Clinical relevance of impaired physiological assessment after percutaneous coronary intervention: a meta-analysis

Background

Despite optimal angiographic result of Percutaneous Coronary Intervention (PCI), residual disease at the site of the culprit lesion can lead to Major Adverse Cardiac Events (MACE) at follow-up [1]. Post-PCI physiological assessment can identify residual stenosis.

Purpose

The aim of this meta-analysis is to investigate data of studies with minimum follow-up of 6 months examining post-PCI physiological assessment in relation with long-term outcomes.

Methods

Studies were included in the meta-analysis after performing systematic search of the literature on 10th of January 2022. The primary endpoint was the incidence of MACE, Vessel-Orientated Cardiac Events (VOCE) or Target Vessel Failure (TVF). Secondary endpoints included the incidence of death, myocardial infarction (MI) and Target Vessel Revascularization (TVR).

Results

Low post-PCI FFR, reported in seven studies [2–8], including 4017 patients, was associated with an increased rate of the primary endpoint (HR 2.06; 95%-CI 1.37–3.08). One study reported about impaired post-PCI (instantaneous wave-free ratio) iFR in relation with MACE, showing a significant association (HR 3.38; 95%-CI 0.99–11.6) [9]. Low post-PCI QFR, reported in three studies [10–12], including 1181 patients, was associated with increased rate of VOCE (HR 3.02; 95%-CI 2.13–4.30). Combining data of all modalities, impaired physiological assessment showed an increased rate of the primary endpoint (HR 2.32; 95%-CI 1.71–3.16) and secondary endpoints including death (HR 1.35; 95%-CI 1.01–1.82), MI (HR 2.50; 95%-CI 1.36–4.58) and TVR (HR 2.88; 95%-CI 1.91–4.35).

Conclusions

Impaired post-PCI physiological assessment is associated with an increase in adverse cardiac events and individual endpoints including death, MI and TVR. Prospective studies are awaited whether physiology-based optimization of PCI results in better clinical outcome.

Funding Acknowledgement

Type of funding sources: None.

The effect of P2Y12 inhibitor monotherapy according to bleeding risk: a systematic review and meta-analysis

Background/Introduction

P2Y12 inhibitor monotherapy is a promising novel strategy to reduce bleeding complications compared to DAPT. To determine which patients benefit most, we investigated the effect according to bleeding risk.

Purpose

The study aim was to analyse the safety and efficacy of P2Y12 inhibitor monotherapy versus dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) in patients with and without high bleeding risk (HBR).

Methods

PubMed was searched for randomized clinical trials (RCTs) comparing P2Y12 inhibitor monotherapy to DAPT after PCI. Risk ratios (RR) and adjusted risk differences (ARD) of net adverse clinical events (NACE), major adverse cardiac and cerebral events (MACCE) and major bleedings were calculated according to bleeding risk.

Results

Five RCTs including 31750 patients were selected. Monotherapy reduced major bleeding significantly in all patients (HBR: RR 0.63, 95% CI: 0.46 to 0.85; non-HBR: RR 0.58, 95% CI: 0.41 to 0.82) with a higher ARD in patients with HBR versus non-HBR. There was no difference between treatment effects on MACCE in both subgroups. Next to the expected higher number of bleeding events, we found an increase in MACCE in patients with HBR which resulted in a non-significant reduction of NACE (RR 0.89, 95% CI: 0.77 to 1.04). In patients without HBR, NACE was significantly reduced by monotherapy (RR 0.80, 95% CI: 0.67 to 0.96).

Conclusions

P2Y12 inhibitor monotherapy post PCI reduces bleeding complications without increasing ischemic events compared to DAPT, regardless of bleeding risk. HBR patients experience more bleeding and ischemic events without a net benefit of monotherapy.

Funding Acknowledgement

Type of funding sources: None.