Interpreting fractional flow reserve-guided percutaneous coronary intervention vs coronary artery bypass grafting outcomes

Abstract

Kataveni et al’s meta-analysis offers an important contemporary synthesis of randomized evidence comparing fractional flow reserve-guided percutaneous coronary intervention and coronary artery bypass grafting (CABG) in multivessel coronary artery disease (CAD). The pooled analysis found no significant difference in all-cause mortality or stroke, yet CABG was superior in reducing myocardial infarction, major adverse cardiac events, and repeat revascularization. These results confirm CABG’s durability even in the era of physiological lesion assessment and second-generation drug-eluting stents. From a traditional Chinese medicine (TCM) perspective, multivessel CAD corresponds to syndromes such as “heart vessel obstruction” and “Qi and blood stagnation”, in which local blockage is compounded by systemic imbalance. While revascularization addresses the structural impediment to blood flow, TCM approaches, including herbal medicine, acupuncture, and lifestyle therapy, aim to improve microcirculation, reduce inflammation, and support recovery, potentially mitigating recurrent ischemic events. This commentary argues that future research should integrate optimal revascularization strategies with rigorously evaluated TCM interventions to address both the anatomical and systemic dimensions of CAD and improve long-term patient outcomes.

Key Words: Fractional flow reserve; Percutaneous coronary intervention; Coronary artery bypass grafting; Traditional Chinese medicine; Integrative cardiology

Core Tip: This commentary highlights that although coronary artery bypass grafting remains superior to fractional flow reserve-guided percutaneous coronary intervention in reducing myocardial infarction and repeat revascularization in multivessel coronary artery disease, optimal outcomes may require an integrative approach. By combining revascularization with evidence-based traditional Chinese medicine to improve systemic vascular health and microcirculation, future strategies could transcend the dichotomy of “surgery vs stenting” and offer more durable, patient-centered benefits.

TO THE EDITOR

The studies by Fearon et al[1] and Takahashi et al[2] provides timely clarity on a question that has persisted in the era of physiological lesion assessment: Does fractional flow reserve (FFR)-guided percutaneous coronary intervention (PCI) match the long-term efficacy of coronary artery bypass grafting (CABG) in patients with multivessel coronary artery disease? Their analysis of three randomized controlled trials involving over 3400 patients demonstrates that while survival and stroke outcomes are comparable, CABG maintains a clear advantage in preventing myocardial infarction, major adverse cardiovascular events, and repeat revascularization[1,2]. Even when lesion selection is optimized with FFR, PCI appears more vulnerable to residual ischemia and disease progression in untreated segments. These findings reinforce a familiar but important principle in interventional cardiology: Anatomical completeness of revascularization, as achieved by CABG, remains critical for durable protection against adverse events, especially in patients with high Synergy between percutaneous coronary intervention with Taxus and cardiac surgery scores or diabetes[1,2]. The equivalence in mortality and stroke underscores that PCI can be a safe alternative for selected patients, particularly those with less complex anatomy or high surgical risk, but the trade-off in event recurrence must be weighed carefully[2].

From a traditional Chinese medicine (TCM) standpoint, multivessel CAD aligns with the concept of “heart vessel obstruction”, typically arising from a combination of Qi deficiency, blood stasis, phlegm-damp retention, and, in some cases, pathogenic cold[3,4]. The pathogenesis involves not only localized vessel narrowing but also systemic derangements that predispose to recurrent obstruction. This parallels the biomedical understanding that atherosclerosis is not merely a focal stenosis but a diffuse, inflammatory, and progressive disease process[3-5]. In TCM clinical practice, herbal prescriptions such as Danshen (Salvia miltiorrhiza), Sanqi (Panax notoginseng), and Honghua (Carthamus tinctorius) are used to invigorate blood, remove stasis, and improve microcirculation[3,5]. Acupuncture at points like Neiguan (PC6) and Xinshu (BL15) may modulate autonomic tone, improve myocardial perfusion, and alleviate angina symptoms[4]. Moreover, TCM lifestyle guidance, including dietary regulation, breathing exercises, and stress reduction, addresses systemic factors such as inflammation, oxidative stress, and metabolic dysregulation, which, in modern terms, contribute to endothelial dysfunction and plaque instability[3-5].

This integrative viewpoint suggests that while CABG or PCI addresses the “root blockage” in the main coronary vessels, adjunctive TCM therapy could target the “soil” in which recurrent events take root, systemic vascular health. Such a combination could, in theory, reduce the higher rates of myocardial infarction and repeat revascularization observed in the PCI group, and even further enhance the benefits of CABG. Future research should explore hybrid management strategies: Optimal anatomical revascularization guided by FFR, combined with evidence-based TCM interventions in the post-procedure phase. Pragmatic trials could assess whether such integration improves long-term event-free survival, quality of life, and cost-effectiveness, while mechanistic studies could elucidate how TCM influences microvascular function, inflammatory pathways, and lipid metabolism in CAD[3-5]. In summary, Takahashi et al’s meta-analysis[2] reaffirms CABG’s durability in multivessel CAD, even in the age of FFR-guided PCI[1]. The next step may lie in transcending the dichotomy of “surgery vs stenting” by incorporating systemic, patient-centered strategies, potentially drawing from both modern cardiology and TCM, to optimize outcomes in this high-risk population[3-5].

ACKNOWLEDGEMENTS

We thank Chen WF, Liu ZX, Yang YQ, and Liu BY for their support.