A Placebo-Controlled Trial of Percutaneous Coronary Intervention for Stable Angina

Patient-centric no-option refractory angina management: establishing comprehensive angina relief (CARE) clinics

INTRODUCTION

Refractory angina (RA) is a debilitating condition characterized by persistent angina despite optimized medical therapy and limited options for further revascularization, leading to diminished quality of life and increased healthcare utilization. The RA patient population is rapidly expanding with significant unmet needs. Specialty clinics should be developed to focus on the long-term efficacy and safety of clinically available and novel treatment strategies, emphasizing quality of life.

AREAS COVERED

Patient-focused Comprehensive Angina Relief (CARE) clinics can enhance care and outcomes by providing individualized management for complex RA. This review summarizes peer-reviewed articles from PubMed and trial data from ClinicalTrials.gov. We discuss the epidemiology and pathophysiology of RA, introduce standardized tools for evaluating angina and psychosocial factors, and address symptom management. We also review treatment options such as risk factor modification, medication, and complex revascularization. Additionally, we explore emerging therapies, including coronary sinus occlusion, regenerative therapy, and neuromodulation for 'no-option' RA.

EXPERT OPINION

In the next five years, patients with refractory chest pain with or without coronary artery disease will increasingly be referred to specialty clinics for follow-up. Conducting more randomized control clinical trials with larger population subsets will bring novel therapies to the forefront.

Comparative outcomes of invasive versus conservative strategy in stable coronary artery disease patients: a risk-stratification-based hypothesis-generative study

BACKGROUND

Whether percutaneous coronary intervention (PCI) can improve the long-term prognosis of patients with stable coronary artery disease (SCAD) in comparison to conservative treatment remains controversial. The present study sought to evaluate the impacts of initial invasive versus conservative strategy on long-term clinical outcomes for patients with SCAD stratified by risk scores.

METHODS

This was a sub-analysis of the multicenter, observational Optimal antiPlatelet Therapy for Chinese patients with Coronary Artery Disease (OPT-CAD) study. Clinical outcomes were compared in SCAD patients who initially received PCI (invasive strategy) or conservative treatment according to risk stratification by OPT-CAD score. The primary outcome was ischemic events at 5 years, composed of cardiac death, myocardial infarction, and ischemic stroke. Secondary outcomes included all-cause death, Bleeding Academic Research Consortium (BARC) types 2, 3, or 5, and 3 or 5 bleeding.

RESULTS

The conservative group comprised 1767 (58.0%) patients and the invasive group comprised 1278 (42.0%) patients. Overall, invasive strategy did not reduce the risk of ischemic events compared with conservative strategy but was associated with an increased risk of BARC 2, 3, or 5 bleeding (adjusted hazard ratio (HR), 1.59; 95% confidence interval (CI), 1.13-2.26; P = 0.009). Similar results were observed in the low-risk patient subset (N = 2030). While in the moderate-to-high-risk subset (N = 1015), invasive strategy was associated with a reduced risk of ischemic events (HR, 0.67; 95% CI, 0.48-0.95; P = 0.02) and all-cause death (HR, 0.73; 95% CI, 0.51-1.03; P = 0.07), and with no excessive risk of bleeding.

CONCLUSIONS

Invasive strategy could not confer additional clinical benefits in patients with SCAD compared to conservative strategy, except in patients at moderate-to-high risk. The OPT-CAD risk score may be valuable to the guidance of optimal treatment strategy in SCAD patients.

Myocardial Perfusion Imaging With PET; A Head-to-Head Comparison of 82Rubidium Versus 15O-water Tracers Using Invasive Coronary Measurements as Reference

BACKGROUND

Myocardial perfusion imaging by positron emission tomography (PET) is recommended as a first-line test in stable patients with chest pain symptoms and as a selective second-line test after an abnormal coronary computed tomography angiography (CTA). It is, however, unknown whether the use of Rubidium-82 (82Rb) versus [15O]H2O (15O-water) affects the diagnostic performance in coronary artery disease (CAD). The aim of this study was to compare 82Rb-PET versus 15O-water-PET head-to-head for diagnosing obstructive CAD.

METHODS

The study included consecutive patients (n=1000) referred for CTA with symptoms suggestive of obstructive CAD. Patients with suspected stenosis based on CTA were referred for both 82Rb-PET, 15O-water-PET, and subsequently invasive coronary angiography (ICA), including 3-vessel fractional flow reserve and coronary flow reserve measurements.

RESULTS

In total, 196/270 (73%) patients with suspected stenosis on CTA completed 82Rb-PET, 15O-water-PET, and ICA. Myocardial blood flow measurements from 82Rb-PET and 15O-water-PET correlated strongly at rest (ρ, 0.62-0.69) but only moderately during hyperemia (ρ, 0.41-0.59). Only weak correlations were demonstrated between myocardial blood flow reserve by both PET tracers compared with ICA coronary flow reserve (ρ, 0.11-0.38). Hemodynamically obstructive CAD defined as ICA fractional flow reserve ≤0.80, was identified in 86/196 (44%) patients. Using predefined cutoffs, the diagnostic accuracies of 82Rb-PET versus 15O-water-PET were similar (sensitivity 69% [58-78%] versus 71% [60-80%], P=0.59; specificity 85% [76-91%] versus 77% [68-85%], P=0.12). Using ICA diameter stenoses >70% as a reference, only 48/196 (24%) patients had anatomically severe CAD, and 82Rb-PET and 15O-water-PET sensitivities increased to >85%.

CONCLUSIONS

For detection of obstructive CAD by PET myocardial perfusion imaging, 82Rb versus 15O-water have similar diagnostic performance.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT04707859.

Clinical implications of the MELD-XI score in patients undergoing percutaneous coronary intervention: Insights from the SAKURA PCI2 Antithrombotic registry

Background

The association between hepatorenal function, assessed by the Model for End-stage Liver Disease eXcluding International normalized ratio (MELD-XI) score, and clinical prognosis remains unclear in patients undergoing percutaneous coronary intervention (PCI). The aim of this study was to evaluate the clinical implications of the MELD-XI score.

Methods

Consecutive patients who underwent PCI from June 2020 to September 2022 in the SAKURA PCI2 Antithrombotic registry, a multi-center observational prospective cohort study, were reviewed. Patients with missing data for calculating the MELD-XI score were excluded. Study participating patients were stratified into two groups based on the MELD-XI score: high (>10) and low (≤10). The primary outcome was defined as two-year all-cause mortality. The secondary outcome was defined as major bleeding in accordance with the Bleeding Academic Research Consortium 3 or 5.

Results

Among 1064 patients, 265 (24.9 %) were stratified into a high MELD-XI score. Patients with a high MELD-XI had higher two-year all-cause mortality than those with a low MELD-XI score (19.6 % vs. 4.7 %, log-rank p < 0.01). This association was supported in the multivariable analysis (adjusted HR 3.26, 95 %CI 1.84-5.75, p < 0.01) and further supported by spline curve analysis. A high MELD-XI score was also associated with an increased risk of major bleeding (adjusted HR 2.94, 95 %Ci 1.55-5.56, p < 0.01).

Conclusions

A high MELD-XI score was associated with an increased risk of all-cause mortality and major bleeding within two years. Therefore, the MELD-XI score could provide valuable additional information for risk stratification in patients undergoing PCI.

Percutaneous Coronary Intervention for Heart Failure due to Coronary Artery Disease

The role of revascularization and percutaneous coronary intervention (PCI) in patients with acute coronary syndrome is well established. However, the incremental value of revascularization over guideline-directed medical therapy is controversial. Currently available data supports the use of PCI to improve angina and quality of life for chronic coronary disease and heart failure (HF). However, there is insufficient data to support revascularization with PCI to improve mortality, reduce cardiovascular events, or improve ejection fraction over medical therapy alone. Additional trials are necessary to identify HF patients who may benefit from revascularization, and the optimal revascularization strategy for this population.

