Impact for Treatment Decision-Making and Clinical Outcome of Angiography-Derived Fractional Flow Reserve
In brief
Angiography-derived FFR leads to revascularization in 41% of patients, noninferior to wire-based FFR
In the PROVISION trial of 401 stable-coronary patients, a wire-free angiography-derived FFR strategy resulted in revascularization in 41.4% of cases versus 37.9% with pressure-wire FFR, meeting the predefined non-inferiority margin. One-year major cardiac events were similar, suggesting a practical alternative that needs larger outcome trials.
- Journal
- JACC. Cardiovascular interventions (Q1)
- Published
- 10 August 2026
- Study design
- Randomized controlled trial
- Evidence level
- Level 1, High (CEBM 1b)
- Authors
- Toru Tanigaki, Takuya Mizukami, Taito Arai, Kenichi Hagiya, Yuetsu Kikuta, Takanori Yoshida, et al.
- PMID
- 42575581
- DOI
- 10.1016/j.jcin.2026.05.028
Why clinicians should know about it
- Picked for Cardiology and Cardiovascular Medicine (top studies of the week, 16 August 2026).
Abstract
BACKGROUND: Pressure wire-based fractional flow reserve (FFR) is the reference standard for physiologic lesion assessment but remains underutilized owing to the need for hyperemia, procedural complexity, and wire-related risks. Angiography-derived FFR provides a wire- and hyperemia-free assessment derived from routine angiography; however, its clinical impact in guiding treatment remains uncertain. OBJECTIVES: This study aimed to determine whether angiography-derived FFR is noninferior to pressure wire-based FFR in guiding revascularization decisions among patients with stable coronary artery disease. METHODS: PROVISION (Prospective randomized trial of clinical outcomes of angiography-based fractional flow reserve guidance versus wire-based fractional flow reserve guidance) was a prospective, multicenter, randomized study. Participants were randomized 1:1 to angiography-derived FFR-guided or pressure wire-based FFR-guided revascularization. The primary endpoint was the noninferiority of angiography-derived FFR in terms of revascularization rate, defined as the proportion of patients undergoing percutaneous coronary intervention or coronary artery bypass grafting based on physiologic assessment. Secondary endpoints included the 1-year incidence of major adverse cardiac events (cardiac death, any myocardial infarction, or ischemia-driven target vessel revascularization). RESULTS: Overall, 401 patients (483 vessels) were enrolled at 13 Japanese centers. Revascularization was performed in 41.4% of patients in the angiography-derived FFR group and 37.9% in the pressure wire-based FFR group (absolute difference: 3.5%; 95% CI: -6.0 to 13.1; P for noninferiority = 0.049). At 1 year, major adverse cardiovascular events occurred in 8.4% and 10.1% of patients, respectively (HR: 0.84; 95% CI: 0.44-1.60; P = 0.591). CONCLUSIONS: Angiography-derived FFR-guided revascularization was noninferior to pressure wire-based FFR-guided strategy for determining revascularization in patients with stable coronary artery disease. This finding suggests that angiography-derived FFR may serve as a practical, wire-free alternative for physiologic guidance of coronary revascularization, warranting confirmation in larger outcome-driven trials. (PROVISION; UMIN000049230).
Abstract as published, via PubMed.
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