Fractional Flow Reserve-Guided PCI as Compared with Coronary Bypass Surgery.

BACKGROUND: Patients with three-vessel coronary artery disease have been found to have better outcomes with coronary-artery bypass grafting (CABG) than with percutaneous coronary intervention (PCI), but studies in which PCI is guided by measurement of fractional flow reserve (FFR) have been lacking. METHODS: In this multicenter, international, noninferiority trial, patients with three-vessel coronary artery disease were randomly assigned to undergo CABG or FFR-guided PCI with current-generation zotarolimus-eluting stents. The primary end point was the occurrence within 1 year of a major adverse cardiac or cerebrovascular event, defined as death from any cause, myocardial infarction, stroke, or repeat revascularization. Noninferiority of FFR-guided PCI to CABG was prespecified as an upper boundary of less than 1.65 for the 95% confidence interval of the hazard ratio. Secondary end points included a composite of death, myocardial infarction, or stroke; safety was also assessed. RESULTS: A total of 1500 patients underwent randomization at 48 centers. Patients assigned to undergo PCI received a mean (±SD) of 3.7±1.9 stents, and those assigned to undergo CABG received 3.4±1.0 distal anastomoses. The 1-year incidence of the composite primary end point was 10.6% among patients randomly assigned to undergo FFR-guided PCI and 6.9% among those assigned to undergo CABG (hazard ratio, 1.5; 95% confidence interval [CI], 1.1 to 2.2), findings that were not consistent with noninferiority of FFR-guided PCI (P = 0.35 for noninferiority). The incidence of death, myocardial infarction, or stroke was 7.3% in the FFR-guided PCI group and 5.2% in the CABG group (hazard ratio, 1.4; 95% CI, 0.9 to 2.1). The incidences of major bleeding, arrhythmia, and acute kidney injury were higher in the CABG group than in the FFR-guided PCI group. CONCLUSIONS: In patients with three-vessel coronary artery disease, FFR-guided PCI was not found to be noninferior to CABG with respect to the incidence of a composite of death, myocardial infarction, stroke, or repeat revascularization at 1 year. (Funded by Medtronic and Abbott Vascular; FAME 3 ClinicalTrials.gov number, NCT02100722.).

Fractional Flow Reserve-Guided PCI or Coronary Bypass Surgery for 3-Vessel Coronary Artery Disease: 3-Year Follow-Up of the FAME 3 Trial.

BACKGROUND: Previous studies comparing percutaneous coronary intervention (PCI) with coronary artery bypass grafting (CABG) in patients with multivessel coronary disease not involving the left main have shown significantly lower rates of death, myocardial infarction (MI), or stroke after CABG. These studies did not routinely use current-generation drug-eluting stents or fractional flow reserve (FFR) to guide PCI. METHODS: FAME 3 (Fractional Flow Reserve versus Angiography for Multivessel Evaluation) is an investigator-initiated, multicenter, international, randomized trial involving patients with 3-vessel coronary artery disease (not involving the left main coronary artery) in 48 centers worldwide. Patients were randomly assigned to receive FFR-guided PCI using zotarolimus drug-eluting stents or CABG. The prespecified key secondary end point of the trial reported here is the 3-year incidence of the composite of death, MI, or stroke. RESULTS: A total of 1500 patients were randomized to FFR-guided PCI or CABG. Follow-up was achieved in >96% of patients in both groups. There was no difference in the incidence of the composite of death, MI, or stroke after FFR-guided PCI compared with CABG (12.0% versus 9.2%; hazard ratio [HR], 1.3 [95% CI, 0.98-1.83]; P=0.07). The rates of death (4.1% versus 3.9%; HR, 1.0 [95% CI, 0.6-1.7]; P=0.88) and stroke (1.6% versus 2.0%; HR, 0.8 [95% CI, 0.4-1.7]; P=0.56) were not different. MI occurred more frequently after PCI (7.0% versus 4.2%; HR, 1.7 [95% CI, 1.1-2.7]; P=0.02). CONCLUSIONS: At 3-year follow-up, there was no difference in the incidence of the composite of death, MI, or stroke after FFR-guided PCI with current-generation drug-eluting stents compared with CABG. There was a higher incidence of MI after PCI compared with CABG, with no difference in death or stroke. These results provide contemporary data to allow improved shared decision-making between physicians and patients with 3-vessel coronary artery disease. REGISTRATION: URL: https://www. CLINICALTRIALS: gov; Unique identifier: NCT02100722.