Computational fluid dynamics model utilizing proper orthogonal decomposition to assess coronary physiology and wall shear stress

BACKGROUND

Percutaneous coronary intervention (PCI) to alleviate symptoms and improve outcomes in patients with symptomatic coronary artery disease. However, conventional assessments like coronary angiography may not fully capture the hemodynamic significance of coronary lesions. This study explores the utility of Proper Orthogonal Decomposition (POD) in elucidating coronary flow dynamics pre- and post-stent placement.

OBJECTIVES

Through the utilization of POD modes, we aim to analyze the intricate geometries of individual patients, extracting dominant POD modes both pre- and post-PCI. By engaging these modes, our objective is to discern changes in velocity patterns and wall shear stress, offering insight into the physiological outcomes of stent interventions in coronary arteries.

METHODS

The POD method with QR-decomposition was employed to generate POD modes, decomposing the vector field of interest into spatial functions modulated by time coefficients. Patients with prior coronary artery bypass surgery, myocardial bridging, collateral arteries, or recent myocardial infarction within 48 h were excluded from the study.

RESULTS

Results demonstrated improved hemodynamic parameters post-PCI, with significant enhancements in coronary flow reserve and reduced wall shear stress. POD analysis revealed that the first five modes effectively characterized flow features, highlighting stenosis, stent deployment, and branch dynamics.

CONCLUSION

This exploratory study demonstrates POD's potential for real-time assessment of coronary lesion significance and post-intervention outcomes. Its efficiency in capturing key flow characteristics offers a promising tool for personalized decision-making in interventional cardiology, enhancing our understanding of coronary hemodynamics and optimizing treatment strategies.

Temporal changes in PET myocardial flow reserve: implications for cardiovascular outcomes

BACKGROUND

The usefulness of serial measurements of myocardial flow reserve (MFR) has received limited study outside transplant vasculopathy.

OBJECTIVES

We describe the trends of myocardial blood flow and perfusion over time in patients undergoing positron emission tomography (PET) myocardial perfusion imaging (MPI) for evaluation of coronary artery disease, and their association with cardiovascular outcomes.

METHODS

We retrospectively analyzed data from 474 patients without history of heart transplant who underwent serial PET MPI (n=948 studies) for the evaluation of coronary artery disease at Yale New Haven Hospital between 2016-2022. Patients were categorized according to MFR trajectory (low to low, low to high, high to low, high to high). Long-term major adverse cardiovascular events (MACE) defined as death or myocardial infarction were analyzed with the Kaplan-Meier method and Cox regression. Log-likelihood, C-statistic and net reclassification were used to assess model performance.

RESULTS

Median interval time between tests was 776 days (IQR: 497-1058). Most common indications for the first and second PET were chest pain and dyspnea. MFR was similar in serial exams (2.1 [1.7, 2.6] vs 2.1 [1.7, 2.5], P=0.75), but rest (1 [0.8, 1.3] vs 0.9 [0.7, 1] P<0.01) and stress flows (2.1 [1.6, 2.8] vs 1.8 [1.4, 2.2], P<0.01) were both reduced on the second PET. MFR increased in patients with revascularization between tests (n=62 patients) (1.6 [1.3, 2.0] vs 1.7 [1.2, 2.2], P=0.04). During the median follow-up time of 17 [8,28] months, the rate of MACE was 12% (51 events) and was higher in the low-to-low and low-to-high categories in multivariable analysis. The model including serial MFR and perfusion performed better than the baseline model including traditional clinical risk factors in terms of likelihood ratio and c-statistic (from 0.74 to 0.80, P=0.04).

CONCLUSIONS

In conclusion, our findings suggest that serial assessment of MFR and perfusion may improve risk stratification beyond traditional clinical risk factors.

Angina in stable coronary artery disease: Data from ORBITA and ORBITA-2

It is now widely accepted that in the setting of stable angina, the primary remit of percutaneous coronary intervention (PCI) is for symptom relief. However, prior to the Objective Randomised Blinded Investigation with optimal medical Therapy of Angioplasty in stable angina (ORBITA) trial, there had been no placebo-controlled trial to assess the efficacy of this common procedure to improve angina. ORBITA randomised 200 patients with significant single-vessel coronary artery disease on maximal anti-anginal medications to either PCI or a placebo procedure. The results were striking and unexpected: after 6 weeks, there was no significant difference in the primary endpoint of treadmill exercise time between groups. Questions arose; how could PCI fail to outperform a placebo procedure, despite resolving significant epicardial stenosis and ischaemia? Clearly the relationship between symptoms, ischaemia and stenosis was more complex than previously understood. ORBITA-2 was designed to assess the effect of PCI compared to placebo in patients with single or multivessel disease, without the possible attenuation of anti-anginal medication, at 12 weeks. In this setting, PCI convincingly improved symptoms, with a significant increment over placebo as assessed by the angina symptom score, a patient-orientated primary endpoint. Taken together, these trials highlight a key insight: when offered first without anti-anginal medications, PCI offers meaningful symptom benefit. When offered after anti-anginal medications, as is recommended by international guidelines, it's added benefit is much smaller. This suggests the sequence of treatment matters, with the first therapy, whether PCI or medications, yielding the most demonstrable benefit, with subsequent interventions then offering little added value. As clinicians, the decision to advocate for PCI or anti-anginal medications first, will depend on many factors including individual patient characteristics and preferences. Importantly, in the absence of a head-to-head placebo-controlled trial of PCI alone versus medication alone, the question of which approach offers the greatest symptomatic benefit remains unresolved.

Management of angina pectoris

Angina pectoris, a primary manifestation of ischemic heart disease, imposes a significant clinical and economic burden globally. This review highlights recent advancements in the management of angina, emphasizing a patient-centred approach that integrates pharmacological, interventional, and lifestyle strategies to reduce cardiovascular risk and improve patient outcomes. For obstructive coronary artery disease, optimal medical therapy represents the cornerstone of treatment. Individualized regimens should be tailored to clinical factors such as blood pressure, heart rate, left ventricular function, comorbidities like heart failure and diabetes, concomitant medications, patient preferences, and drug availability. Myocardial revascularization is reserved for select cases to alleviate symptoms or improve prognosis. For angina or ischemia with non-obstructive coronary arteries (ANOCA/INOCA), precise endotype classification, differentiating microvascular angina, vasospastic angina, mixed type and non-coronary chest pain, enables personalized treatment strategies. Lifestyle interventions, including smoking cessation, weight management, adherence to Mediterranean diet, and exercise therapy, are essential components of care, promoting improved cardiovascular outcomes and quality of life. Structured exercise programs, particularly within cardiac rehabilitation settings, have demonstrated efficacy in enhancing functional capacity and reducing adverse events. Emerging therapies, including pharmacological agents and novel interventional approaches such as the coronary sinus reducer, hold promise for addressing unmet needs in refractory angina and challenging ANOCA/INOCA cases. Future directions should prioritize the integration of precision medicine, digital health technologies, and multidisciplinary care to optimize outcomes and advance personalized angina management.

Elderly patients treated with Onyx versus Orsiro drug-eluting coronary stents in a randomized clinical trial with long-term follow-up

BACKGROUND

Percutaneous coronary intervention (PCI) with new-generation drug-eluting stents is increasingly performed in elderly patients, who generally have more comorbidities and more technically challenging target lesions. Nevertheless, there is a paucity of reported data on the long-term safety and efficacy of PCI with contemporary stents in elderly all-comers.

METHODS

This prespecified secondary analysis of a large-scale randomized clinical trial (BIONYX; clinicaltrials.gov:NCT02508714) compared in elderly all-comers (≥ 75 years) the 5-year outcome after PCI with the novel, more radiopaque Onyx zotarolimus-eluting stent (ZES) versus the Orsiro sirolimus-eluting stent (SES). We assessed the main composite endpoint target vessel failure (TVF: cardiac death, target vessel myocardial infarction, or target vessel revascularization) and several secondary endpoints.

