Quantitative flow ratio versus fractional flow reserve: 2-year follow-up of the FAVOR III Europe trial

Clinical Snapshot

Key Findings

• P Value: p=0.064

• Effect Size: Hazard ratio 1.34 favouring FFR

• Primary Outcome: MACE at 2 years: 9.7% (QFR) vs 7.4% (FFR)

• Nnt Or Sensitivity: Number needed to harm approximately 43 patients (based on 2.3% absolute risk increase)

• Confidence Interval: 95% CI: 0.98-1.81

Clinical Application

QFR technology available in major Australian centres, though FFR remains gold standard Relevant to Australian interventional cardiology practice; FFR guidance aligns with current CSANZ and international guidelines; PBS coverage considerations for both technologies Patients with intermediate coronary stenoses requiring physiological assessment in Australian catheter laboratories

Abstract

BACKGROUND: Quantitative flow ratio (QFR) is an angiography-based method for estimating fractional flow reserve (FFR). The FAVOR III Europe trial showed that QFR guidance did not meet non-inferiority to FFR guidance, as measured by a composite endpoint of all-cause death, myocardial infarction, and unplanned revascularisation at 12 months. AIMS: We sought to report the 2-year outcomes of the QFR-guided diagnostic strategy and the FFR-guided strategy as applied in the FAVOR III Europe trial. METHODS: FAVOR III Europe was a multicentre, randomised, open-label, non-inferiority trial. A total of 2,000 patients from 34 European medical centres were randomised to undergo QFR- or FFR-guided revascularisation of intermediate coronary artery stenoses. Endpoints assessed at the 2-year follow-up included the rates of major adverse cardiac events (MACE) and its individual components of all-cause death, myocardial infarction, and unplanned revascularisation. The rates of MACE were compared for superiority by unadjusted Cox regression analysis. The outcomes from 1 to 2 years were explored in a landmark analysis. RESULTS: At 2 years, the rates of MACE were 9.7% in the QFR group and 7.4% in the FFR group (hazard ratio [HR] 1.34, 95% confidence interval [CI]: 0.98-1.81; p=0.064). In the landmark analysis, the rates of MACE between 1 and 2 years were 3.2% in the QFR group and 3.2% in the FFR group (HR 0.97, 95% CI: 0.58-1.62; p=0.92). CONCLUSIONS: The excess risks associated with QFR-guided revascularisation compared with FFR were confined to the first year. From 1 to 2 years, the rates of MACE developed similarly in the QFR and the FFR groups.

References

1. 1.Andersen, B. K., Holm, N. R., Sejr-Hansen, M., Erriquez, A., Råmunddal, T., Stähli, B. E., Guiducci, V., Mogensen, L. J. H., Westra, J., Escaned, J., Christiansen, E. H., & FAVOR III Europe Investigators. (2026). Quantitative flow ratio versus fractional flow reserve: 2-year follow-up of the FAVOR III Europe trial. EuroIntervention, Article EIJ-D-25-01255. https://doi.org/10.4244/EIJ-D-25-01255