Diagnostic performance and prognostic impact of coronary angiography-based Index of Microcirculatory Resistance assessment: A systematic review and meta-analysis.

BACKGROUND: The Index of Microcirculatory Resistance (IMR), measured with a pressure-thermistor tipped coronary guidewire has been established as a gold standard for coronary microvascular assessment. Angiography-based IMR (angio-IMR) is a novel method to derive IMR without intracoronary instrumentation or the need for adenosine. METHODS: PubMed and Embase databases were systemically searched in November 2021 for studies that measured angio-IMR. The primary outcomes were pooled sensitivity and specificity as well as the area under the curve (AUC) of the summary receiver operating characteristic curve using IMR as a reference standard. RESULTS: A total of 129 records were initially identified and 8 studies were included in the final analysis. Overall, 1653 lesions were included in this study, of which 733 were in patients presenting with ST-segment elevation myocardial infarction. Angio-IMR yielded high diagnostic performance predicting wire-based IMR with pooled sensitivity = 0.81 (95% confidence interval: 0.76, 0.85), specificity = 0.80 (0.72, 0.86), and AUC = 0.86 (0.82, 0.88), which was similar irrespective of patient presentation. When the clinical outcome was compared between high versus low angio-IMR in patients presenting with myocardial infarction, high angio-IMR predicted an increased risk of major adverse cardiac events (MACE). CONCLUSION: Our study found that coronary angio-IMR has relatively high diagnostic performance as well as prognostic values predicting MACE, supporting its use in clinical practice.

Optimization of the Hydrothermal Activation Treatment with Sodium Hydroxide Solution for the Conversion of Coal Fly Ash to Zeolite and Its Adsorption Capability of Lead (II) Ions from the Liquid Phase.

Coal fly ash (FA) was treated by hydrothermal activation with sodium hydroxide solution at different concentrations to optimize the conversion method. Zeolite of the sodium type is prepared from coal FA by 1, 1.5, and 3 mol/L sodium hydroxide solutions (ZE1, ZE1.5, and ZE3). These adsorbents' morphology, crystal structure, scanning electron microscopy, Fourier transform (FT)-IR spectra, cation exchange capacity (CEC), specific surface area and pore volumes, and pHpzc were determined. An adsorption experiment was performed to evaluate the effects of contact time, pH, temperature, and coexistence. From the results, the values of CEC and specific surface area of prepared samples was in the order ZE3 < ZE1.5 < ZE1. The similar trends were observed in lead ions adsorption. In addition, our obtained data elucidate that the ion exchange with sodium ions in the interlayer ZE1 is one of the adsorption mechanisms of Pb2+ from water layer. Finally, lead ions adsorbed on ZE1 could be desorbed using a hydrochloric acid solution, showing that ZE1 could be reused as a water purification agent.

Improvement in adsorption of Hg2+ from aqueous media using sodium-type fine zeolite grains.

To increase the adsorption capability of Hg2+ from aqueous media, we prepared sodium-type fine zeolite grains with various particle sizes (denoted as ZE1, ZE2 and ZE3). The particle sizes of ZE1, ZE2 and ZE3 were 16.363 ± 0.365, 1.454 ± 0.357 and 0.607 ± 0.377 µm, respectively. Moreover, the CEC, specific surface area and pore volume were in the order ZE1 (42 mmol/g and 23.5 m2/g) < ZE2 (72 mmol/g and 67.1 m2/g) < ZE3 (135 mmol/g and 176.6 m2/g). Subsequently, the Hg2+ adsorption capability was investigated. The performance of tested agents on Hg2+ adsorbed was in the order ZE1 (5.0 mg/g) < ZE2 (9.4 mg/g) < ZE3 (20.2 mg/g). It was concluded that fine crystalline zeolite was important in enhancing the adsorption capability of Hg2+. In addition, the mechanism of adsorption of Hg2+ on the ZE samples was evaluated. Our results suggested that Hg2+ was exchanged with sodium ions in the interlayers of ZE samples with correlation coefficients of 0.966-0.979. Our findings revealed that these ZE samples constitute potential agents for the adsorption of Hg2+ from aqueous media.

Adsorption Performance on As(III) from Aqueous Solution Using the Complex Nickel-Aluminum Hydroxides.

