FFR-Guided PCI Costs 30% Less Than Surgery for 3-Vessel Disease

A FAME 3 analysis shows fractional flow reserve-guided stenting yields equivalent quality-adjusted survival and faster functional recovery.

For Doctors in a Hurry

Researchers investigated whether modern percutaneous coronary intervention remains more cost-effective than coronary artery bypass grafting for patients with multivessel disease.
The FAME 3 trial randomized 1,500 patients with three-vessel disease to receive either bypass surgery or fractional flow reserve-guided stenting.
Cumulative five-year costs were 30% higher for surgery (95% CI: 16%-46%; P < 0.001), while quality-adjusted life-years showed no significant difference.
The authors concluded that fractional flow reserve-guided intervention provides superior long-term economic value compared to bypass surgery for multivessel disease.
Clinicians may consider these findings when discussing treatment options, as stenting achieved equivalent clinical outcomes at substantially lower costs.

The Shifting Value Proposition in Multivessel Revascularization

Determining the optimal revascularization strategy for patients with multivessel coronary artery disease remains a central challenge in clinical cardiology. Historical meta-analyses involving 13,592 patients have frequently favored coronary artery bypass grafting, which demonstrated a 25 percent lower risk of myocardial infarction (Risk Ratio 0.75; 95 percent Confidence Interval, 0.58 to 0.96) compared to percutaneous coronary intervention [1, 2]. In diabetic cohorts, surgical approaches provide a significant survival advantage (Risk Ratio 1.51 for death with percutaneous intervention), though this benefit is balanced against a higher perioperative stroke risk (2.3 percent for stenting versus 3.8 percent for surgery) [3, 4]. While the use of second-generation everolimus-eluting stents has improved outcomes, percutaneous approaches still correlate with higher rates of major adverse cardiovascular events at long-term follow-up (Hazard Ratio 1.47; P=0.04) [5, 6]. A new analysis of the FAME 3 trial now examines whether fractional flow reserve-guided intervention (a physiological assessment using pressure wires to measure blood flow across a stenosis) can improve the long-term economic value of stenting, which previously demonstrated 30 percent lower cumulative costs while maintaining equivalent quality-adjusted life-years (a standard metric combining survival time with health-related quality of life) [7].

Trial Design and Economic Methodology

The FAME 3 randomized trial enrolled 1,500 patients with 3-vessel coronary artery disease to compare the long-term outcomes and economic viability of two primary revascularization strategies. Participants were assigned to either coronary artery bypass grafting (CABG) or fractional flow reserve-guided percutaneous coronary intervention (PCI). In the percutaneous intervention arm, clinicians utilized fractional flow reserve (a technique using pressure wires to measure the pressure drop across a stenosis, identifying lesions that cause significant ischemia) to guide the placement of zotarolimus drug-eluting stents. This physiological guidance ensures that only hemodynamically significant lesions are treated, reducing unnecessary stent placement compared to traditional angiography-guided approaches.

To establish a comprehensive economic and clinical profile, the researchers documented resource use and quality of life over a 5-year follow-up period. The study calculated costs by applying Medicare reimbursement rates to the specific resources used by each patient, providing a standardized financial baseline. Quality of life was assessed using the EuroQOL EQ-5D instrument, a standardized questionnaire that measures health status across five dimensions: mobility, self-care, usual activities, pain or discomfort, and anxiety or depression. From these EQ-5D utility values, the authors calculated quality-adjusted life-years (QALYs) to quantify the overall disease burden. Finally, the researchers employed multivariable regression (a statistical method that adjusts for multiple patient variables simultaneously) to compare outcomes by treatment assignment, ensuring the cost and effectiveness data were rigorously adjusted for potential confounding factors.

Equivalent Quality of Life with Lower Cumulative Costs

The economic analysis of the FAME 3 trial revealed that cumulative costs over 5 years were 30% higher in patients assigned to CABG compared to those who received fractional flow reserve-guided PCI (95% CI: 16% to 46%; P < 0.001). This substantial cost disparity persisted despite the initial procedural expenses associated with drug-eluting stents, indicating that the resource intensity of surgical intervention and subsequent recovery drives a higher long-term financial burden. When evaluating the clinical value of these expenditures through QALYs, the researchers found that the two strategies yielded nearly identical results.

Specifically, QALYs over 5 years were 4.05 ± 0.84 for the PCI group and 4.03 ± 0.82 for the CABG group. The difference in QALYs between groups did not reach statistical significance, demonstrating that neither approach provided a superior long-term health-related quality of life. However, the temporal pattern of recovery favored the less invasive approach, as EQ-5D scores improved more rapidly after PCI than after surgery. For the practicing cardiologist, this faster functional gain suggests that while both treatments eventually achieve similar stability in health status, patients undergoing stenting return to their baseline quality of life more quickly in the immediate post-procedural period.

Functional Recovery and Employment Outcomes

For clinicians managing younger patients with multivessel disease, the choice between revascularization strategies often hinges on the speed of functional recovery and the ability to maintain professional responsibilities. The FAME 3 trial provided specific insights into this demographic by analyzing employment status at the five-year mark for participants who were under 65 years of age at the time of enrollment. This subset of the population represents a group where the socioeconomic impact of treatment choice is particularly pronounced, as the faster initial recovery observed with PCI may translate into more stable long-term workforce participation.

The longitudinal data revealed a statistically significant difference in vocational outcomes between the two treatment arms. Among patients under 65 years of age at enrollment, 56% of those in the PCI group were employed at 5 years, compared to 47% in the CABG group (P = 0.025). This 9% absolute difference in employment rates suggests that the less invasive nature of fractional flow reserve-guided stenting offers a meaningful advantage for patients who prioritize a return to work. When counseling patients on the trade-offs between the established durability of surgical bypass and the more rapid functional gains of stenting, these findings provide clinicians with objective data regarding the long-term occupational stability associated with each approach.

Long-Term Value and Cost-Effectiveness Benchmarks

To determine the stability of these economic findings, the researchers calculated the incremental cost-effectiveness ratio (a metric used to compare the added financial cost of a treatment to the additional health benefits it provides) based on both the observed 5-year outcomes and projected life expectancies. The investigators assessed the variability of these results using 10,000 bootstrap replications, a statistical technique that involves repeatedly sampling the trial data to estimate the reliability of the conclusions. This rigorous sensitivity analysis demonstrated that PCI had greater economic value than CABG over 5 years, showing lower costs and higher QALYs in 66% of the bootstrap replications.

When evaluating the surgical arm against standard value benchmarks, the data indicated that CABG was not a cost-effective alternative to stenting in this population. The incremental cost-effectiveness ratios for CABG were above the $150,000 per QALY benchmark in 98% of the bootstrap replications, suggesting that the additional expense of surgery does not meet traditional thresholds for value in the United States healthcare system. These findings remained essentially unchanged in several lifetime projections based on the trial follow-up data, reinforcing the long-term financial and clinical implications of the treatment choice.

For clinicians managing complex 3-vessel coronary artery disease, these economic data provide a clear framework for shared decision-making. The study concludes that fractional flow reserve-guided PCI using zotarolimus drug-eluting stents provides equivalent clinical outcomes to CABG at a substantially lower cost. By integrating physiological assessment with modern drug-eluting stents, physicians can achieve comparable patient survival and quality of life while significantly reducing the financial burden on both the patient and the healthcare system.

Study Info

Economic Outcomes and Quality of Life After CABG or PCI for Multivessel Disease

Mark A. Hlatky, Victoria Y. Ding, Frederik M. Zimmermann, Zsolt Piróth, et al.

Journal Journal of the American College of Cardiology

Published October 01, 2025