Clinical outcomes of FFR-guided revascularisation of non-culprit lesions in NSTE-ACS.
Paolucci L, De Bruyne B, et al. • EuroIntervention : journal of EuroPCR in collaboration with the Working Group on Interventional Cardiology of the European Society of Cardiology • 2026
FFR-guided revascularisation is associated with a similar clinical benefit in NSTE-ACS and CCS settings, and an FFR-guided strategy should be considered to safely reduce unnecessary PCI in patients with NSTE-ACS.
Key Findings
Results
The relationship between an FFR-guided strategy and the risk of MACE at 1 year was similar across NSTE-ACS and CCS patient groups.
2,493 patients were pooled from five randomised clinical trials comparing FFR- and angiography-guided PCI.
1,316 (52.8%) patients had CCS and 1,177 (47.2%) had NSTE-ACS.
p-value for interaction between coronary syndrome subtype and FFR-guided strategy for MACE = 0.792, indicating no significant difference in treatment effect between groups.
Results
No significant interaction between coronary syndrome subtype and FFR-guided strategy was found for any individual component of MACE at 1 year.
All-cause death: p-value for interaction = 0.459.
Myocardial infarction: p-value for interaction = 0.996.
Repeat revascularisation: p-value for interaction = 0.290.
These findings indicate that the benefit of FFR guidance was consistent across NSTE-ACS and CCS for all secondary endpoints.
Results
The similar clinical outcomes between FFR-guided and angiography-guided strategies across NSTE-ACS and CCS were confirmed through extended follow-up at 5 years.
An extended exploratory analysis at 5 years of follow-up was performed.
Results confirmed the findings observed at 1 year.
No significant interaction between syndrome subtype and treatment strategy was identified at long-term follow-up.
Results
In NSTE-ACS patients randomised to FFR-guided revascularisation, the number of deferred lesions was not associated with an increased risk of MACE.
This analysis specifically examined patients with NSTE-ACS in the FFR-guided arm.
Deferral of lesions based on FFR did not translate into higher MACE risk.
This finding supports the safety of deferring non-flow-limiting lesions in the NSTE-ACS setting.
Methods
Individual patient data from five randomised clinical trials were pooled to compare FFR- and angiography-guided PCI across coronary syndrome subtypes.
The pooled dataset included data from the PRIME Collaboration.
Patients were stratified according to coronary syndrome subtype: CCS or NSTE-ACS.
The primary outcome was MACE at 1 year.
Individual patient data meta-analysis methodology was used, enabling stratified and interaction analyses.
What This Means
This research examined whether using fractional flow reserve (FFR) — a wire-based pressure measurement taken during a heart procedure to determine whether a blocked artery is actually restricting blood flow — leads to better patient outcomes compared to making treatment decisions based on visual assessment of X-ray images alone. The study focused on patients with non-ST-elevation acute coronary syndromes (NSTE-ACS), a type of unstable heart condition, and compared them to patients with stable chronic coronary syndrome (CCS). Data from 2,493 patients across five clinical trials were combined and analyzed.
The study found that the benefit of using FFR to guide which arteries to treat was similar in both NSTE-ACS and CCS patients. Patients guided by FFR had a trend toward fewer major adverse cardiovascular events (such as heart attacks, deaths, or need for repeat procedures) compared to those guided by angiography alone, and this benefit was consistent regardless of whether the patient had an acute or stable condition. Importantly, when FFR indicated that a blockage was not significantly restricting blood flow and treatment was deferred (skipped), this did not lead to worse outcomes — suggesting that withholding unnecessary procedures was safe.
This research suggests that FFR-guided decision-making could be a useful tool in NSTE-ACS patients to avoid unnecessary coronary stenting procedures without increasing cardiovascular risk. Performing fewer unnecessary procedures could reduce patient exposure to procedural complications, costs, and recovery time. These findings support consideration of FFR as part of standard practice when evaluating non-culprit (non-primary) blocked arteries in patients presenting with this type of acute heart condition.
Paolucci L, De Bruyne B, Rioufol G, Hahn J, Chen S, Koo B, et al.. (2026). Clinical outcomes of FFR-guided revascularisation of non-culprit lesions in NSTE-ACS.. EuroIntervention : journal of EuroPCR in collaboration with the Working Group on Interventional Cardiology of the European Society of Cardiology. https://doi.org/10.4244/EIJ-D-26-00055