Prepared by: Dr. Selim Süleyman Sert

Name of the study: Randomized Study Comparing Angiography Guidance With Physiology Guidance After PCI: The EASY-PREDICT Study

Published in Congress: EuroPCR 2025

Link: https://www.ahajournals.org/doi/10.1161/CIRCINTERVENTIONS.125.015165

Introduction
While coronary angiography remains the gold standard for evaluating coronary artery stenosis, its predictive value for detecting myocardial ischemia is limited. Physiological indices such as fractional flow reserve (FFR) have gained increasing attention for optimizing outcomes after percutaneous coronary intervention (PCI). However, the clinical impact of post-PCI physiological assessment compared to standard angiographic guidance remains unclear.

Objective
This randomized study aimed to compare clinical outcomes between routine post-PCI physiological assessment (including Pd/Pa, diastolic pressure ratio [dPR], and FFR) and angiography-guided PCI alone.

Methods
This was a single-center, randomized, single-blind study that included patients over 18 years of age undergoing diagnostic angiography and potential PCI. After successful PCI, patients were randomized into two groups:

• In the angiography group, the procedure ended after successful stent implantation.
• In the physiology group, Pd/Pa, dPR, and FFR were measured. If post-PCI FFR was ≤0.80, operators were instructed to perform further optimization steps.

The primary endpoint was the rate of target vessel failure (TVF), defined as a composite of cardiac death, myocardial infarction (MI), and target vessel revascularization at 18 months.

Results
A total of 221 patients were randomized (110 angiography, 111 physiology). In the physiology group, suboptimal post-PCI physiological results were found in 17% of cases, leading to additional optimization interventions. Final average post-PCI values were:

• Pd/Pa: 0.95±0.04
• dPR: 0.94±0.06
• FFR: 0.90±0.07

Only 7% of lesions had final FFR ≤0.80. At 18 months, TVF occurred in 17.4% of the angiography group and 18% of the physiology group (P=0.88). There were no significant differences in cardiac death, MI, or target vessel revascularization. Angina scores, medication use, and quality of life were also similar between the groups.

Conclusion
In an all-comers PCI population, routine post-PCI physiological assessment was not associated with improved clinical outcomes compared to standard angiographic guidance. Further research is warranted to identify whether specific lesions or patient subsets may benefit from this approach.

Commentary
This study demonstrates that post-PCI physiology guidance does not offer clear clinical benefit over angiography-guided PCI. Although additional optimization was performed in 17% of cases with initially suboptimal physiology, this did not translate into better outcomes. While some literature suggests that post-PCI FFR >0.90 is associated with improved prognosis, this trial does not support the widespread implementation of routine post-PCI physiology in all patients. Targeted application in selected cases and larger studies are needed to better define its role.