Stress cardiac magnetic resonance vs. fractional flow reserve-guided management for intermediate coronary stenosis: a single-center retrospective propensity-matched study with 12-month follow-up.

PURPOSE: Invasive fractional flow reserve (FFR) is currently regarded as a reference standard for the functional assessment of intermediate coronary lesions; however, stress perfusion cardiac magnetic resonance (CMR) offers a non-invasive alternative that potentially streamlines clinical decision-making. Evidence comparing the real-world clinical effectiveness and economic implications of these two modalities, particularly within resource-constrained healthcare environments, remains sparse. This study sought to evaluate whether a CMR-guided strategy could reduce revascularization rates and hospital costs while showing comparable short-term clinical outcomes to an FFR-guided strategy in a real-world matched cohort.

METHODS: We conducted a retrospective cohort study at a tertiary cardiovascular center in China, screening patients with angiographically intermediate coronary stenosis (40%-90% diameter stenosis) evaluated between January 2021 and December 2024. To rigorously control for selection bias inherent in observational data, we implemented a 1:1 propensity score matching (PSM) analysis based on extensive baseline covariates. The primary clinical endpoint was a composite of major adverse cardiovascular events (MACE) at 12 months, defined as cardiac death, non-fatal myocardial infarction, or ischemia-driven target vessel revascularization. Secondary endpoints included procedural efficiency, contrast volume consumption, and total hospitalization costs.

RESULTS: In the final propensity-matched cohort of 240 patients, the CMR-guided strategy was associated with a lower PCI utilization rate than the FFR-guided strategy (34.2% vs. 48.3%; odds ratio 0.55; 95% CI, 0.33 to 0.93; P = 0.036). The CMR group also had lower total hospitalization costs (mean difference, -¥9,785.3; 95% CI, -¥13,253.4 to -¥6,317.3; P < 0.001) and lower iodinated contrast volume. At 12 months, MACE occurred in 10.0% of patients in the FFR group and 10.8% in the CMR group, with no statistically significant between-group difference (HR 1.05; 95% CI, 0.48 to 2.30; log-rank P = 0.902). Exploratory subgroup analyses showed no significant interaction across prespecified subgroups.

CONCLUSION: In this matched retrospective cohort, CMR-guided management was associated with lower PCI utilization and lower hospitalization costs, while 12-month MACE rates were not significantly different from those observed with FFR-guided management. These findings suggest that CMR-guided evaluation may be a useful gatekeeper approach in selected patients, although confirmation in larger prospective studies is required.