Medicine & Dentistry, Lahore 54000, Punjab, Pakistan

Satish Kumar Dudekula, Department of Cardiology, University of Perpetual Help System Dalta, Las Piñas CPO 1740, Metro Manila, Philippines

Usman Ul Haq, Department of Medicine, Medway Maritime Hospital NHS Foundation Trust, Gillingham ME7 5NY, United Kingdom

Asraf Hussain, Department of Cardiology, Chitwan Medical College, Bharatpur 33915, Nepal

Muhammad Muneeb Khawar, Department of Cardiology, King Edward Medical University, Lahore 05450, Punjab, Pakistan

Co-first authors: Suhas Kataveni and Ezza Ellahi.

Author contributions: Kataveni S and Ellahi E contribute equally to this study as co-first authors; Kataveni S, Ellahi E, Zafar F, and Veettil INK conceptualized the study; Kataveni S, Iqbal A, Erambalur S, and Yathindra MR designed the methodology; Veettil INK and Dudekula SK handled software; Ellahi E, Sabarish S, and Kvn M performed validation; Zafar F, Iqbal A, and Hussain A conducted formal analysis; Erambalur S, Yathindra MR, Nawaz S, and Dhir B performed investigation; Sabarish S, Kvn M, and Khawar MM provided resources; Nawaz S, Dhir B, and Dudekula SK curated data; Kataveni S, Ellahi E, Zafar F, and Iqbal A wrote the original draft; Karuppan Veettil IN, Erambalur S, Yathindra MR, Sabarish S, Hussain A, and Khawar MM reviewed and edited the manuscript; Ul Haq U and Hussain A prepared visualization; Kataveni S and Karuppan Veettil IN supervised the study; Ellahi E and Kvn M administered the project; all authors have read and approved the final manuscript.

Conflict-of-interest statement: The authors disclose that they have no conflict of interest related to the subject of this study.

PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.

Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/

Corresponding author: Asraf Hussain, MD, Department of Cardiology, Chitwan Medical College, Bharatpur-10, Chitwan, Bharatpur 33915, Nepal. drasrafcardiology@gmail.com

Received: June 23, 2025
Revised: July 5, 2025
Accepted: August 15, 2025
Published online: September 26, 2025
Processing time: 87 Days and 19.3 Hours

Abstract

BACKGROUND

Coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) are well-established treatments for multivessel coronary artery disease (CAD), a condition where multiple heart arteries are narrowed. A newer approach, fractional flow reserve (FFR)-guided PCI, uses a specialized measurement to select which artery blockages to treat, aiming to enhance patient outcomes. Despite its adoption, the comparative effectiveness of FFR-guided PCI vs CABG remains unclear, particularly regarding key health outcomes such as survival, heart-related complications, and the need for further procedures.

AIM

To evaluate the safety and effectiveness of FFR -guided PCI compared to CABG in patients with multivessel CAD.

METHODS

This meta-analysis followed standard reporting guidelines and included randomized controlled trials (RCTs) comparing FFR-guided PCI with CABG in patients with multivessel CAD. We searched medical databases, including PubMed, EMBASE, ScienceDirect, and ClinicalTrials.gov, from their start to May 2025. We calculated combined risk ratios (RRs) with 95% confidence intervals (95%CIs) to analyze the data.

RESULTS

Three RCTs were analyzed. There was no notable difference in all-cause mortality between FFR-guided PCI and CABG (RR = 1.01, 95%CI: 0.78-1.31, P = 0.93). However, FFR-guided PCI showed higher rates of major adverse cardiac events (MACEs; RR = 1.30, 95%CI: 1.11-1.52, P = 0.001), myocardial infarction (RR = 1.49, 95%CI: 1.11-2.01, P = 0.009), and repeat revascularization (RR = 2.25, 95%CI: 1.78-2.85, P < 0.00001). Stroke rates were comparable between the two treatments (RR = 0.80, 95%CI: 0.54-1.20, P = 0.28).

CONCLUSION

FFR-guided PCI and CABG have similar rates of all-cause mortality and stroke in patients with multivessel CAD. However, CABG results in fewer MACEs, myocardial infarctions, and repeat procedures.

Keywords: Percutaneous coronary intervention; Coronary artery bypass grafting; Fractional flow reserve; Multivessel coronary artery disease; Meta-analysis

Core Tip: This meta-analysis compares fractional flow reserve (FFR)-guided percutaneous coronary intervention (PCI) with coronary artery bypass grafting (CABG) for multivessel coronary artery disease. While both treatments show similar all-cause mortality and stroke rates, CABG significantly reduces major adverse cardiac events, myocardial infarction, and repeat revascularization. These findings highlight CABG’s superior efficacy in managing complex coronary disease, challenging the broader adoption of FFR-guided PCI. The results underscore the need for tailored treatment strategies and further trials to optimize outcomes in diverse patient populations.