Eurointervention最新文献

Background: Trials assessing the prognostic influence of the completeness, timing, and guidance of percutaneous coronary intervention (PCI) for haemodynamically stable acute myocardial infarction (MI) and multivessel coronary artery disease (MV-CAD) have provided heterogeneous results.

Aims: We aimed to comprehensively and simultaneously assess the available evidence on the completeness, timing, and guidance of PCI for acute MI and MV-CAD.

Methods: Major electronic databases were screened to identify randomised trials comparing at least two PCI strategies for acute MI and MV-CAD. Recurrent MI and cardiac death were the primary and co-primary outcomes. Frequentist and Bayesian 5- and 3-node network meta-analyses were conducted along with complementary analyses to explore potential sources of heterogeneity.

Results: Fourteen trials, including 14,433 patients, were pooled. In the frequentist 5-node analysis, angiography-guided immediate complete revascularisation (CR) reduced MI compared with infarct-related artery (IRA)-only revascularisation (hazard ratio [HR] 0.42, 95% confidence interval [CI]: 0.27-0.66), angiography-guided staged CR (HR 0.56, 95% CI: 0.36-0.87), and functionally guided staged CR (HR 0.37, 95% CI: 0.20-0.69). Functionally guided immediate CR was associated with reduced MI compared with IRA-only revascularisation (HR 0.53, 95% CI 0.34-0.82). The Bayesian analysis confirmed only an advantage of angiography-guided immediate CR over IRA-only revascularisation. In frequentist 3-node analysis, immediate CR reduced MI (HR 0.51, 95% CI: 0.37-0.70) and cardiac death (HR 0.68, 95% CI: 0.50-0.93) compared with IRA-only revascularisation and MI compared with staged CR (HR 0.55, 95% CI: 0.38-0.79). The Bayesian analysis did not confirm the reduction in cardiac death. CR, regardless of the type of guidance and especially when immediate, reduced the rate of any revascularisation compared with IRA-only revascularisation.

Conclusions: In haemodynamically stable patients with acute MI and non-complex MV-CAD undergoing PCI, immediate CR following successful culprit lesion treatment reduces recurrent MI compared with IRA-only revascularisation and staged CR. Whether CR is associated with reduced cardiovascular death remains uncertain.

Background: A discrepancy exists between the European and American guideline recommendations for the routine use of proton pump inhibitors (PPIs) in patients treated with dual antiplatelet therapy (DAPT).

Aims: This study aimed to determine the association between the co-prescription of PPIs and DAPT and the occurrence of gastrointestinal bleeding and ischaemic events in patients with acute myocardial infarction (AMI) undergoing percutaneous coronary intervention (PCI).

Methods: A search was conducted using a nationwide Korean claims database to identify patients with AMI undergoing PCI with DAPT. Patients were matched using a large-scale propensity score (PS) algorithm according to the co-prescription of PPIs. The primary efficacy endpoint was major gastrointestinal bleeding requiring transfusion with hospitalisation within 1 year. The primary safety endpoint was major adverse cardiac and cerebrovascular events (MACCE), a composite of cardiovascular death, spontaneous myocardial infarction, repeat revascularisation and ischaemic stroke within 1 year.

Results: Among the total population, 30.0% of patients (n=35,566) received PPIs with DAPT after PCI for AMI. After PS matching, 35,560 pairs were generated. Compared to patients without PPIs, those on PPIs were associated with a significantly lower 1-year risk of major gastrointestinal bleeding (0.7% vs 0.4%, hazard ratio [HR] 0.59, 95% confidence interval [CI]: 0.48-0.73). The 1-year risk of MACCE did not differ significantly between the groups with or without PPIs (13.4% vs 13.1%, HR 0.98, 95% CI: 0.94-1.02). The beneficial effects of PPIs on gastrointestinal bleeding, without increased risk of cardiovascular events, were observed consistently, regardless of P2Y₁₂ inhibitor type, PPI type, or individual bleeding risk.

