FFR or 3d-quantitative coronary angiography-based vessel-FFR guided revascularisation – The FAST III trial
Reported from ACC.26
Chiara De Biase provides her take on the FAST III Trial presented by Joost Daemen at ACC.26 in New Orleans. She reviews the comparison between vFFR and FFR, highlighting key findings and their impact on revascularisation strategies.
FAST III Trial overview
The results of the international, open-label, multicenter FAST III trial were presented at the last ACC 2026 congress with a simultaneous publication in the New England Journal of Medicine.
FFR vs vFFR: study objective
This trial showed a comparison between conventional pressure-wire-measured fractional flow reserve (FFR) and the novel 3D quantitative-coronary-angiography-based vessel-FFR (vFFR) in guiding coronary revascularisation.
What is vFFR?
The vFFR is a pressure-wire and hyperemia-free angiography-based method that derives the FFR from accurate, high-quality, orthogonal angiographic images, reconstructing a 3D quantitative coronary angiography.
Study design and lesion criteria
This randomised trial was designed to assess the non-inferiority of the vFFR versus the conventional FFR to guide revascularisation for intermediate coronary stenosis, defined as lesions between 30% and 80% in vessels with a diameter ≥ 2.5 mm.
Patients were collected between November 2021 and May 2024. The patients included in the 1:1 randomisation presented with chronic coronary syndrome, unstable angina or non-ST-elevation myocardial infarction (NSTEMI).
Exclusion criteria
Left main stenosis, aorta-ostial lesions with > 50% stenosis, lesions located at or supplied by a by-pass graft, TIMI flow grade < 3 and thrombotic lesions were not considered for the analysis. Moreover, severe vessel tortuosity or overlap represented exclusion criteria since the vFFR would not have resulted sufficiently accurate.
Primary and secondary endpoints
The primary end point of the trial is a composite of all-cause death, any myocardial infarction, or any revascularisation within one year after randomisation.
Secondary end points are:
- Composite of cardiac death, study-vessel myocardial infarction or clinically indicated study-vessel revascularisation (study-vessel failure)
- Components of the composite endpoints
- Stroke
- Definite and probable stent thrombosis
Study population and baseline characteristics
The final analysis, out of 2,235 patients from 37 centres, included 1,116 patients, for a total of 1,417 lesions, in the vFRR guided-revascularisation group and 1,095 patients, for a total of 1,403 lesions, in the FFR guided-revascularisation group.
Mean age was about 67 years old in both groups, with around 24% of female in each arm.
Admission for acute coronary syndrome was reported in 18.7% of patients, and 26.6% of patients presented with diabetes mellitus.
One-year outcomes
A total of 97.1% of the patients in the vFFR group and 96.7% of those in the FFR group completed the 1-year follow-up.
At 1 year, the primary end-point event occurred in 80 patients (7.5%) in the vFFR group and in 79 patients (7.5%) in the FFR group. The incidence of serious adverse events appeared to be similar in the two groups.
Revascularisation findings and interpretation
Despite the similar results in outcomes at 1 year, the group randomised to vFFR experienced a higher revascularisation rate compared to the one where conventional FFR guided the intervention. For sure, the two methods are different, and understanding their differences is fundamental before their use in clinical practice, in order to understand the benefits and limits of both methods.
Future study is warranted to determine whether the higher percentage of patients receiving coronary interventions in the vFFR group than in the FFR group indicates that vFFR better detected physiologically relevant lesions or whether there was a systemic shift in decision making derived from patient characteristics and/or lesion location.
Conclusion and take-home message
In conclusion, the trial demonstrated the non-inferiority of vFFR-guided revascularisation vs FFR-guided strategy among patients with intermediate coronary-artery lesions with respect to a composite of death, myocardial infarction, or revascularisation at one year.
Related content published in EuroIntervention
Masdjedi K, Tanaka N, Van Belle E, et al. Vessel fractional flow reserve (vFFR) for the assessment of stenosis severity: the FAST II study. EuroIntervention 2022;17:1498-505.
Masdjedi K, van Zandvoort LJC, Balbi MM, et al. Validation of a three-dimensional quantitative coronary angiography- based software to calculate fractional flow reserve: the FAST Study
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