RESULTS

Of 2,488 trial participants, 475(19.1%) were elderly (79.5 ± 3.5 years), including 165(34.7%) women. There was a significant between-stent difference in the main endpoint TVF in favor of the Onyx ZES (14.4% vs. 24.2%, HR: 0.60, 95% CI 0.39-0.93, plog-rank = 0.02). The time-to-event curves displayed between-stent dissimilarities across all components of TVF, yet not statistically significant. Landmark analysis between 1- and 5-year follow-up showed in Onyx ZES-treated patients significantly lower rates of TVF (7.8% vs.8.9%, p = 0.002) and target vessel revascularization (3.0% vs.8.3%, p = 0.029). In addition, the 5-year rates of all-cause mortality and several composite endpoints were lower (p < 0.03) in Onyx ZES-treated patients.

CONCLUSIONS

In elderly all-comer patients, those treated with Onyx ZES showed a lower 5-year incidence of the main endpoint of safety and efficacy, as well as several secondary endpoints, than patients treated with Orsiro SES. Further research on this issue is warranted.

CLINICAL TRIAL REGISTRATION INFORMATION

https://clinicaltrials.gov/study/NCT02508714.

The History of Angina and Its Remedies: COURAGE, ORBITA, and a Path Forward

The recent publication of the second Objective Randomised Blinded Investigation with optimal medical Therapy of Angioplasty in stable angina trial has renewed debate surrounding the indications and benefits of percutaneous coronary intervention (PCI) in stable angina. The second Objective Randomised Blinded Investigation with optimal medical Therapy of Angioplasty in stable angina results show that PCI improves anginal symptoms in the absence of antianginal medications. Taken together with the first Objective Randomised Blinded Investigation with optimal medical Therapy of Angioplasty in stable angina and Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation trial results, proponents argue that in contrast to current guidance, PCI and aggressive medical therapy are both equally acceptable initial antianginal strategies and subject to patient preference. Drawing on the history of randomized studies of interventional management for stable angina, we detail our reservations with this interpretation. More broadly, we highlight the merits of elegantly designed sham-controlled trials in answering lingering clinical questions. Finally, we offer select frameworks for more conclusive trials designed to answer the looming question that cardiologists face: does the landscape of randomized evidence support a medication-first, PCI-first, or shared decision-making treatment paradigm in stable angina?

Microvascular resistance reserve: impact on health status and myocardial perfusion after revascularization in chronic coronary syndrome

BACKGROUND AND AIMS

The microvascular resistance reserve (MRR) is a novel invasive index of the microcirculation, which is independent of epicardial stenoses, and has both diagnostic and prognostic implications. This study investigates whether MRR is associated with health status outcomes by revascularization in patients with moderate coronary stenoses.

METHODS

Consecutive patients with stable chest pain and moderate (30%-90% diameter) stenoses on invasive coronary angiography (n = 222) underwent invasive physiology assessment. Revascularization was performed according to guideline recommendations. At baseline and follow-up, health status and myocardial perfusion were assessed by the Seattle Angina Questionnaire (SAQ) and positron emission tomography. The primary endpoint was freedom from angina at follow-up with secondary endpoints including changes in health status by SAQ domains and myocardial perfusion by MRR and revascularization status. Low MRR was defined as ≤3.0.

RESULTS

Freedom from angina occurred in 38/173 patients. In multivariate analyses, MRR was associated with freedom from angina at follow-up (odds ratio 0.860, 95% confidence interval 0.740-0.987). By MRR and revascularization groups, patients with normal MRR who did not undergo revascularization, and patients with abnormal MRR who underwent revascularization, had improved health status of angina frequency [mean difference SAQ angina frequency score 8.5 (3.07-13.11) and 13.5 (2.82-23.16), respectively]. For both groups, health status of physical limitation [mean difference in SAQ physical limitation score 9.7 (4.79-11.93) and 8.7 (0.53-13.88), respectively] and general health status [mean difference in SAQ summary score 9.3 (5.18-12.50) and 10.8 (2.51-17.28), respectively] also improved. Only patients with abnormal MRR who underwent revascularization had improved myocardial perfusion.

CONCLUSIONS

In patients with moderate coronary stenoses, MRR seems to predict the symptomatic and perfusion benefit of revascularization.

CLINICAL TRIAL IDENTIFIERS

NCT03481712 and NCT04707859.

Quality of Life Outcomes With a Risk-Based Precision Testing Strategy Versus Usual Testing in Stable Patients With Suspected Coronary Disease: Results From the PRECISE Randomized Trial

BACKGROUND

The PRECISE (Prospective Randomized Trial of the Optimal Evaluation of Cardiac Symptoms and Revascularization) trial compared an investigational precision diagnostic testing strategy (n=1057) with usual testing (n=1046) in patients with stable chest pain and suspected coronary artery disease. Quality of life (QOL) outcomes were a prespecified secondary end point.

METHODS

We assessed QOL by structured interviews in all trial participants at baseline and 45 days, 6 months, and 12 months postrandomization. QOL assessments included angina-related QOL (19-item Seattle Angina Questionnaire [SAQ-19]), generic health status (EQ-5D), and a 4-item care satisfaction survey (at 45 days only). The prespecified primary comparison was the 6-month SAQ Summary score outcomes (scale, 0 to 100; higher scores indicate greater health status). QOL data collection rates were high, with 99% complete baseline SAQ scores and 86.5% complete at the 6-month primary comparison follow-up. All comparisons were made as randomized.

RESULTS

At baseline, mean SAQ Summary scores were 70.9 in the Precision Strategy group (n=1050) and 70.4 in the Usual Testing group (n=1042). By 6 months, mean SAQ Summary scores had improved to 89.9 in the Precision Strategy group and 89.2 in the Usual Testing group, with a mean adjusted difference of 0.8 (95% CI, -0.3 to 2.0). The SAQ component scores showed similar improvement from baseline in both groups and no statistically significant or clinically meaningful differences between the 2 groups at any follow-up time point. By 6 months, 66% of patients in both groups were chest pain-free. EQ-5D visual analog scores also improved from baseline and showed no difference between groups during follow-up. Care satisfaction scores were high and similar at 45 days.

CONCLUSIONS

In stable patients with symptoms suggesting coronary artery disease, angina-related and overall QOL improved substantially over the initial 6 months independent of the testing strategy assigned.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03702244.

Economic Outcomes With Precision Diagnostic Testing Versus Usual Testing in Stable Chest Pain: Results From the PRECISE Randomized Trial

BACKGROUND

The PRECISE (Prospective Randomized Trial of the Optimal Evaluation of Cardiac Symptoms and Revascularization) demonstrated that a precision diagnostic strategy reduced the primary composite of death, nonfatal myocardial infarction, or catheterization without obstructive coronary artery disease by 65% in patients with nonacute chest pain compared with usual testing. Medical cost was a prespecified secondary end point.

METHODS

PRECISE randomized 2103 patients between December 2018 and May 2021 to usual testing or a precision strategy that used deferred testing for the lowest risk patients (20%) and coronary computed tomographic angiography with selective computed tomography-derived fractional flow reserve for the remainder. Resource use consumption data were collected from all study participants and hospital cost data from US participants (n=1125) to estimate total medical costs. The primary and secondary economic outcomes were total costs at 12 months and at 45 days, respectively, from the US health care system perspective. The mean cost differences between the 2 strategies were reported by intention-to-treat.

RESULTS

At 45 days, total costs were similar between the precision strategy and usual testing (mean difference, $182 [95% CI, -$555 to $661]). By 12 months, percutaneous coronary intervention and coronary artery bypass surgery had been performed in 7.2% and 2.0% of precision strategy patients and 3.5% and 1.7% of usual testing patients, respectively. At 1 year, precision strategy costs were $5299 versus $4821 for usual testing (mean difference, $478 [95% CI, -$889 to $1437]; P=0.43). Precision care decreased mean per-patient diagnostic cost by 27% and increased mean per-patient revascularization costs by 67%.

