Recent coronary revascularisation trials have questioned the benefit of percutaneous coronary intervention (PCI) over medical therapy in chronic stable angina (CSA) and its non-inferiority to coronary artery bypass grafting (CABG) in left main and three-vessel coronary disease. This raises the question of how to further improve PCI outcomes in the drug-eluting stent era. The Fractional Flow Reserve (FFR) versus Angiography for Multivessel Evaluation (FAME) study has shown that PCI guided by FFR, rather than by angiography alone, reduces major adverse cardiac events (MACE). This suggests that revascularisation guided by functional assessment may be the key to improving PCI outcomes. Indeed, cross-study extrapolation of the benefits of FFR guidance in FAME to the Clinical Outcomes Utilizing Revascularisation and Aggressive Drug Evaluation (COURAGE) and PCI versus Coronary Artery Bypass Grafting for Severe Coronary Artery Disease (SYNTAX) trials supports the hypothesis that with FFR guidance PCI can provide added benefit over medical therapy in CSA, and can achieve noninferiority to CABG in left main and three-vessel coronary disease.
