Clinical Impact of Physiology-Guided PCI: 1-year Results of the Post-Revascularization Optimization and Physiological Evaluation of Intermediate Lesions using Fractional Flow Reserve (PROPHET-FFR) Study

Background: The clinical value of physiological assessment after percutaneous coronary intervention (PCI) remains uncertain. We evaluated clinical outcomes associated with post-PCI physiology and temporal trends in its adoption. Methods: PROPHET-FFR (NCT05056662) is an ambispective observational study of patients undergoing invasive physiological assessment of intermediate coronary stenoses. Patients were categorized into three strategies: deferred revascularization based on non-ischemic physiology (deferred PCI), PCI for ischemic lesions without post-PCI physiological assessment (conventional PCI), and physiology-guided PCI with post-PCI assessment and optimization when indicated (post-PCI physiology). Temporal trends in the use of post-PCI physiology and physiology-guided optimization were evaluated, together with the incidence of 12-month major adverse cardiovascular events (MACE), comprising cardiovascular death, spontaneous myocardial infarction, and target-vessel revascularization (TVR). Propensity score matching between conventional PCI and post-PCI physiology was performed to confirm the primary findings. Results: Among 1,986 patients, 1,307 underwent deferred PCI, 331 conventional PCI, and 348 post-PCI physiology. At 12 months, MACE occurred in 4.1%, 7.6%, and 3.4%, respectively (p=0.011). Compared with conventional-PCI, post-PCI physiology had lower MACE (3.4% vs 7.6%; p=0.019), primarily driven by reduced TVR (2.6% vs 5.4%; p=0.057), with consistent findings after propensity score matching (226 patients/group; 2.7% vs 8.0%; p=0.0114). Post-PCI physiology increased from 11.8% to 22.8% across registry phases (p<0.001), with a numerical increase in physiology-guided optimization (11.6% vs 18.1%; p=0.08). Conclusions: In this observational study, post-PCI physiology appears to be associated with lower 12-month MACE compared with conventional PCI, with consistent findings after propensity score matching.