CONCLUSIONS

In the PRECISE trial, the precision strategy, a risk-based approach endorsed by current clinical practice guidelines, improved the clinical efficiency of testing and had similar costs to usual testing at 45 days and a nonsignificant $478 cost difference at 1 year.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03702244.

Application of Drug-Coated Balloons in Complex High Risk and Indicated Percutaneous Coronary Interventions

There is a growing trend of patients with significant comorbidities among those referred for percutaneous coronary intervention (PCI). Consequently, the number of patients undergoing complex high risk indicated PCI (CHIP) is rising. CHIP patients frequently present with factors predisposing to extensive drug-eluting stent (DES) implantation, such as bifurcation and/or heavily calcified coronary lesions, which exposes them to the risks associated with an increased stent burden. The drug-coated balloon (DCB) may overcome some of the limitations of DES, either through a hybrid strategy (DCB and DES combined) or as a leave-nothing-behind strategy (DCB-only). As such, there is a growing interest in extending the application of DCB to the CHIP population. The present review provides an outline of the available evidence on DCB use in CHIP patients, which comprise the elderly, comorbid, and patients with complex coronary anatomy. Although the majority of available data are observational, most studies support a lower threshold for the use of DCBs, particularly when multiple CHIP factors coexist within a single patient. In patients with comorbidities which predispose to bleeding events (such as increasing age, diabetes mellitus, and hemodialysis) DCBs may encourage shorter dual antiplatelet therapy duration-although randomized trials are currently lacking. Further, DCBs may simplify PCI in bifurcation lesions and chronic total coronary occlusions by reducing total stent length, and allow for late lumen enlargement when used in a hybrid fashion. In conclusion, DCBs pose a viable therapeutic option in CHIP patients, either as a complement to DES or as stand-alone therapy in selected cases.

Identification and characteristics of distressed patients with coronary heart disease and insufficiently controlled medical risk factors: baseline findings and sex differences from the multicenter TEACH trial

Introduction

Medical risk factors and psychological distress are important targets for secondary prevention of coronary heart disease (CHD). The multicenter randomized controlled TEACH study is the first trial testing a blended collaborative care (BCC) intervention vs. usual care in a cohort of only patients with CHD. The current manuscript analyzes the availability of distressed CHD patients for a BCC intervention trial and the baseline risk profile of the randomized cohort, especially focusing on sex differences.

Methods

Hospitalized CHD patients with positive HADS and/or PSS-4 screening were rescreened three months later and those still distressed were offered participation in the RCT if they had insufficiently controlled medical risk factors (smoking, physical inactivity, elevated blood pressure, LDL cholesterol, and/or HbA1c). The current manuscript describes the TEACH screening process and presents baseline data of the randomized cohort.

Results

Of 2,785 screened patients, 457 patients with persistent distress and insufficiently controlled risk factors were randomized. Older age and lower distress but not sex independently predicted dropout before randomization. In the randomized cohort (mean age 62.9 ± 9.5 years, 77.4% men), women were older than men (p=0.025), more likely to be retired (52.4% vs. 38.6%; p=0.012) and to live without a partner (48.6% vs. 24.8%, p<0.001). Compared to men, they had lower diastolic blood pressure (p=0.003) but higher rates of physical inactivity (56.0% vs. 41.8%; p=0.012) and positive family history of premature atherosclerotic disease (45.7% vs. 29.8%; p=0.009). They also had a lower rate of previous coronary bypass surgery (21.0% vs. 39.2%, p<0.001). A mental disorder had been diagnosed in 54% of all randomized patients and 42% had previously received mental health treatment, both reported substantially more frequently by women than men (both p<0.001). Satisfaction with care before the trial did not differ by sex but was far lower for psychosocial care than for treatment of heart disease (p<0.001).

Discussion

TEACH enrolled a patient sample with persisting distress and a typical risk factor profile. Women differed from men in relevant aspects of their RF profiles and mental health and should receive special attention in future analyses and treatment planning for patients with CHD.

Clinical Trial Registration

German Clinical Trials Register, https://drks.de/search/de/trial/DRKS00020824, identifier DRKS00020824.

Acupuncture combined with multiple therapies for angina pectoris: a systematic review and network meta-analysis

Objective

Acupuncture combined with multiple treatment modalities has been widely employed for treating angina pectoris. This paper compared the efficacy of acupuncture combined with multiple treatment modalities for angina pectoris by network meta-analysis (NMA).

Methods

As of November 2023, this study searched eight electronic databases for randomized controlled trials (RCTs) of acupuncture combined with multiple modalities for the treatment of angina pectoris based on antianginal therapies. Primary efficacy indicators included the number of angina episodes and duration of episodes, and secondary indicators included clinical efficacy based on symptom improvement and electrocardiographic efficacy based on ST-segment and T-wave improvement. The Cochrane Risk of Bias tool 2.0 (RoB 2.0) was used for risk of bias assessment. A random-effects Bayesian NMA was performed using R (version 4.3.1) and Stata (version 16.0).

Results

46 RCTs were enrolled, with 3976 patients with angina pectoris. In reducing the number of angina episodes, acupuncture [MD: -3.79; 95% CrI (-6.34, -1.31)] and acupuncture + TCM [MD: -3.06; 95% CrI (-5.49, -0.62)] were superior to antianginal therapies, with acupuncture having the best efficacy (SUCRA: 78.2%). In shortening the duration of angina episodes, electroacupuncture (EA) + traditional Chinese medicine (TCM) was the most effective (SUCRA: 95.1%), superior to antianginal therapies [MD: -5.04; 95% CrI (-9.18, -0.89)], adjunctive therapy [MD: 7; 95% CrI (1.58, 12.39)], rehabilitation therapy [MD: -5.38; 95% CrI (-10.75, -0.05)], and warm acupuncture + adjunctive therapy [MD: -6.71; 95% CrI (-13, -0.48)]. In terms of clinical efficacy, thumbtack needling had the best efficacy (SUCRA: 82.1%), superior to TCM [RR: 1.3; 95% CrI (1.02, 1.69)] and antianginal therapies [RR: 0.75; 95% CrI (0.6,0.91)]. In electrocardiographic efficacy, EA showed the best efficacy (SUCRA: 92.9%), superior to antianginal therapies [RR: 0.52; 95% CrI (0.35, 0.71)] and acupuncture [RR: 0.62; 95% CrI (0.39, 0.91)].

Conclusion

Acupuncture performs best in reducing anginal episodes; EA + TCM is the most effective in shortening the duration of anginal episodes; thumbtack needling is the most effective in clinical efficacy; and EA shows optimal results in electrocardiographic efficacy. To further validate these findings, multicenter and large-sample RCTs are needed.

Systematic Review Registration

PROSPERO [CRD42024505456].

Randomized comparison of the combined Sirolimus eluting and endothelial progenitor cell combo Stent vs. biolimus eluting absorbable polymer coated biomatrix alpha stent in patients undergoing percutaneous coronary intervention: Rationale and study design of the Scandinavian Organization for randomized trials with clinical outcome (SORT OUT) XI trial

RATIONALE

The biodegradable polymer Biomatrix Alpha stent contains biolimus A9 drug which is a sirolimus derivative increased in lipophicity. The biodegradable polymer sirolimus eluting Combo stent is a dual-therapy sirolimus-eluting and CD34+ antibody coated stent capturing endothelial progenitor cells (EPCs).

HYPOTHESIS

The main hypothesis of the SORT OUT XI trial was that the biodegradable polymer biolimus A9 Biomatrix Alpha stent is noninferior to the biodegradable polymer sirolimus eluting Combo stent in an all-comers population with coronary artery disease undergoing percutaneous coronary intervention (PCI).

