The optimal management of intermediate coronary stenosis remains uncertain. A multinational randomized trial compared fractional flow reserve (FFR)–guided and intravascular ultrasound (IVUS)–guided treatment strategies with extended follow-up. The study, published in the Journal of the American College of Cardiology, enrolled 1,682 patients with de novo intermediate lesions (40%-70% stenosis, vessel ≥2.5 mm) across 18 sites in Korea and China.

Patients were randomized 1:1 to FFR or IVUS guidance. Over a median of 6.3 years, 22.0% of patients experienced the composite endpoint of all-cause death, myocardial infarction, or any revascularization, with no significant difference between groups (23.1% FFR vs 20.9% IVUS; HR 1.15; 95% CI 0.93–1.42; P = 0.208). The FFR group recorded a higher rate of late revascularization (14.9% vs 11.8%; HR 1.32; P = 0.049), mainly due to deferred lesions requiring intervention after 2 years. However, overall target vessel PCI was lower with FFR than with IVUS (38.8% vs 60.5%; P < 0.001).

The trial shows that both FFR- and IVUS-guided strategies achieve comparable long-term outcomes. FFR reduces the overall need for PCI despite more late revascularizations, confirming that both methods are safe and effective options for patients with intermediate coronary stenosis.