We thank Dr. Barbosa and colleagues for their interest in our meta-analysis evaluating fractional flow reserve (FFR)-guided complete revascularization (CR) versus culprit-only percutaneous coronary intervention (PCI) for patients with myocardial infarction (MI) and multivessel coronary artery disease [1], [2]. In our study, we used a frequentist approach to analyze five randomized controlled trials comparing FFR-guided CR with culprit-only PCI in this patient population [3], [4], [5], [6], [7]. Our study demonstrated a 27% lower risk of composite adverse events (a composite of all-cause death, MI, stroke, and repeat revascularization) driven by a 39% reduction in repeat revascularization with FFR-guided CR compared with culprit-only PCI at a median follow-up of 3 years [1].

However, the frequentist framework may be limited when applied to a meta-analysis including a relatively small number of trials with significant heterogeneity [8]. In this setting, the point estimates and confidence intervals (CI) may not fully capture uncertainties surrounding the true treatment effect, particularly with respect to inter-study variability. [8] We appreciate the Bayesian framework used by Barbosa et al. to further interrogate this clinically important question [2]. Their findings demonstrated an odds ratio of 0.67 (95% credible interval [CrI] 0.47–0.94) and a high posterior probability (98%) of a reduction in composite adverse events with an FFR-guided CR approach [2]. Their findings align with ours and provide a valuable complementary perspective, highlighting the benefits of FFR-guided CR [1], [2].

Since the completion of our meta-analysis, the recently published South Limburg Myocardial Infarction (SLIM) trial has provided additional randomized evidence in this space [9]. The SLIM trial focused on patients with NSTEMI and multivessel disease and demonstrated that FFR-guided CR during the index PCI procedure was associated with a significant reduction in the primary composite outcome compared with culprit-only PCI (5.5% vs 13.6%; hazard ratio [HR] 0.38, 95% CI 0.20–0.72). This reduction was primarily driven by a reduction in repeat revascularization, with no significant differences observed in individual hard endpoints such as all-cause mortality, stroke, or MI [9]. These findings are concordant with our pooled analysis, in which the observed benefit of FFR-guided CR was similarly driven by reductions in repeat revascularization and cardiac death, without a significant impact on all-cause mortality or recurrent MI [1]. Taken together, both our study and the SLIM trial suggest that the principal advantage of physiology-guided CR likely lies in reducing residual ischemia and the need for subsequent revascularization rather than consistently preventing ischemic events in the short term [1], [9].