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Published on: August 28, 2018
Computed Tomography Angiography or Standard Care After Left Main PCI?
Fabrizio D'Ascenzo1, Enrico Cerrato2, Ovidio De Filippo3
1Division of Cardiology, Cardiovascular and Thoracic Department, "Citta della Salute e della Scienza" Hospital, Turin, Italy; Department of Medical Sciences, University of Turin, Turin, Italy.
Insights
Routine coronary computed tomography angiography (CCTA) after left main percutaneous coronary intervention (PCI) did not significantly reduce major adverse events. However, CCTA did lower spontaneous myocardial infarction rates but increased imaging-triggered revascularizations.
Area of Science:
- Cardiology
- Interventional Cardiology
- Medical Imaging
Background:
- The clinical utility of routine coronary computed tomography angiography (CCTA) following percutaneous coronary intervention (PCI) for unprotected left main (LM) disease remains unclear.
- Assessing the impact of CCTA-guided follow-up versus standard care is crucial for optimizing patient management.
Purpose of the Study:
- To evaluate whether CCTA-guided follow-up improves clinical outcomes compared to symptoms- or ischemia-driven care after LM PCI.
- To determine the efficacy and safety of routine CCTA in patients undergoing LM PCI.
Main Methods:
- A prospective, multicenter, open-label randomized trial (PULSE) involving 606 patients treated with second-generation drug-eluting stents.
- Patients were randomized 1:1 to receive CCTA at 6 months or standard care.
- The primary endpoint was a composite of all-cause death, spontaneous myocardial infarction (MI), unstable angina, or stent thrombosis at 18 months.
Main Results:
- The primary composite endpoint occurred in 11.9% of the CCTA group versus 12.5% of the control group (HR: 0.97; P = 0.80).
- The CCTA arm showed a significantly reduced risk of spontaneous MI (0.9% vs 4.9%; P = 0.004).
- An increased risk of imaging-triggered target-lesion revascularization (TLR) was observed in the CCTA arm (4.9% vs 0.3%; P = 0.001), while clinically driven TLR rates were similar.
Conclusions:
- Routine CCTA after LM PCI did not reduce the composite primary endpoint but was associated with fewer spontaneous MIs and more imaging-triggered revascularizations.
- Further research is warranted to clarify the value of CCTA in specific complex anatomic subsets of patients.
Background:
The clinical benefit of routine coronary computed tomography angiography (CCTA) after percutaneous coronary intervention (PCI) for unprotected left main (LM) disease is uncertain.
Objectives:
The authors evaluated whether CCTA-guided follow-up improves clinical outcomes vs symptoms- or ischemia-driven care after LM PCI.
Methods:
PULSE was a prospective, multicenter, open-label randomized trial. A total of 606 patients treated with second-generation drug-eluting stents were enrolled (October 2019 to September 2024) and randomized 1:1 to CCTA at 6 months (experimental) or standard care (control). The primary endpoint was a composite of all-cause death, spontaneous myocardial infarction (MI), unstable angina, or definite or probable stent thrombosis at 18 months. Secondary endpoints included target-lesion revascularization (TLR) and each primary endpoint component.
Results:
CCTA was completed in 272/303 experimental patients (89.8%) after a median of 200 days (IQR: 181-270 days). The primary endpoint occurred in 36/303 experimental patients vs 38/303 control patients (11.9% vs 12.5%; HR: 0.97; 95% CI: 0.76-1.23; P = 0.80). Compared with the control arm, the CCTA arm showed a reduced risk of spontaneous MI (0.9% vs 4.9%; HR: 0.26; 95% CI: 0.07-0.91; P = 0.004) and an increased risk of imaging-triggered TLR (4.9% vs 0.3%; HR: 7.7; 95% CI: 1.70-33.7; P = 0.001), whereas clinically driven TLR rates were similar (5.3% vs 7.2%; HR: 0.74; 95% CI: 0.38-1.41; P = 0.32).
Conclusions:
Routine CCTA after LM PCI did not reduce the composite primary endpoint, but was associated with fewer spontaneous MIs and more imaging-triggered revascularizations. Future trials to clarify its value in complex anatomic subsets appear to be warranted. (Angiographic Control vs Ischemia-Driven Management of Patients Treated With PCI on Left Main With Drug-Eluting Stents [PULSE; NCT04144881]).
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