In this study, complex nickel-aluminum hydroxides were prepared at different molar ratios (NA12, NA11, NA21, NA31, and NA41), and their adsorption capability on arsenic ions (As(III)) from aqueous media was assessed. The physicochemical properties such as morphology, X-ray diffraction pattern, specific surface area, numbers of hydroxyl groups, and surface pH were investigated. In addition, the effect of contact time, temperature, and pH on the adsorption capability on As(III) was also evaluated. NA41 exerted the highest adsorption capability on As(III) comparable to other prepared adsorbents. However, the specific surface area and numbers of hydroxyl groups did not significantly affect the adsorption capability on As(III). The equilibrium adsorption of As(III) using NA41 was achieved within 24 h, and the obtained results corresponded to a pseudo-second-order model with correlation coefficient value of 0.980. Additionally, the adsorption isotherms were well described by both the Langmuir and Freundlich equations. The optimal pH condition for removal of As(III) using NA41 was found to be approximately 6-8. Finally, the adsorption mechanism of As(III) was assessed by analyzing the binding energy and elemental distribution, which indicated that the electrostatic interaction and ion exchange influenced the adsorption of As(III) under experimental conditions. These results demonstrated the potential candidate of NA41 as an effective adsorbent on As(III) removal from aqueous media.

Long-term clinical outcomes with use of an angiotensin-converting enzyme inhibitor early after heart transplantation.

BACKGROUND: The safety and efficacy of angiotensin converting enzyme inhibition (ACEI) after heart transplantation (HT) is unknown. This study examined long-term clinical outcomes after ACEI in HT recipients. METHODS: The ACEI after HT study was a prospective, randomized trial that tested the efficacy of ACEI with ramipril after HT. In this study, long-term clinical outcomes were assessed in 91 patients randomized to either ramipril or placebo (median, 5.8 years). The primary endpoint was a composite of death, retransplantation, hospitalization for rejection or heart failure, and coronary revascularization. RESULTS: The primary endpoint occurred in 10 of 45 patients (22.2%) in the ramipril group and in 14 of 46 patients (30.4%) in the placebo group (Hazard ratio (HR), 0.68; 95% CI, 0.29-1.51; P = .34). When the analysis was restricted to comparing patients who remained on a renin-angiotensin system inhibitor beyond 1 year with those who did not, there was a trend to improved outcomes (HR, 0.54; 95% CI, 0.22-1.28, P = .16). There was no significant difference in creatinine, blood urea nitrogen, and potassium at 3 years after randomization. The cumulative incidence of the primary endpoint was significantly higher in patients in whom the index of microcirculatory resistance increased from baseline to 1 year compared with those in whom it did not (39.1 vs 17.4%, HR: 3.36; 95% CI, 1.07-12.7; P = .037). CONCLUSION: The use of ramipril after HT safely lowers blood pressure and is associated with favorable long-term clinical outcomes. Clinical Trial Registration-URL: https://www.clinicaltrials.gov. Unique identifier: NCT01078363.

Determining of the Water Quality of the Ping River at Different Seasons in Northern Thailand.

The water quality in a river (water environment) is very important for human health and aquatic organisms. In 2015, the highly regarded Water Resources Management Strategy of Thailand was announced by The Ministry of Industry in Thailand. In this study, the water quality of the Ping river in Northern Thailand, including Chiang Mai and Lamphun provinces, was focused on and measured for three different seasons (summer, rainy, and winter seasons). Anions (F-, Cl-, NO2-, NO3-, and SO42-) and cations (Na+, Mg2+, Si4+, S6+, K+, and Ca2+) were qualified by an ion chromatograph and an inductively coupled plasma optical emission spectrometry, respectively. The concentration of anions and cations (except for Mg2+ and Ca2+) in the Ping river at upstream (countryside) locations were lower than that at downstream (closer main city) locations, which indicated that the fertilizers, industrial or household wastewaters had been flowing into the Ping river at downstream locations. Additionally, the concentration of anions and cations in the rainy season was higher than other seasons. The present results provide the water quality of the Ping river which was not yet reported officially by the Thailand government.

Fractional Flow Reserve and Quality-of-Life Improvement After Percutaneous Coronary Intervention in Patients With Stable Coronary Artery Disease.