METHODS

The SORT OUT XI study was a randomized, multicenter, single blinded, all-comer, 2-arm, noninferiority trial comparing the biodegradable polymer biolimus A9 Biomatrix Alpha stent to the biodegradable polymer sirolimus eluting Combo stent in 3 Danish University Hospitals in Western Denmark. The composite primary endpoint was target lesion failure (TLF) within 12 months. TLF was defined as composite of cardiac death, myocardial infarction not related to other than index lesion or target lesion revascularization. Clinically driven event detection was used and no planned follow up was performed. With a sample size of 1,564 patients in each treatment arm, a 2-group large-sample normal approximation test of proportions with a 1-sided 5% significance level had a 90% power to detect noninferiority with a predetermined noninferiority margin of 2.1%.

RESULTS

The trial ran from August 14, 2019 to March 19, 2023. A total of 3141 patients were enrolled and randomized 1:1 to Combo stent (n = 1,573) and Biomatrix Alpha stent (n = 1,568).

CONCLUSION

The SORT OUT XI trial will assess if the biolimus A9 eluting Biomatrix Alpha stent is noninferior to the dual-therapy Combo stent with respect to target lesion failure.

CLINICALTRIALS

GOV: NCT03952273.

Subendocardial ischemia: does CMD really exist?

Patients with angina but without obstructive epicardial coronary disease still require a specific mechanistic diagnosis to enable targeted treatment. The overarching term "coronary microvascular dysfunction" (CMD) has been applied broadly - but is it correct? We present a series of case examples culminating a systematic exploration of our large clinical database to distinguish among four categories of coronary pathophysiology. First, by far the largest group of "no stenosis angina" patients exhibits subendocardial ischemia during intact flow through diffuse epicardial disease during dipyridamole vasodilator stress. Second, rare patients indeed have ischemic signs or symptoms due solely to reduced flow attributable to microvascular dysfunction but without subendocardial hypoperfusion. Third, a previously unrecognized group of patients displays significant ST-segment changes and rare angina but normal high dipyridamole induced coronary flow and intact normal subendocardial uptake, perhaps due to a stretch mechanism from hyperemia. Fourth, ischemia due to reduced flow plus a subendocardial defect can arise as a secondary effect of a variety of global cardiac pathology, for example severe diffuse atherosclerosis, severe aortic stenosis, or a primary cardiomyopathy. Because subendocardial ischemia dominates the pathophysiologic epidemiology of these patient categories, understanding its mechanisms and therefore potential treatment targets will bring the largest clinical benefits to the largest number of patients. However, its diagnosis requires meticulous attention to exclude caffeine that can lead to a "false positive" diagnosis of CMD, absolute flow quantification to avoid confusing high resting flow with normal stress flow from reduced flow capacity, and quantification of subendocardial blood flow.

Fractional Flow Reserve and Instantaneous Wave-Free Ratio as Predictors of the Placebo-Controlled Response to Percutaneous Coronary Intervention in Stable Coronary Artery Disease

BACKGROUND

ORBITA-2 (the Placebo-Controlled Trial of Percutaneous Coronary Intervention for the Relief of Stable Angina) provided evidence for the role of percutaneous coronary intervention (PCI) for angina relief in stable coronary artery disease. Fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) are often used to guide PCI; however, their ability to predict placebo-controlled angina improvement is unknown.

METHODS

Participants with angina, ischemia, and stable coronary artery disease were enrolled, and anti-anginal medications were stopped. Participants reported angina episodes daily for 2 weeks using the ORBITA smartphone symptom application (ORBITA-app). At the research angiogram, FFR and iFR were measured. After sedation and auditory isolation, participants were randomized to PCI or placebo before entering a 12-week blinded follow-up phase with daily angina reporting. The ability of FFR and iFR, analyzed as continuous variables, to predict the placebo-controlled effect of PCI was tested using Bayesian proportional odds modeling.

RESULTS

Invasive physiology data were available for 279 patients (140 PCI and 139 placebo). The median (interquartile range) age was 65 years (59.0-70.5), and 223 (79.9%) were male. Median FFR was 0.60 (0.46-0.73), and median iFR was 0.76 (0.50-0.86). The lower the FFR or iFR, the greater the placebo-controlled improvement with PCI across all end points. There was strong evidence that a patient with an FFR at the lower quartile would have a greater placebo-controlled improvement in angina symptom score with PCI than a patient at the upper quartile (FFR, 0.46 versus 0.73: odds ratio, 2.01; 95% credible interval, 1.79-2.26; probability of interaction, >99.9%). Similarly, there was strong evidence that a patient with an iFR at the lower quartile would have greater placebo-controlled improvement in angina symptom score with PCI than a patient with an iFR at the upper quartile (iFR, 0.50 versus 0.86: odds ratio, 2.13; 95% credible interval, 1.87-2.45; probability of interaction, >99.9%). The relationship between benefit and physiology was seen in both Rose angina and Rose nonangina.

CONCLUSIONS

Physiological stenosis severity, as measured by FFR and iFR, predicts placebo-controlled angina relief from PCI. Invasive coronary physiology can be used to target PCI to those patients who are most likely to experience benefit.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03742050.

Renal denervation for hypertension

Innovative therapies for hypertension are desperately needed given the rising prevalence and falling rates of control of hypertension despite an abundance of available medical therapies. Procedural interventions lower blood pressure without depending on adherence to medications, and endovascular renal denervation (RDN) is the interventional procedure with the best evidence base for the treatment of hypertension. After nearly two decades of study, with major refinements to devices, technique and trial design, two different systems for RDN received approval from the FDA in late 2023 for the treatment of hypertension. These decisions were based on a portfolio of sham-controlled clinical trials demonstrating efficacy and safety of both radiofrequency and ultrasound RDN in treating patients across the spectrum of hypertension, including patients with mild disease taking no or one medication as well as those with moderate and truly resistant hypertension. In this Review, we begin by summarizing the background and scope of the global problem of hypertension control and explore the evolution and mechanism of RDN. We then detail early studies and randomized clinical trials demonstrating the efficacy and safety of RDN procedures, review international statements, and provide practical guidance on patient selection and implementation of RDN, including the crucial aspects of building a hypertension team and of involving patients in shared decision-making.

Medical Therapy Alone, Percutaneous Coronary Intervention, or Coronary Artery Bypass Grafting for Treatment of Coronary Artery Disease

In this review, we describe how the management of coronary artery disease (CAD) has become increasingly complex due to the rapid evolution of pharmacotherapy and procedural techniques. The expanding array of treatment options has driven researchers to investigate the optimal combination of therapies; while the findings offer invaluable insights, the sheer volume and occasional contradictions can foster confusion. Given the diverse spectrum of CAD and its manifestations, a tailored treatment decision is critical for each patient. We hope to demonstrate that by integrating the key messages from clinical trials and prioritizing patient comprehension and preference, healthcare providers can guide their patients toward appropriate treatment options, ultimately leading to enhanced care.

Reduction of Coronary Flow Velocity Reserve as the Main Driver of Prognostically Beneficial Coronary Revascularization

BACKGROUND

Regional wall motion abnormality (RWMA) can be absent during stress echocardiography (SE) in patients with chronic coronary syndromes (CCS) and angiographically significant coronary artery disease (CAD) despite a reduction of coronary flow velocity reserve (CFVR).

OBJECTIVES

To assess the value of a physiology-driven approach, based on CFVR, to coronary revascularization in patients with physiologically and anatomically significant disease of the left anterior descending (LAD) coronary artery.

METHODS

In a 3-center, observational study with retrospective analysis of prospectively acquired data, 749 patients with CCS, CFVR of the LAD ≤2.0, and ≥50% diameter stenosis of the LAD were enrolled. All patients were evaluated with dipyridamole (0.84 mg/kg in 6') SE. Patients were followed for 6.4 ± 4.5 years for the outcome of all-cause death.

