Key result
PCI for ≥90% coronary stenosis in TAVI patients cuts MACE ~47% vs conservative treatment.
Why the study?
CAD is common in patients undergoing TAVI, but the optimal CAD treatment strategy in this population remains debated.
Does percutaneous coronary intervention reduce major adverse cardiovascular events in patients with severe symptomatic aortic stenosis and coexisting stable CAD undergoing TAVI compared to conservative treatment?
RCT (n=455)
randomized
Does percutaneous coronary intervention reduce major adverse cardiovascular events in patients with severe symptomatic aortic stenosis and coexisting stable CAD undergoing TAVI compared to conservative treatment?
Effect estimate: HR 0.53 (95% CI 0.34-0.82)
Absolute Event Rate: 24% vs 37%
p-value: p=0.017
In patients undergoing TAVI with coexisting stable CAD, performing PCI is associated with reduced MACE only when coronary stenosis is ≥90%.
Supports selective PCI for ≥90% stenosis in TAVI; resolves part of CAD management debate by showing no benefit for milder lesions.
Background Coronary artery disease (CAD) is common in patients undergoing transcatheter aortic valve implantation (TAVI), and optimal treatment strategy of CAD in this population remains debated. Purpose To analyse the impact of the diameter of coronary stenosis on outcomes in patients undergoing percutaneous coronary intervention (PCI) with TAVI. Methods This study was based on the NOTION-3 trial, which randomized 455 patients (median age 82 years; 67% male; median Society of Thoracic Surgeons–Predicted Risk of Mortality score 3%) with severe symptomatic aortic stenosis and coexisting stable CAD to receive either PCI or conservative treatment of CAD with TAVI. In this sub-analysis, patients were stratified to three groups according to the diameter of coronary stenosis (50-69%, N=40; 70-89%, N=144; and ≥90%, N=271). The primary outcome was major adverse cardiovascular events (MACE), a composite of all-cause death, myocardial infarction and urgent revascularization. Results At a median follow-up of 2 years (interquartile range 1-4), PCI was not associated with lower incidence of MACE in patients with coronary stenosis of 50-69% (28% vs. 32%; hazard ratio (HR): 0.94, 95% confidence interval (CI): 0.30-2.97, p=0.78) and 70-89% (31% vs. 34%; HR: 1.06, 95% CI: 0.60-1.88, p=0.76) compared to conservative treatment. In patients with coronary stenosis of ≥90%, the incidence of MACE was significantly lower in patients undergoing PCI (24% vs. 37%; HR: 0.53, 95% CI: 0.34-0.82, p=0.017), mainly driven by reduction in the incidence of myocardial infarction (6.5% vs. 17%; HR: 0.34, 95% CI: 0.15-0.73, p=0.005) and urgent revascularization (1.4% vs. 14%; HR: 0.10, 95% CI: 0.02-0.42, p<0.001). Conclusions In patients undergoing TAVI with coexisting stable CAD, PCI in case of a coronary stenosis of ≥90% was associated with a lower incidence of a composite of all-cause death, myocardial infarction and urgent revascularization compared to conservative treatment, suggesting the use of PCI in this population.
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Riihiniemi et al. (2025) conducted an RCT in severe symptomatic aortic stenosis and coexisting stable CAD (n=455). Percutaneous coronary intervention (PCI) vs. Conservative treatment was evaluated on Major adverse cardiovascular events (MACE) in patients with ≥90% stenosis (HR 0.53, 95% CI 0.34-0.82, p=0.017). PCI for coronary stenosis ≥90% in patients undergoing TAVI reduced MACE compared to conservative treatment (24% vs 37%; HR 0.53; 95% CI 0.34-0.82; p=0.017).
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