BACKGROUND: Whether the benefit in quality of life (QOL) after percutaneous coronary intervention depends on the severity of the stenosis as determined by fractional flow reserve (FFR) remains unknown. This study sought to investigate the relationship between FFR values and improvement in QOL. METHODS: From the FAME 1 and 2 trials (Fractional Flow Reserve Versus Angiography for Multivessel Evaluation), we identified 706 stable patients with coronary artery disease who had at least 1 lesion with an FFR≤0.80 that was treated with percutaneous coronary intervention and 185 patients with coronary artery disease who had no lesion with an FFR≤0.80 and were treated medically who served as a reference group. QOL was assessed by the European Quality of Life-5 Dimensions index at baseline, 1 month, and 1 year. We assessed the relationship between QOL improvement (defined as the change in European Quality of Life-5 Dimensions index from baseline) and FFR as a continuous value and according to abnormal FFR tertile. RESULTS: QOL improved significantly after percutaneous coronary intervention in each abnormal FFR tertile, whereas it did not change in the reference group. The lowest abnormal FFR subgroup had the greatest improvement in QOL at 1 month ( P<0.001). In mixed-effects models for repeated measures, lower FFR ( P=0.002 for 1 month and 0.049 for 1 year), greater delta FFR ( P=0.021 for 1 month and 0.025 for 1 year), and higher angina class ( P=0.001 for 1 month and <0.001 for 1 year) were associated with the greatest magnitude of QOL improvement at both 1 month and 1 year. CONCLUSIONS: Among patients with stable coronary artery disease, FFR and angina severity predict QOL improvement after percutaneous coronary intervention. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov . Unique identifiers: NCT00267774 and NCT01132495.

Adsorption of Nitrite and Nitrate Ions from an Aqueous Solution by Fe-Mg-Type Hydrotalcites at Different Molar Ratios.

In this study, we prepared Fe-Mg-type hydrotalcites (Fe-HT3.0 and Fe-HT5.0) with different molar ratios and evaluated their adsorption capability for nitrite and nitrate ions from aqueous solution. Fe-HT is a typical hydrotalcite-like layered double hydroxide. Adsorption isotherms, as well as the effects of contact time and pH were investigated, and it was found that Fe-HT can adsorb larger amounts of nitrite and nitrate ions than Al-HT (normal-type hydrotalcite). Adsorption isotherm data were fitted to both Freundlich (correlation coefficient: 0.970-1.000) and Langmuir (correlation coefficient: 0.974-0.999) equations. Elemental analysis and binding energy of Fe-HT surface before and after adsorption indicated that the adsorption mechanism was related to the interaction between the adsorbent surface and anions. In addition, the ion exchange process is related to the adsorption mechanism. The adsorption amount increased with increasing temperature (7-25°C). The experimental data fit the pseudo-second-order model better than the pseudo-first-order model. The effect of pH on adsorption was not significant, which suggested that Fe-HT could be used over a wide pH range (4-12). These results indicate that Fe-HT is a good adsorbent for the removal of nitrite and nitrate ions from aqueous solution.

Invasive Assessment of Coronary Physiology Predicts Late Mortality After Heart Transplantation.

BACKGROUND: The aim of this study is to determine the prognostic value of invasively assessing coronary physiology early after heart transplantation. METHODS AND RESULTS: Seventy-four cardiac transplant recipients had fractional flow reserve, coronary flow reserve, index of microcirculatory resistance (IMR), and intravascular ultrasound performed down the left anterior descending coronary artery soon after (baseline) and 1 year after heart transplantation. The primary end point was the cumulative survival free of death or retransplantation at a mean follow-up of 4.5±3.5 years. The cumulative event-free survival was significantly lower in patients with a fractional flow reserve <0.90 at baseline (42% versus 79%; P=0.01) or an IMR ≥20 measured 1 year after heart transplantation (39% versus 69%; P=0.03). Patients in whom IMR decreased or did not change from baseline to 1 year had higher event-free survival compared with patients with an increase in IMR (66% versus 36%; P=0.03). Fractional flow reserve <0.90 at baseline (hazard ratio, 0.13; 95% confidence interval, 0.02-0.81; P=0.03), IMR ≥20 at 1 year (hazard ratio, 3.93; 95% confidence interval, 1.08-14.27; P=0.04), and rejection during the first year (hazard ratio, 6.00; 95% confidence interval, 1.56-23.09; P=0.009) were independent predictors of death/retransplantation, whereas intravascular ultrasound parameters were not. CONCLUSIONS: Invasive measures of coronary physiology (fractional flow reserve and IMR) determined early after heart transplantation are significant predictors of late death or retransplantation.

Impact of analysis interval size on the quality of optical frequency domain imaging assessments of stent implantation for lesions of the superficial femoral artery.