Conclusions: In real-world data from a large study of East Asian patients with AMI undergoing PCI and maintaining DAPT, PPI use significantly reduced the risk of major gastrointestinal bleeding without increasing ischaemic events, irrespective of bleeding risk or type of P2Y₁₂ inhibitor. (ClinicalTrials.gov: NCT06241833).

Background: Recent trials have shown that intravascular imaging (IVI)-guided percutaneous coronary intervention (PCI) improves clinical outcome, as compared to angiography-guided PCI, in complex coronary artery lesions. However, it is unclear whether this benefit is affected by overall lesion complexity in each patient.

Aims: The present study sought to investigate the impact of overall lesion complexity on the benefit of IVI-guided PCI.

Methods: A total of 4,611 patients with complex coronary artery lesions from the RENOVATE-COMPLEX-PCI trial (n=1,639) and the institutional registry of the Samsung Medical Center (n=2,972) were classified according to the number of complex lesion features found in each patient. The primary outcome was target vessel failure (TVF) at 3 years, a composite of cardiac death, target vessel myocardial infarction, or target vessel revascularisation.

Results: The cutoff value for the number of complex lesion features to predict TVF, determined using the maximally selected log-rank test, was 3. Patients with ≥3 complex lesion features had a higher risk of TVF than those with <3 complex lesion features (11.0% vs 7.2%, hazard ratio [HR] 1.59, 95% confidence interval [CI]: 1.28-1.96; p<0.001). IVI-guided PCI significantly reduced the risk of TVF compared with angiography-guided PCI in both groups (≥3 complex lesion features: 7.4% vs 14.4%, HR 0.49, 95% CI: 0.35-0.69; p<0.001; <3 complex lesion features: 5.7% vs 8.1%, HR 0.72, 95% CI: 0.53-0.98; p=0.039). The benefit of IVI-guided PCI tended to increase as the number of complex lesion features increased (absolute risk reduction for TVF: -0.012 vs -0.027 vs -0.055 vs -0.077, respectively, for 1 vs 2 vs 3 vs ≥4 complex lesion features; interaction p=0.048).

Conclusions: In patients with complex coronary artery lesions, IVI-guided PCI showed a lower risk of TVF across all degrees of lesion complexity. The prognostic benefit of IVI-guided PCI tended to increase as patients had more complex lesion features. (RENOVATE-COMPLEX-PCI [ClinicalTrials.gov: NCT03381872]; Institutional cardiovascular catheterisation database of the Samsung Medical Center [ClinicalTrials.gov: NCT03870815]).

Background: Safe deferral of revascularisation is a key aspect of physiology-guided percutaneous coronary intervention (PCI). While recent evidence gathered in the FAVOR III Europe trial showed that quantitative flow ratio (QFR) guidance did not meet non-inferiority to fractional flow reserve (FFR) guidance, it remains unknown if QFR might have a specific value in revascularisation deferral.

Aims: We aimed to evaluate the safety of coronary revascularisation deferral based on QFR as compared with FFR.

Methods: Patients randomised in the FAVOR III trial in whom PCI was deferred in at least one coronary artery, based on QFR or FFR>0.80, were included in the present substudy. The primary outcome was the 1-year rate of major adverse cardiac events (MACE), with results reported for two subsets of deferred patients: (1) any study lesion deferral and (2) complete study lesion deferral.

Results: A total of 523 patients (55.2%) in the QFR group and 599 patients (65.3%) in the FFR group had at least one coronary revascularisation deferral. Of these, 433 patients (82.8%) and 511 (85.3%) patients, respectively, had complete study lesion deferral. In the "complete study lesion deferral" patient group, the occurrence of MACE was significantly higher in QFR-deferred patients as compared with FFR-deferred patients (24 [5.6%] vs 14 [2.8%], adjusted hazard ratio [HR] 2.07, 95% confidence interval [CI]: 1.07-4.03; p=0.03). In the subgroup of "any study lesion deferral", the MACE rate was 5.6% vs 3.6% (QFR vs FFR), adjusted HR 1.55, 95% CI: 0.88-2.73; p=0.13.

Conclusions: QFR-based deferral of coronary artery revascularisation resulted in a higher incidence of 1-year MACE as compared with FFR-based deferral.