Angiography-Derived Fractional Flow Reserve During Percutaneous Coronary Intervention

BACKGROUND: Angiography-derived fractional flow reserve (Angio-FFR) is an emerging tool for guiding percutaneous coronary intervention (PCI). Its uptake and outcomes compared with pressure wire (PW)-based assessment in the United States are unknown. METHODS: We conducted a cohort study using US Medicare beneficiary data from January 1, 2019 to December 31, 2024. Propensity score matching (1:3) of Angio-FFR to PW was performed in patients who underwent PCI during the same procedure, and separately among those who did not undergo PCI during the same procedure. The primary outcome was the cumulative incidence of major adverse cardiovascular events through 2 years, including all-cause death, myocardial infarction, and repeat revascularization. Secondary outcomes included individual major adverse cardiovascular event components, 30-day acute kidney injury, and 30-day major bleeding. Falsification end points (hospitalization for pneumonia and hip fracture) were used to assess unmeasured confounding. RESULTS: Of 466 535 angiograms that included intraprocedural physiological assessment, 1.00% (N=4672) used Angio-FFR. Annual use increased from 0.47% in 2019 to 3.85% in 2024. Among patients with PCI, 1591 Angio-FFR and 4773 PW-matched patients with PCI had similar major adverse cardiovascular event rates through 2 years (24.8% versus 23.5%; hazard ratio, 1.01 [95% CI, 0.85-1.20]). Secondary outcomes and falsification end points were not significantly different. In non-PCI patients, 2532 Angio-FFR and 7596 PW-matched patients also had similar major adverse cardiovascular events through 2 years (24.1% versus 23.9%; hazard ratio, 0.97 [95% CI, 0.84-1.11]). CONCLUSIONS: Angio-FFR usage in the United States is modest but increasing. Angio-FFR guidance during angiography versus PW was associated with comparable outcomes through 2 years.