IntroductionFractional flow reserve is an established method for assessing coronary artery stenosis severity. However, long-term outcome data in a real-world population is lacking.AimsWe aim to determine whether FFR use is superior to angiography alone in relation to cardiac death and all-cause death in a real-world population.MethodsPatients undergoing angiography between June-2017 and June-2018 recorded by the Centre-for-Health-Record-Linkage (CHeReL) were included. The CHeReL database captures health data from ≥97% of all healthcare facilities in the state of New South Wales, with a population of 7.5 million people. The cohort was stratified into angiography-FFR group when concomitant FFR was performed, and the angiography-only group which included all patients undergoing angiography without concomitant FFR. The primary and secondary outcomes were cardiac death and all-cause death respectively.ResultsThe study cohort comprised 34,597 patients, in which 32,863 (95%) patients underwent angiography alone and 1,734 (5%) patients had angiography combined with FFR. At 1-year follow-up, the angiography-FFR group had a lower occurrence of the endpoints of cardiac death (0.8% vs 2.3%, P<0.001) and all-cause death (1.7% vs 4.7%, P<0.001) compared to the angiography-only group. Multivariable Cox regression analysis showed FFR use to be associated with lower rates of both cardiac death (hazard ratio HR 0.55, 95% confidence interval CI 0.32-0.93, P=0.025) and all-cause death (HR 0.55, 95% CI 0.38-0.79, P=0.001) independent of age, sex, facility, country of birth, referral source, marital status, Charlson comorbidity index, valvular heart disease, pre-existing atrial fibrillation (AF), presenting illnesses including AF, congestive heart failure or acute coronary syndrome, planned percutaneous coronary intervention or coronary artery bypass graft surgery, and concomitant or subsequent cardiac valve surgery.ConclusionsFFR use was associated with a reduction in both cardiac death and all-cause death in this real-world study.