Angiography-derived versus pressure-wire–based physiological assessment to guide percutaneous coronary intervention: a systematic review and meta-analysis of randomised controlled trials

Introduction Angiography-derived fractional flow reserve (FFR) has emerged as a wire-free alternative to pressure-wire–based physiological assessment for guiding percutaneous coronary intervention (PCI). However, comparative clinical outcomes and procedural implications remain uncertain. Methods A systematic review and meta-analysis of randomised controlled trials (RCTs) was conducted in accordance with PRISMA guidelines. Databases were searched from inception to April 2026. Studies comparing angiography-derived FFR with pressure-wire–based strategies in patients undergoing PCI were included. Risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals (CIs) were pooled using a random-effects model. Pre-specified subgroup analyses were performed based on technology type and comparator composition. Results Three RCTs were included. Angiography-derived strategies demonstrated no significant difference compared with wire-based approaches for the primary composite outcome (RR: 1.14; 95% CI: 0.85 to 1.55), all-cause mortality, cardiac mortality, myocardial infarction (MI), or revascularization. However, angiography-derived guidance significantly reduced procedural time (MD: − 2.83 min; 95% CI: − 4.94 to − 0.72), fluoroscopy time (MD: − 2.50 min; 95% CI: − 3.38 to − 1.61), and contrast volume (MD: − 6.99 mL; 95% CI: − 11.57 to − 2.40). Conclusions Angiography-derived physiological assessment provides comparable 1-year clinical outcomes to pressure-wire–based strategies while improving procedural efficiency. However, outcomes may vary by platform, highlighting the importance of technology-specific evaluation in future research.