Angiography-Based Tool Matches Standard FFR for Coronary Revascularization Guidance

The current standard, fractional flow reserve, requires vasoactive medication and intravascular wiring, which can add complexity, time, and risk, limiting adoption. A newly introduced angiography-based technique aims to simplify this assessment while preserving clinical decision accuracy. Researchers now report randomized trial results indicating comparable outcomes to the standard approach.

Vessel fractional flow reserve (vFFR) analyzes three-dimensional reconstructions from routine coronary angiography to estimate pressure-derived flow limitation across a stenosis. By leveraging software-based computation, it avoids pharmacologic hyperemia and the insertion of a pressure wire or catheter into the target artery. This approach is part of a broader effort to deliver less-invasive physiology that could be incorporated into everyday catheterization workflows.

The FAST-III trial evaluated whether vFFR yields similar guidance to conventional fractional flow reserve in patients with intermediate coronary lesions requiring physiologic assessment. Investigators enrolled 2,235 patients across seven European countries, with a mean age of 67 years; women comprised 24%. Most participants reported exertional chest pain, while 19% presented with or were at high risk for myocardial infarction. Patients were randomized to conventional fractional flow reserve or vFFR, and those with positive findings proceeded to percutaneous coronary intervention or bypass surgery. The primary endpoint was a one-year composite of all-cause death, myocardial infarction, or any repeat revascularization; a key secondary endpoint was study vessel failure, defined as cardiac death, myocardial infarction, or revascularization of the assessed vessel.

Primary endpoint events occurred in 7.5% of patients in both arms. Study vessel failure was observed in 4% of the vFFR group and 4.6% of the conventional group. The trial was not blinded, and only 19% of patients presented with myocardial infarction, which investigators noted as limitations. A planned next step is to analyze whether vFFR offers cost advantages relative to wire-based assessment.

These findings were presented at the American College of Cardiology’s Annual Scientific Session (ACC.26) and published online in the New England Journal of Medicine on March 29, 2026. According to the investigators, minimally invasive physiology methods such as vFFR could broaden access to ischemia-guided revascularization and potentially improve outcomes if validated across care settings.

“Our new method produced very similar outcomes at one year compared with the standard of care. We have also shown that this technique can easily be incorporated into routine clinical practice,” said Joost Daemen, MD, Ph.D., associate professor in the Department of Cardiology at the Erasmus University Medical Center in Rotterdam, Netherlands, and first author of the study.