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Updated: Jun 4, 2025
Author Spotlight: Enhancing Coronary Artery Revascularization
Published on: September 15, 2023
Anatomic vs. Ischemia-Driven Strategies for Percutaneous Coronary Revascularization in Chronic Coronary Syndrome: A
Federico Giacobbe1, Eduardo Valente1, Giuseppe Giannino1
1Division of Cardiology, Department of Medical Science, AOU Città della Salute e della Scienza di Torino, Turin, Italy.
Insights
Percutaneous coronary intervention (PCI) guided by ischemia assessment, whether invasive or non-invasive, reduces major adverse clinical events (MACE) in chronic coronary syndromes (CCS) patients compared to optimal medical therapy (OMT) alone.
Area of Science:
- Cardiology
- Interventional Cardiology
Background:
- The benefit of percutaneous coronary intervention (PCI) in addition to optimal medical therapy (OMT) for patients with chronic coronary syndromes (CCS) is not fully established.
- PCI strategies can be guided by either angiographic findings or ischemia assessment, necessitating a comparison of these approaches.
Purpose of the Study:
- To compare the effectiveness of different PCI guidance strategies against OMT alone in patients with CCS.
- To evaluate the impact of ischemia-guided PCI versus angio-guided PCI on clinical outcomes.
Main Methods:
- A network meta-analysis of randomized controlled trials (RCTs) was conducted.
- Studies compared OMT alone versus PCI guided by angiography, non-invasive ischemia assessment, or invasive ischemia assessment.
- Primary endpoint was major adverse clinical events (MACE); secondary endpoints included cardiovascular death, myocardial infarction (MI), and unplanned revascularization.
Main Results:
- 18 studies with 17,512 patients were analyzed, with a mean follow-up of 3.5 years.
- Ischemia-guided PCI (both invasive and non-invasive) significantly reduced MACE compared to OMT alone.
- Non-invasive ischemia-guided PCI reduced MI risk (HR: 0.61), and invasive assessments (iFR, FFR) showed the highest probability of reducing revascularization needs.
Conclusions:
- Ischemia-guided PCI, utilizing either invasive or non-invasive methods, is superior to OMT alone in reducing MACE for CCS patients.
- The choice of ischemia assessment influences outcomes, with non-invasive tests improving MI risk and invasive assessments (iFR, FFR) best for preventing revascularization.
Introduction:
In patients with chronic coronary syndromes (CCS), the benefit of percutaneous coronary intervention (PCI) added to optimal medical therapy (OMT) remains unclear. The indication to PCI may be driven either by angiographic evaluation or ischemia assessment, thus depicting different potential strategies which have not yet been thoroughly compared.
Methods:
Randomized controlled trials (RCTs) comparing OMT versus PCI angio-guided or versus PCI non-invasive or invasive ischemia guided were identified and compared via network meta-analysis. Major adverse clinical events (MACE), as defined by each included trial, were the primary endpoint, while cardiovascular (CV) death, myocardial infarction (MI), and unplanned revascularization the secondary ones.
Results:
18 studies, encompassing 17,512 patients, were included, with a mean follow-up of 3.5 years. PCI guided by ischemia defined either invasively or not was associated with a reduced risk of MACE compared with OMT alone. Furthermore, PCI guided by non-invasive assessment of ischemia was associated with a reduced risk of MI compared with OMT (hazard ratio [HR]: 0.61 [95% confidence interval: 0.37-0.94). This strategy ranked best also in preventing CV death. Notably, iFR and FFR guided approaches showed the highest probability of performing best for reduction of subsequent revascularizations.
Conclusion:
In patients with CCS, ischemia-guided PCI, either by invasive or non-invasive assessment, resulted in a reduced risk of MACE compared with OMT alone. The use of invasive or non-invasive tests influenced the benefit of ischemia-driven PCI: non-invasive tests significantly reduced risk of MI compared with OMT, while iFR or FFR showed the highest probability of reducing the need of subsequent revascularization.
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