RESULTS

Inducible RWMA was present in 295 patients (39%). Coronary flow velocity reserve was lower in patients with inducible RWMA compared to those without (1.51 ± 0.28 vs 1.65 ± 0.25; P < .001). Coronary revascularization was performed in 514 (69%) patients (388 with percutaneous coronary intervention, 126 with coronary artery bypass surgery). Of them, 226 exhibited inducible RWMA and 288 exhibited isolated reduction of CFVR. During the follow-up, 185 (25%) deaths occurred. The 10-year survival in the entire study population was 70%. The survival at 10 years was markedly lower in conservatively treated patients compared to invasively treated patients (53 vs 76%; P < .0001), with no significant difference between those with solitary reduction of CFVR and reduction of CFVR accompanied by concurrent inducible RWMA. Propensity score-weighted all-cause mortality risk was significantly higher for conservative than for invasive strategy (propensity score adjusted hazard ratio = 2.12; 95% CI, 1.51-2.96; P < .0001).

CONCLUSIONS

In patients with CCS and physiologically and anatomically significant LAD disease, coronary revascularization driven by a reduction in CFVR is accompanied by a prognostic benefit independently of the presence of inducible RWMA.

Bayesian Analytical Methods in Cardiovascular Clinical Trials: Why, When, and How

The Bayesian analytical framework is clinically intuitive, characterised by the incorporation of previous evidence into the analysis and allowing an estimation of treatment effects and their associated uncertainties. The application of Bayesian statistical inference is not new to the cardiovascular field, as illustrated by various recent randomised trials that have applied a primary Bayesian analysis. Given the guideline-shaping character of trials, a thorough understanding of the concepts and technical details of Bayesian statistical methodology is of utmost importance to the modern practicing cardiovascular physician. This review presents a step-by-step guide to interpreting and performing a Bayesian (re)analysis of cardiovascular clinical trials, while highlighting the main advantages of Bayesian inference for the clinical reader. After an introduction of the concepts of frequentist and Bayesian statistical inference and reasons to apply Bayesian methods, key steps in performing a Bayesian analysis are presented, including verification of the clinical appropriateness of the research question, quality and completeness of the trial design, and adequate elicitation of the prior (ie, one's belief toward a certain treatment before the current evidence becomes available); identification of the likelihood; and their combination into a posterior distribution. Examination of this posterior distribution offers not only the possibility of determining the probability of treatment superiority, but also the probability of exceeding any chosen minimal clinically important difference. Multiple priors should be transparently prespecified, limiting post hoc manipulations. Using this guide, 3 cardiovascular randomised controlled trials are reanalysed, demonstrating the clarity and versatility of Bayesian inference.

Aortic Stenosis and Coronary Artery Disease: Decision-Making Between Surgical and Transcatheter Management

Aortic stenosis (AS) and coronary artery disease (CAD) frequently coexist and share pathophysiological mechanisms. The proportion of patients with AS and CAD requiring revascularization varies widely because of uncertainty about best clinical practices. Although combined surgical aortic valve replacement and coronary artery bypass grafting has been the standard of care, management options in patients with AS and CAD requiring revascularization have expanded with the advent of transcatheter aortic valve replacement (TAVR). Potential alternative treatment pathways include revascularization before TAVR, concomitant TAVR and percutaneous coronary intervention, percutaneous coronary intervention after TAVR and deferred percutaneous coronary intervention or hybrid procedures. Selection depends on underlying disease severity, antithrombotic treatment strategies, clinical presentation, and symptom evolution after TAVR. In patients undergoing surgical aortic valve replacement, the addition of coronary artery bypass grafting has been associated with improved long-term mortality, especially if CAD is complex. although it is associated with higher periprocedural risk. The therapeutic impact of percutaneous coronary intervention in patients with TAVR is less well-established. The multitude of clinical permutations and remaining uncertainties do not support a uniform treatment strategy for patients with AS and CAD. Therefore, to provide the best possible care for each individual patient, heart teams need to be familiar with the available data on AS and CAD. Herein, we provide an in-depth review of the evidence supporting the decision-making process between transcatheter and surgical approaches and the key elements of treatment selection in patients with AS and CAD.

Left ventricular systolic function after percutaneous coronary intervention: patterns of change and prognosis according to clinical presentation of coronary artery disease

BACKGROUND

Whether there are differences in the left ventricular ejection fraction change (ΔLVEF) after percutaneous coronary intervention (PCI) and its association with long-term prognosis according to coronary artery disease (CAD) presentations is unknown. We assessed ΔLVEF after PCI and its association with 5-year mortality in various CAD presentations.

METHODS

This study included 8181 patients with paired (before and 6-8 months after PCI) angiographic LVEF measurements: 4582 patients with chronic coronary disease (CCD), 1972 patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS) and 1627 patients with ST-segment elevation myocardial infarction (STEMI). ΔLVEF (LVEF at 6-8 months minus baseline LVEF) was classified as follows: decline (ΔLVEF < 0), moderate improvement (ΔLVEF > 0 to < 10%) and large improvement (ΔLVEF ≥ 10%). The primary endpoint was 5 year mortality.

RESULTS

In patients with CCD, NSTE-ACS and STEMI, ΔLVEF (median [25th-75th percentiles]) was 0.0% [- 3.0%; 4.0%], 1.0% [- 2.0%; 5.0%] and 3.0% [- 2.0%; 10.0%], respectively (P < 0.001). In patients with a decline, moderate improvement and large improvement of LVEF, 5-year mortality was 10.0%, 10.4% and 12.3% in patients with CCD, 10.8%, 10.7% and 18.1% in patients with NSTE-ACS and 10.6%, 8.2% and 5.2% in patients with STEMI. After adjustment, ΔLVEF was associated with 5-year mortality in patients with CCD (adjusted hazard ratio [HR] = 0.90, 95% confidence interval [0.83-0.97]) and STEMI (adjusted HR = 0.85 [0.75-0.95]) but not in patients with NSTE-ACS (adjusted HR = 0.97 [0.85-1.10]), with all 3 risk estimates calculated for 5% increment in the ΔLVEF.

CONCLUSIONS

The type of CAD presentation appears to impact both LVEF change after PCI and its association with 5-year mortality.

Post-PCI coronary physiology: clinical outcomes and can we optimize?

Invasive coronary physiology is well-established for identifying stable lesions appropriate for revascularization with percutaneous coronary intervention (PCI). Furthermore, fractional flow reserve (FFR)-guided PCI is associated with better clinical outcomes compared with routine angiography-guided PCI. The rise of intravascular imaging-guided PCI has generated great interest in optimizing the technical results of a PCI procedure, and this has now extended to an interest in optimizing coronary physiology following PCI. In this review, we examine the relationship between post-PCI physiology and clinical outcomes, including relief from angina, a relationship which is independent of the initial FFR value. In addition, we highlight the utility of pullback coronary pressure assessment for identifying mechanisms of suboptimal final FFR, such as patient characteristics (diffuse atherosclerosis), PCI technique, and certain artifacts in pressure-wire measurements. It is our view that the final FFR value can only be modestly improved, or optimized, with respect to clinical outcomes. The most significant clinical impact is obtained from the change in FFR (ΔFFR) from before to after PCI, which can be anticipated ahead of time by operators and used to guide lesion selection, or exclusion, for PCI.

Percutaneous coronary revascularization versus medical therapy in chronic coronary syndromes: An updated meta-analysis of randomized controlled trials

INTRODUCTION

Coronary artery disease (CAD) is a main cause of morbidity and mortality. The effectiveness of coronary revascularization in chronic coronary syndromes (CCS) is still debated. Our recent study showed the superiority of coronary revascularization over optimal medical therapy (OMT) in reducing cardiovascular (CV) mortality and myocardial infarction (MI). The recent publication of the ORBITA-2 trial suggested superiority of percutaneous coronary revascularization (PCI) in reducing angina and improving quality of life. Therefore, we aimed to provide an updated meta-analysis evaluating the impact of PCI on both clinical outcomes and angina in CCS.

METHODS

Relevant studies were screened in PubMed/Medline until 08/01/2024. Randomized controlled trials (RCTs) comparing PCI to OMT in CCS were selected. The primary outcome was CV death. Secondary outcomes were MI, all-cause mortality, stroke, major bleeding and angina severity.