OBJECTIVES: This study aimed to investigate the influence of analysis interval size on optical frequency domain imaging (OFDI) assessment of stent therapy for lesions of the superficial femoral artery (SFA). BACKGROUND: No consensus or validating data are available with respect to the methodology of intravascular imaging analysis for the peripheral arteries. METHODS: OFDI was performed for 30 SFA lesions, during endovascular therapy and at the 6-month follow-up. Initially, lumen and stent borders were traced at 1-mm axial intervals. Volumes were calculated using a PC-based software, and the volume index (VI) was defined as the volume divided by the stent length. Two additional OFDI analyses were performed using 2-mm and 5-mm intervals, thereby reducing the number of cross-sectional image frames analyzed. RESULTS: The mean stent length was 89.7 ± 35.2 mm. The mean difference in baseline minimum lumen area (MLA) was 0.4 mm2 between MLA values from the 1-mm and 2-mm interval analyses, and 2.2 mm2 between MLA values from the 1-mm and 5-mm interval analyses. In volumetric analysis, there were excellent correlations and good agreements for stent, lumen, and neointimal VI measurements obtained on the basis of different analysis intervals. CONCLUSIONS: Using large intervals in OFDI analyses of SFA lesions resulted in few differences in measurement variability of volumetric parameters. However, planar analysis for MLA assessment can be susceptible to high variability when large intervals are applied. © 2016 Wiley Periodicals, Inc.

Left ventricular myocardial function assessed by three-dimensional speckle tracking echocardiography in Takotsubo cardiomyopathy.

BACKGROUND: We aimed to investigate left ventricular (LV) functional recovery in Takotsubo cardiomyopathy (TC) using three-dimensional (3D) speckle tracking echocardiography. METHODS: Twenty-one patients with TC who underwent routine and 3D echocardiography as well as electrocardiography were enrolled. 3D images were analyzed to measure 3D radial strain and area tracking (area change of each LV segment). Postsystolic shortening (PSS) or thickening (PST) was defined as a further shortening or thickening occurred after the end-systole. 3D echocardiography and ECG were repeated at 4 weeks and 6 months later. RESULTS: Mean age was 70.9±11.1 years, and 18 (86%) patients were female. All patients presented classical type of TC with apical ballooning. LV ejection fraction (EF) improved from 49.9±7.2 to 64.9±6.0% (P<.001) at 4 weeks without segmental wall-motion abnormality. However, PSS or PST still existed in 43% of LV segments, and electrocardiographic abnormality was also observed in 51% at 4 weeks and disappeared at 6 months. Mean 3D radial strain decreased from baseline to 6 months at base (36.1±19.6 vs 28.0±12.6%, P=.04), whereas it increased at mid (16.2±7.2 vs 28.7±9.1%, P=.03) and the apex (8.0±4.4 vs 21.2±7.9%, P<.001). Mean area tracking increased from baseline to 6 months at mid and apex (-28.5±9.5 vs -44.5±9.6%, P<.001 for mid, and -24.2±13.0 vs -42.9±16.8%, P=.002 for the apex), while it did not change at base (-37.0±8.9 vs -41.9±9.6%, P=NS). CONCLUSIONS: Patients with TC show abnormal wall motion during acute phase. Even after LV wall-motion recovery, subtle abnormalities of regional LV function appear to persist at 4 weeks followed by normalization at 6 months.

Left atrial function and phenotypes in asymmetric hypertrophic cardiomyopathy.

BACKGROUND: Few studies have analyzed changes in left atrial (LA) function associated with different phenotypes of asymmetric hypertrophic cardiomyopathy (HCM). We sought to demonstrate the association of impairments in LA function with disease phenotype in patients with obstructive and nonobstructive HCM. METHODS: From Stanford Cardiomyopathy Registry, we randomly selected 50 age-/sex-matched healthy controls, 35 patients with nonobstructive HCM (HCM 1), 35 patients with obstructive HCM (HCM 2), and 35 patients with obstructive HCM requiring septal reduction therapy (HCM 3). Echocardiography was performed to evaluate left ventricular (LV) strain as well as LA function including LA emptying fraction and LA strain. RESULTS: The mean age was 51±14 years and 57% were male. LA volume index differed among all four predefined groups (25.6±6.7 mL/m2 in controls, 32.2±13.3 mL/m2 in HCM 1, 42.0±12.9 mL/m2 in HCM 2, 52.4±15.2 mL/m2 for HCM 3, and P<.05 all between groups). All measurement of LA function was impaired in patients with HCM than controls. Total and passive LA function was further impaired in HCM 2 or 3 compared with HCM 1, while active LA function was not different among the three groups. Among LV strains, only septal longitudinal strain differed among all groups (-18.5±1.9% in controls, -14.5±1.9% in HCM 1, -13.3±1.8% in HCM 2, -11.6±2.3% in HCM 3, and P<.05 all between groups). CONCLUSIONS: LA function was impaired in patients with HCM even in minimally symptomatic nonobstructive phenotype. Total and passive LA function was further impaired in patients with obstructive HCM.

