Abstract Introduction The distal coronary-to-aortic pressure ratio (P_d/P_a) is a non-hyperaemic physiological index to assess the functional severity of coronary stenoses. Studies comparing P_d/P_a with fractional flow reserve (FFR) show superior diagnostic efficiency for myocardial ischaemia. Nevertheless, a direct comparison regarding long-term clinical outcomes is still not available. The present observational study compared the prognostic value of P_d/P_a and FFR for major adverse cardiac events (MACE) during a 10-year follow-up period after deferral of revascularisation. Methods Between April 1997 and September 2006, we evaluated 154 coronary stenoses (154 patients) in which revascularisation was deferred with intracoronary pressure and flow measurements during the resting and hyperaemic state. Long-term follow-up (median: 11.8 years) was performed to document the occurrence of MACE, defined as a composite of cardiac death, myocardial infarction and target vessel revascularisation. Results The study population comprised angiographically intermediate coronary stenoses, with a mean diameter stenosis of 53 ± 8%, and intermediate physiological severity with a median FFR of 0.82 (Q1, Q3: 0.76, 0.88). The association of P_d/P_a with long-term MACE was similar to that of FFR [FFR-standardised hazard ratio (sHR): 0.77, 95% confidence interval (CI): 0.61–0.98; P_d/P_a-sHR: 0.80, 95% CI: 0.67–0.96]. In the presence of disagreement between P_d/P_a and FFR, normal P_d/P_a was generally associated with high coronary flow reserve (CFR) and a favourable clinical outcome, whereas abnormal P_d/P_a was generally associated with CFR around the ischaemic cut-point and an impaired clinical outcome, regardless of the accompanying FFR value. Conclusion The present study suggests that P_d/P_a provides at least equivalent prognostic value compared with FFR. When P_d/P_a disagreed with FFR, the baseline index conferred superior prognostic value in this study population.