FFR-guided PCI had a similar risk of subsequent target vessel revascularization (TVR) compared to IVI-guided PCI (OR 1.26; 95% CI 0.79–1.99; p = 0.33; I² = 50%; Figure 1 A), indicating that FFR was noninferior to IVI in preventing post-PCI TVR.

Forest plots comparing fractional flow reserve with intravascular imaging. (A) Target vessel revascularization with fractional flow reserve versus intravascular imaging. (B) Stent thrombosis with fractional flow reserve versus intravascular imaging. (C) All-cause mortality with fractional flow reserve versus intravascular imaging. (D) Cardiovascular mortality with fractional flow reserve versus intravascular imaging. (E) Myocardial infarction with fractional flow reserve versus intravascular imaging. (F) Stroke with fractional flow reserve versus intravascular imaging.

FFR and IVI demonstrated nearly identical risks of post-PCI stent thrombosis (OR 0.56; 95% CI 0.08–4.09; p = 0.57; I² = 0%; Figure 1 B).

Both FFR and IVI demonstrated statistically equivalent risk profiles in terms of all-cause mortality (OR 0.61; 95% CI 0.40–0.91; p = 0.02; I² = 0%; Figure 1 C).

Both FFR and IVI were comparable in the associated risk of cardiovascular mortality (OR 0.97; 95% CI 0.52–1.79; p = 0.91; I² = 0%; Figure 1 D).

FFR-guided PCI was associated with a statistically significantly higher risk of subsequent myocardial infarction (MI) compared to IVI (OR 1.49; 95% CI 1.03–2.14; p = 0.03; I² = 0%; Figure 1 E).

Stroke risk was similar in FFR-guided PCI when compared to IVI-guided PCI (OR 0.64; 95% CI 0.26–1.59; p = 0.34; I² = 0%; Figure 1 F).

The included studies exhibited an overall low to moderate risk of bias. Three RCTs were found to have “some concerns,” while the remaining 2 had “high” risk of bias based on the Cochrane tool for risk of bias. Based on the NIH quality assessment tool, 1 study was found to be of ‘good’ quality, whereas the remaining 4 were found to be of ‘fair’ quality. Publication bias assessment through statistical tests, Egger’s and Begg-Mazumdar’s, indicated minimal bias.

This meta-analysis demonstrates comparable efficacy between FFR- and IVI-guided PCI across key clinical endpoints, including target vessel revascularization and cardiovascular mortality, while identifying a higher risk of myocardial infarction but a lower risk of all-cause mortality with FFR guidance. These findings reinforce the complementary roles of these 2 strategies in contemporary interventional cardiology. Previously, Liu et al. reported similar MACE rates but highlighted fewer interventions with FFR, suggesting its advantage in minimizing unnecessary stenting. Similarly, Iannaccone et al. showed that both FFR and IVUS reduced MI and TVR compared to angiography alone, but IVUS uniquely reduced MACE and stent thrombosis, particularly in ACS patients. In contrast, our direct comparative analysis, with a larger patient population found no significant differences in TVR, stent thrombosis, or cardiovascular mortality, supporting clinical equivalence between FFR- and IVI-guided PCI, particularly with advancements in FFR technologies and optimized stenting. Our study found that although FFR-guided PCI was associated with a higher risk of subsequent MI, it appeared more protective against all-cause mortality, suggesting that physiologic guidance may confer survival benefit in select patients and underscoring the importance of individualized risk assessment.

Physiological assessment via FFR and anatomical evaluation by IVI serve complementary purposes: FFR identifies ischemia-inducing lesions, minimizing unnecessary interventions, and confirms the absence of ischemia after PCI, whereas IVI optimizes stent deployment to reduce complications such as malapposition and edge dissections. Importantly, these modalities are not mutually exclusive but complementary; in appropriately selected patients, their combined use, FFR for lesion selection and IVI for procedural optimization, can ensure a high-quality, physiologically complete, and anatomically optimized PCI. Current ACC/AHA and ESC guidelines recommend integrating both modalities based on lesion complexity and resource availability. Nevertheless, practical considerations frequently favor FFR due to its cost-effectiveness, procedural simplicity, and broader accessibility, factors proven to decrease procedural time and healthcare costs. Conversely, IVI’s broader adoption remains limited by high equipment costs, extended procedural durations, and more intensive training requirements.

The present study’s limitations include the small number of available studies, primarily observational or open label, introducing inherent biases that may affect generalizability. The absence of patient-level data limited detailed subgroup analyses. Nevertheless, this meta-analysis effectively demonstrates comparable clinical outcomes between FFR- and IVI-guided PCI across major endpoints. Given FFR’s cost-effectiveness, procedural simplicity, and wider availability, it represents a pragmatic choice in routine clinical settings. Further research should explore integrated hybrid strategies and artificial intelligence applications to refine precision-guided PCI, ultimately enhancing patient outcomes and optimizing resource utilization in interventional cardiology.