RESULTS

Nineteen RCTs involving 8616 patients were included. Median follow-up duration was 3.3 years. Revascularization significantly reduced CV death (4.2% vs. 5.5%; OR = .77; 95% CI .62-.96, p = .02). Subgroup analyses favoured revascularization in patients without chronic total occlusions (CTOs) (p = .052) and those aged <65 years (p = .02). Finally, a follow-up duration beyond 3 years showed increased benefit of coronary revascularization (p = .04). Secondary outcomes analyses showed no significant differences, except for a lower angina severity in the revascularization group according to the Seattle Angina Questionnaire (SAQ) (p = .04) and to the Canadian Cardiovascular Society (CCS) classification (p = .005).

CONCLUSIONS

PCI compared to OMT significantly reduces CV mortality and angina severity, improving quality of life in CCS patients. This benefit was larger without CTOs, in patients aged <65 years and with follow-up duration beyond 3 years.

Predictors of symptom improvement in patients with chronic coronary syndrome after percutaneous coronary intervention

BACKGROUND

Decreases in symptom load and improvements in quality of life are important goals in the invasive treatment of symptomatic chronic coronary syndrome (CCS). To date, it is not known which patients profit most from the invasive treatment.

METHODS

This sub-analysis of the prospective, multi-centre PLA-pCi-EBO trial includes 145 patients with symptomatic CCS and successful PCI. The prespecified endpoints angina pectoris and quality of life (Seattle Angina Questionnaire-SAQ) were assessed 1 and 6 months after PCI. Predictors of symptom improvement were analyzed by logistic regression analysis.

RESULTS

Quality of life, physical limitation, and angina frequency markedly improved 6 months after PCI. Worse baseline health status (i.e., low SAQ subscales) was the best predictor of highly clinically relevant improvements (≥ 20 points in SAQ subscales) in symptom load and quality of life. Demographic factors (age, sex, body-mass index) and cardiovascular disease severity (number of involved vessels, ejection fraction) did not predict relevant improvements after PCI. The influence of psychologic traits has not previously been assessed. We found that neither optimism nor pessimism had a relevant effect on symptomatic outcome. However, patients who exercised more after PCI had a much larger improvement in quality of life despite no differences in physical limitation or angina frequency.

CONCLUSION

PCI effectively reduces symptom load and improves quality of life in patients with symptomatic CCS. Reduced baseline health status (symptom load, quality of life) are the only relevant predictors for improvements after PCI. Physical activity after PCI is associated with greater benefits for quality of life.

TRIAL REGISTRY

The German Clinical Trials Register registration number is DRKS0001752.

CTCA Prior to Invasive Coronary Angiography in Patients With Previous Bypass Surgery: Patient-Related Outcomes, Imaging Resource Utilization, and Cardiac Events at 3 Years From the BYPASS-CTCA Trial

BACKGROUND

In patients with previous coronary artery bypass grafting, computed tomography cardiac angiography (CTCA) before invasive coronary angiography (ICA) was demonstrated in the BYPASS-CTCA trial (Randomized Controlled Trial to Assess Whether Computed Tomography Cardiac Angiography Can Improve Invasive Coronary Angiography in Bypass Surgery Patients) to reduce procedure time and incidence of contrast-associated acute kidney injury, with greater levels of patient satisfaction. Patient-related outcomes, utilization of further diagnostic imaging resources, and longer-term incidence of major adverse cardiac events were key secondary end points not yet reported.

METHODS

Patients with prior coronary artery bypass grafting referred for ICA were randomized 1:1 to undergo CTCA before ICA or ICA alone and followed up for a median of 3 (2.2-3.4) years. Angina status was assessed using the Seattle Angina Questionnaire and overall quality of life using the EQ-5D-5L. The incidence of noninvasive imaging use and major adverse cardiac events were compared between the 2 groups.

RESULTS

In all, 688 patients were randomized, 344 to CTCA+ICA and 344 to ICA only. The mean age of participants was 69.8 years, with 45% undergoing ICA for acute coronary syndromes and the remainder stable angina. At 3 months follow-up, patients in the CTCA+ICA group were more likely to be angina-free (51.7% versus 43.2%; P=0.03) with greater quality of life (EQ-5D-5L index, 81.6 versus 74.4; P=0.001), although these improvements did not persist. At 3 years follow-up, imaging resource use (35.8% versus 45.1%; odds ratio, 0.68 [95% CI, 0.50-0.92]; P=0.013) and incidence of major adverse cardiac events were lower in the CTCA+ICA group (35.8% versus 43.5%; hazard ratio, 0.73 [95% CI, 0.58-0.93]; P=0.010).

CONCLUSIONS

In patients with prior coronary artery bypass grafting undergoing ICA, CTCA before ICA leads to reductions in the use of imaging resources and the rate of major cardiac events out to 3 years, but with similar patient-related outcome measures. Together with the initial findings of BYPASS-CTCA, these data are supportive of routinely undertaking a CTCA before ICA in patients with prior coronary artery bypass grafting.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03736018.

Zibotentan in Microvascular Angina: A Randomized, Placebo-Controlled, Crossover Trial

BACKGROUND

Microvascular angina is associated with dysregulation of the endothelin system and impairments in myocardial blood flow, exercise capacity, and health-related quality of life. The G allele of the noncoding single nucleotide polymorphism RS9349379 enhances expression of the endothelin-1 gene (EDN1) in human vascular cells, potentially increasing circulating concentrations of Endothelin-1 (ET-1). Whether zibotentan, an oral ET-A receptor selective antagonist, is efficacious and safe for the treatment of microvascular angina is unknown.

METHODS

Patients with microvascular angina were enrolled in this double-blind, placebo-controlled, sequential crossover trial of zibotentan (10 mg daily for 12 weeks). The trial population was enriched to ensure a G allele frequency of 50% for the RS9349379 single nucleotide polymorphism. Participants and investigators were blinded to genotype. The primary outcome was treadmill exercise duration (seconds) using the Bruce protocol. The primary analysis estimated the mean within-participant difference in exercise duration after treatment with zibotentan versus placebo.

RESULTS

A total of 118 participants (mean±SD; years of age 63.5 [9.2]; 71 [60.2%] females; 25 [21.2%] with diabetes) were randomized. Among 103 participants with complete data, the mean exercise duration with zibotentan treatment compared with placebo was not different (between-treatment difference, -4.26 seconds [95% CI, -19.60 to 11.06] P=0.5871). Secondary outcomes showed no improvement with zibotentan. Zibotentan reduced blood pressure and increased plasma concentrations of ET-1. Adverse events were more common with zibotentan (60.2%) compared with placebo (14.4%; P<0.001).

CONCLUSIONS

Among patients with microvascular angina, short-term treatment with a relatively high dose (10 mg daily) of zibotentan was not beneficial. Target-related adverse effects were common.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT04097314.

The "Small" Clinical Trial: Methods, Analysis, and Interpretation in Acute Care Cardiology

Clinical trials in acute care settings, particularly those involving small populations or high mortality contexts, present unique challenges in design and analysis. In this review we explore novel statistical approaches and methodological considerations for such trials, with a focus on cardiovascular therapies. We discuss the concept of "small" sample sizes and their limitations and cover various analytical frameworks, including frequentist and Bayesian approaches, and emphasize their implications for result interpretation and reproducibility. We examine end points such as "days alive and free specific to disease state," which combines mortality and morbidity measures, the win ratio for hierarchical end points, and ordinal scales that capture detailed patient outcomes. These methods potentially increase statistical power and provide more clinically relevant measures compared with traditional binary outcomes; an extensive use of simulations is used to clarify this point. The use of longitudinal ordinal models is presented as a promising method to capture complex patient trajectories over time, offering insights into treatment effects at various disease stages. We also address the potential of adaptive platform trials for rare conditions, allowing for more efficient use of limited patient populations. In this overview we aim to guide researchers and clinicians in selecting optimal trial designs and analytical strategies, to ultimately improve the quality, efficiency, and interpretability of evidence in acute care cardiology.

