The Year in Cardiology

Coronary Interventions: The Year in Cardiology 2019

Andreas Baumbach; Christos V. Bourantas; PatrickW. Serruys; William Wijns

Disclosures

Eur Heart J. 2020;41(3):394-405. 

In This Article

Chronic Coronary Syndromes

Revascularization vs. Medical Therapy

Despite the robust evidence supporting the prognostic implications of complete revascularization in patients admitted with a STEMI, studies examining the value of PCI in improving outcomes in patients with a chronic coronary syndrome show mixed results. A retrospective analysis including 16 029 patients who had positron emission computed tomography myocardial perfusion imaging demonstrated that an early surgical or percutaneous revascularization was associated with improved prognosis in patients with an ischaemic burden >5–10%.[3] These findings, however, were not confirmed in a post hoc analysis of the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial that included 1379 patients who had stress perfusion imaging and quantitative coronary angiography.[4] At 7.9 years of follow-up, the extent of CAD—defined by the number of the diseased vessels—and not the severity of ischaemia was a predictor of survival. Percutaneous coronary intervention in this cohort did not improve outcomes over optimal medical therapy; more importantly, there was no interaction between the extent of ischaemia or CAD and the treatment strategy (i.e. conservative vs. PCI).

In line with these findings, the International Study Of Comparative Health Effectiveness With Medical And Invasive Approaches (ISCHEMIA study) that included 5179 patients, with moderate or severe ischaemia in non-invasive imaging, who were randomized to optimal medical therapy or optimal medical therapy plus PCI demonstrated no differences in outcomes between groups at 3.3 years of follow-up for the composite endpoint of cardiovascular death, MI, admission for unstable angina, heart failure symptoms, or resuscitated cardiac arrest (15.5% vs. 13.8%, P = 0.34).[5] In this study, PCI was associated with an improvement in the quality of life, a reduction in the angina symptoms and a lower incidence of spontaneous MI [hazard ratio (HR) 0.67, 95% confidence interval (CI) 0.53–0.83; P < 0.01]. An important limitation of the ISCHEMIA study is the high (28%) crossover rate from the conservative to the invasive arm which may have affected the reported results; the as-treated analysis has not been reported yet.

The association between the presence of viable myocardium, surgical revascularization, and clinical outcomes was recently evaluated by a post hoc analysis of the Surgical Treatment for Ischaemic Heart Failure (STICH) study.[6] This analysis, that included 601 patients who had a left ventricular ejection fraction ≤35% and viability assessment, failed to demonstrate an impact of the presence or absence of myocardial viability on the survival benefit noted in patients undergoing surgical revascularization at 10.4-year follow-up. The REVascularisation for Ischaemic VEntricular Dysfunction (REVIVED) study (NCT01920048) is currently examining the safety and efficacy of PCI in improving prognosis in patients with heart failure.

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