Routine Stress Testing After PCI in Patients With and Without Acute Coronary Syndrome: A Secondary Analysis of the
Jinho Lee1,2, Do-Yoon Kang1, Hoyun Kim1
1Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.
Insights
Patients with acute coronary syndrome (ACS) undergoing high-risk percutaneous coronary intervention (PCI) face higher risks. Routine stress testing 12 months post-PCI did not show improved outcomes compared to standard care alone.
Area of Science:
- Cardiology
- Interventional Cardiology
- Clinical Trials
Background:
- The optimal follow-up strategy for patients after percutaneous coronary intervention (PCI) is not well-defined.
- Patients with acute coronary syndrome (ACS) undergoing PCI have a higher risk of adverse events.
Purpose of the Study:
- To evaluate clinical outcomes in patients with and without ACS after high-risk PCI.
- To compare routine stress testing at 12 months versus standard care alone as a follow-up strategy.
Main Methods:
- The POST-PCI trial was a randomized clinical trial involving 1706 patients.
- Patients were stratified by ACS presentation and randomized to routine functional testing or standard care.
- The primary outcome was a composite of death, myocardial infarction, or unstable angina hospitalization over 2 years.
Main Results:
- Patients with ACS had a 55% higher risk of the primary outcome compared to those without ACS.
- No significant difference in 2-year primary outcomes was observed between routine testing and standard care in either ACS or non-ACS groups.
- Higher rates of invasive angiography and repeat revascularization were noted in the routine testing group after one year.
Conclusions:
- Patients with ACS undergoing high-risk PCI do not benefit from routine 12-month surveillance stress testing compared to standard care.
- The findings suggest that standard care alone is sufficient for follow-up in this patient population.
- Further research may explore tailored surveillance strategies based on individual risk.
Importance:
The appropriate follow-up surveillance strategy for patients with acute coronary syndrome (ACS) who have undergone percutaneous coronary intervention (PCI) remains unknown.
Objective:
To assess clinical outcomes in patients with and without ACS who have undergone high-risk PCI according to a follow-up strategy of routine stress testing at 12 months after PCI vs standard care alone.
Design, Setting, And Participants:
The POST-PCI (Pragmatic Trial Comparing Symptom-Oriented vs Routine Stress Testing in High-Risk Patients Undergoing Percutaneous Coronary Intervention) trial was a randomized clinical trial that compared follow-up strategies of routine functional testing vs standard care alone 12 months after high-risk PCI. Patients were categorized as presenting with or without ACS. Patients were enrolled in the trial from November 2017 through September 2019, and patients were randomized from 11 sites in South Korea; data analysis was performed in 2022.
Intervention:
Patients categorized as presenting with or without ACS were randomized to either a routine functional testing or standard care alone follow-up strategy 12 months after high-risk PCI.
Main Outcomes And Measures:
The primary outcome was a composite of death from any cause, myocardial infarction, or hospitalization for unstable angina at 2 years following randomization. Kaplan-Meier event rates through 2 years and Cox model hazard ratios (HRs) were generated, and interactions were tested.
Results:
Of 1706 included patients, 350 patients (20.5%) were female, and the mean (SD) patient age was 64.7 (10.3) years. In total, 526 patients (30.8%) presented with ACS. Compared with those without ACS, patients with ACS had a 55% greater risk of the primary outcome (HR, 1.55; 95% CI, 1.03-2.33; P = .03) due to higher event rates in the first year. The 2-year incidences of the primary outcome were similar between strategies of routine functional testing or standard care alone in patients with ACS (functional testing: 16 of 251 [6.6%]; standard care: 23 of 275 [8.5%]; HR, 0.76; 95% CI, 0.40-1.44; P = .39) and in patients without ACS (functional testing: 30 of 598 [5.1%]; standard care: 28 of 582 [4.9%]; HR, 1.04; 95% CI, 0.62-1.74; P = .88) (P for interaction for ACS = .45). Although a landmark analysis suggested that the rates of invasive angiography and repeat revascularization were higher after 1 year in the routine functional testing group, the formal interactions between ACS status and either invasive angiography or repeat revascularization were not significant.
Conclusion And Relevance:
Despite being at higher risk for adverse clinical events in the first year after PCI than patients without ACS, patients with ACS who had undergone high-risk PCI did not derive incremental benefit from routine surveillance stress testing at 12 months compared with standard care alone during follow-up.
Trial Registration:
ClinicalTrials.gov Identifier: NCT03217877.
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