Physiology-Guided Coronary Revascularization Versus Angiography in Chronic Coronary Syndromes: A Systematic Review of Major Adverse Cardiovascular Events

Coronary angiography often fails to reflect the physiological significance of coronary stenoses in patients with chronic coronary syndromes (CCS), defined according to the contemporary European Society of Cardiology (ESC) criteria as stable coronary artery disease (CAD) without acute coronary syndrome. This review aims to compare physiology-guided versus angiography-guided coronary revascularization across percutaneous and surgical strategies in stable CAD. This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines and included randomized controlled trials and observational studies comparing physiology-guided (fractional flow reserve (FFR), instantaneous wave-free ratio (iFR), quantitative flow ratio (QFR)) and angiography-guided revascularization in CCS. PubMed, ScienceDirect, and Cochrane Library were searched. Risk of bias was assessed using the Cochrane Risk of Bias tool and Newcastle-Ottawa Scale, with narrative synthesis applied due to heterogeneity. Physiology-guided coronary revascularization was associated with lower early major adverse cardiovascular events (MACE) after percutaneous coronary intervention (PCI), with similar long-term outcomes compared with angiography-guided strategies. In the FAME trials, FFR-guided PCI reduced one-year MACE, while differences attenuated at two and five years. Across surgical and mixed revascularization studies, composite ischemic outcomes were largely comparable between physiology-guided and angiography-guided approaches. In FAME 3, FFR-guided PCI was compared directly with coronary artery bypass grafting (CABG), demonstrating no significant difference in death, stroke, or myocardial infarction at five years, although myocardial infarction and repeat revascularization were more frequent with PCI, reflecting differences between revascularization modalities rather than physiology-guided versus angiography-guided decision-making. Mortality rates were generally low and similar across strategies, with one long-term observational CABG study suggesting reduced death or myocardial infarction with physiology guidance. Graft patency and short-term surgical outcomes were comparable, supporting the safety of deferring physiologically non-significant lesions. In CCS, physiology-guided revascularization improves early PCI outcomes and safely reduces unnecessary interventions, while providing comparable long-term clinical, mortality, and surgical outcomes to angiography-guided strategies.