Invasive coronary microcirculation assessment--current status of index of microcirculatory resistance.

Assessment of the coronary microvasculature in the clinical setting is a key issue, given that microvascular dysfunction itself has a predictive value for cardiovascular events. The index of microcirculatory resistance (IMR) is an invasive method of interrogating the microvasculature and provides further insight into the physiology of cardiovascular diseases. It is simple and readily applicable in the cardiac catheterization laboratory where many patients first present for evaluation of their coronary circulation. In contrast to other invasive and non-invasive tests, this method is known to be stable and reproducible under various hemodynamics and even in the presence of epicardial coronary artery stenosis. IMR has been shown to have prognostic value in patients with ST-segment elevation myocardial infarction; therefore it can be a surrogate marker of cardiovascular events. At the same time, it has the potential to be a therapeutic as well as an investigational tool in the physiology of cardiovascular diseases. This review summarizes the development of IMR, tips and tricks for its measurement, and its usefulness in various clinical settings.

Impact of target lesion coronary calcification on stent expansion.

BACKGROUND: Stent underexpansion remains a concern as a cause of drug-eluting stent (DES) failure. Although coronary calcification is considered to be a contributing factor in stent underexpansion, previous intravascular ultrasound studies have failed to demonstrate this relationship. We investigated whether stent expansion could be predicted by coronary calcification as assessed by optical coherence tomography (OCT). METHODS AND RESULTS: We enrolled 51 de novo native coronary artery lesions treated by a single 2nd-generation DES (3 types). Prior to stent deployment, the arc and area of calcium at the target lesion were measured using OCT. After successful stent implantation, OCT imaging was repeated to assess minimal stent diameter and area (MSD and MSA). Stent expansion was defined as MSD (or MSA) divided by the values predicted by the manufacturers' compliance charts. Patients were divided into 4 groups according to the median values of the arc and area of calcium. Mean stent expansion was 73.3±8.7% for MSD and 65.2±12.0% for MSA. Stent expansion defined by MSD was significantly different among the 4 groups (P=0.02). A similar trend was observed for stent expansion defined by MSA (P=0.16). CONCLUSIONS: The extent of target lesion calcification as assessed by OCT may be an important determinant of the expansion of 2nd-generation DES.

Comparison among various physiology and angiography-guided strategies for deferring percutaneous coronary intervention: A network meta-analysis.

BACKGROUND/PURPOSE: It is unclear whether coronary physiology or coronary angiography (CA)-guided strategy is the more preferable approach for deferring percutaneous coronary intervention (PCI). We sought to evaluate the clinical efficacy of various PCI strategies through a network meta-analysis of randomized controlled trials (RCTs). METHODS/MATERIALS: We searched multiple databases for RCTs investigating the impact of the following strategies for the purpose of determining whether or not to defer PCI: fractional flow reserve, instantaneous wave-free ratio, quantitative flow ratio (QFR), and CA. We conducted a network meta-analysis for trial-defined major adverse cardiovascular events (MACE), all-cause death, cardiovascular death, myocardial infarction (MI), target lesion revascularization (TLR), and stent thrombosis. We performed a subgroup analysis for those with acute coronary syndrome (ACS). RESULTS: Our search identified 12 eligible RCTs including a total of 13,177 patients. QFR-guided PCI was associated with reduced MACE, MI, and TLR compared with CA-guided PCI (relative risk (RR) 0.68; 95 % confidence interval (CI] [0.49 to 0.94], RR 0.58; 95 % CI [0.36 to 0.96], and RR 0.58; 95 % CI [0.38 to 0.91], respectively). There were no significant differences in any pairs for all-cause death, cardiovascular death, or stent thrombosis. QFR was ranked the best in most outcomes. In the subgroup analysis of the ACS cohort, there were no significant differences in MACE between any comparisons. CONCLUSIONS: QFR was associated with reduced MACE, MI, and TLR compared with CA, and ranked the best in most outcomes. However, this was not applied in the ACS cohort.