Non-invasive physiological assessment of coronary artery obstruction on coronary computed tomography angiography

Computed tomography-derived fractional flow reserve (CT-FFR) enhances the specificity of coronary computed tomography angiography (CCTA) to that of the most specific non-invasive imaging techniques, while maintaining high sensitivity in stable coronary artery disease (CAD). As gatekeeper for invasive coronary angiography (ICA), use of CT-FFR results in a significant reduction of negative ICA procedures and associated costs and complications, without increasing cardiovascular events. It is expected that CT-FFR algorithms will continue to improve, regarding accuracy and generalisability, and that introduction of new features will allow further treatment guidance and reduced invasive diagnostic testing. Advancements in CCTA quality and artificial intelligence (AI) are starting to unfold the incremental diagnostic and prognostic capabilities of CCTA's attenuation-based images in CAD, with future perspectives promising additional CCTA parameters which will enable non-invasive assessment of myocardial ischaemia as well as CAD activity and future cardiovascular risk. This review discusses practical application, interpretation and impact of CT-FFR on patient care, and how this ties into the CCTA 'one stop shop' for coronary assessment and patient prognosis. In this light, selective adoption of the most promising, objective and reproducible techniques and algorithms will yield maximal diagnostic value of CCTA without overcomplicating patient management and guideline recommendations.

The role of advanced physiological guidance in contemporary coronary artery disease management

PURPOSE OF REVIEW

This review evaluates the emerging role of the pullback pressure gradient (PPG) as a standardized metric for assessing coronary artery disease (CAD) patterns and its implications for clinical decision-making when managing patients undergoing percutaneous coronary interventions (PCIs). By integrating PPG with existing physiological assessments, this review highlights the potential benefits of PPG in predicting treatment outcomes and refining therapeutic strategies for CAD.

RECENT FINDINGS

Recent studies, particularly the PPG Global study have demonstrated a strong correlation between PPG values and post-PCI outcomes, revealing that focal disease is associated with improved fractional flow reserve (FFR) and lower rates of adverse events than vessels with diffuse disease (low PPG). Additionally, PPG has been linked to specific atherosclerotic plaque characteristics, indicating its utility in identifying high-risk plaques. The integration of PPG with advanced imaging techniques further enhances the understanding of CAD patterns and their implications for treatment planning.

SUMMARY

The PPG represents a significant advancement in the management of CAD, providing a reproducible and objective assessment of coronary artery disease patterns that can inform clinical decision-making. As research continues to explore the relationship among PPG, atherosclerotic characteristics, and patient outcomes, its integration into routine practice is expected to improve the effectiveness of PCI and optimize patient management strategies. Future studies are warranted to establish specific PPG thresholds and further investigate its potential in identifying vulnerable plaques and guiding treatment decisions.

Outcomes with revascularisation versus conservative management of participants with 3-vessel coronary artery disease in the ISCHEMIA trial

BACKGROUND

Whether revascularisation (REV) improves outcomes in patients with three-vessel coronary artery disease (3V-CAD) is uncertain.

AIMS

Our objective was to evaluate outcomes with REV (percutaneous coronary intervention [PCI] or coronary artery bypass graft surgery [CABG]) versus medical therapy in patients with 3V-CAD.

METHODS

ISCHEMIA participants with 3V-CAD on coronary computed tomography angiography without prior CABG were included. Outcomes following initial invasive management (INV) with REV (PCI or CABG) versus initial conservative management (CON) with medical therapy alone were evaluated. Regression modelling was used to estimate the outcomes if all participants were to undergo prompt REV versus those assigned to CON. Outcomes were cardiovascular (CV) death/myocardial infarction (MI), death, CV death, and quality of life. Bayesian posterior probability for benefit (Pr [benefit]) for 1 percentage point lower 4-year rates with REV versus CON were evaluated.

RESULTS

Among 1,236 participants with 3V-CAD (612 INV/624 CON), REV was associated with lower 4-year CV death/MI (adjusted 4-year difference: -4.4, 95% credible interval [CrI] -8.7 to -0.3 percentage points, Pr [benefit]=94.8%) when compared with CON, with similar results for PCI versus CON (-5.8, 95% CrI: -10.8 to -0.5 percentage points, Pr [benefit]=96.4%) and CABG versus CON (-3.7, 95% CrI: -8.8 to 1.5 percentage points, Pr [benefit]=84.7%). Adjusted 4-year REV versus CON differences were as follows: death -1.2 (95% CrI: -4.7 to 2.2) percentage points, CV death -2.3 (95% CrI: -5.5 to 0.8) percentage points, with similar results for PCI and for CABG. The Pr (benefit) for death with REV (PCI or CABG) versus CON was 49-63%. The adjusted 12-month Seattle Angina Questionnaire-7 summary score differences favoured REV: REV versus CON 4.6 (95% CrI: 2.7-6.4) percentage points; PCI versus CON 3.6 (95% CrI: 1.2-5.8) percentage points and CABG versus CON 4.3 (95% CrI: 1.5-6.9) percentage points with high Pr (benefit).

CONCLUSIONS

In participants with 3V-CAD, REV (either PCI or CABG) was associated with a lower 4-year CV death/MI rate and improved quality of life, with similar results for PCI versus CON and CABG versus CON. The differences in all-cause mortality between REV and CON were small with wide confidence intervals. (ClinicalTrials.gov: NCT01471522).

Prognostic role of persistent angina after percutaneous revascularization in chronic coronary syndrome with altered angiography and stress CMR

INTRODUCTION AND OBJECTIVES

In patients with established chronic coronary syndrome (CCS), the significance of persistent angina is controversial. We aimed to evaluate the prognostic role of persistent angina in symptomatic CCS patients with abnormal stress cardiovascular magnetic resonance (CMR) and altered angiographic findings undergoing percutaneous revascularization.

METHODS

We analyzed 334 CCS patients with Canadian Cardiovascular Society angina class ≥2, perfusion deficits on stress CMR and severe lesions in angiography who underwent medical therapy optimization plus CMR-guided percutaneous revascularization. We investigated the association of persistent angina at 6 months postintervention with subsequent cardiac death, myocardial infarction, and hospital admission.

RESULTS

All patients had angina class ≥2 (mean: 2.8±0.7), abnormal stress CMR (mean ischemic burden: 5.8±2.7 segments), and severe angiographic lesions. The angina resolution rates were 81% at 6 months, and 81%, 81%, and 77% at 1, 2, and 5 years, respectively. During a median follow-up of 8.9 years, persistent angina was independently associated with higher rates of subsequent cardiac death (13% vs 4%; HR, 3.7; 95%CI, 1.5-9.2; P=.005), myocardial infarction (24% vs 6%; HR, 4.9; 95%CI, 2.4-9.9; P<.001), and hospital admission for heart failure (27% vs 13%; HR, 2.7; 95%CI, 1.5-5.2; P=.001).

CONCLUSIONS

In CCS patients with robust diagnostic evidence from symptoms, stress CMR, and angiography, persistent angina after percutaneous revascularization is a strong predictor of subsequent cardiac death, myocardial infarction, and hospital admission for heart failure.

PET myocardial perfusion imaging: Trends, challenges, and opportunities

Various non-invasive images are used in clinical practice for the diagnosis and prognostication of chronic coronary syndromes. Notably, quantitative myocardial perfusion imaging (MPI) through positron emission tomography (PET) has seen significant technical advancements and a substantial increase in its use over the past two decades. This progress has generated an unprecedented wealth of clinical information, which, when properly applied, can diagnose and fine-tune the management of patients with different types of ischemic syndromes. This state-of-art review focuses on quantitative PET MPI, its integration into clinical practice, and how it holds up at the eyes of modern cardiac imaging and revascularization clinical trials, along with future perspectives.