Why the study?
In patients with chronic coronary syndrome, the decision to perform PCI may be driven by angiographic evaluation or by non-invasive or invasive ischemia assessment, representing different strategies that had not yet been compared.
Does percutaneous coronary intervention (guided by angiography, non-invasive ischemia, or coronary physiology) reduce major adverse clinical events compared to optimal medical therapy in patients with chronic coronary syndrome?
Meta-Analysis (n=17,512)
Does percutaneous coronary intervention (guided by angiography, non-invasive ischemia, or coronary physiology) reduce major adverse clinical events compared to optimal medical therapy in patients with chronic coronary syndrome?
Answers are grounded in this paper and cite their sources.
In chronic coronary syndrome, guiding PCI with invasive (FFR/iFR) or non-invasive ischemia assessment reduces MACE compared to optimal medical therapy alone, whereas non-invasive ischemia guidance specifically reduces myocardial infarction.
Background In patients with chronic coronary syndrome (CCS), percutaneous coronary intervention (PCI) stands out as an alternative to optimal medical therapy (OMT). The decision to perform a PCI may be driven either by angiographic evaluation or ischemia assessment, thus depicting different potential strategies which have not yet been compared. Purpose To compare different strategies of percutaneous revascularization (angiography, non-invasive ischemia and coronary physiology (FFR or iFR) guided) in order to identify a potential benefit of PCI depending on the guidance chosen in CCS. Methods Randomized controlled trials (RCTs) comparing OMT vs. PCI-angio guided or vs. PCI guided by non-invasive or invasive ischemia assessment were included and compared via network metanalysis. Major adverse clinical events (MACE), as defined by each included trial, were the primary end point, while cardiovascular (CV) death, myocardial infarction and subsequent revascularization the secondary ones. Results 18 studies, encompassing 17512 patients, were included followed up for a weighted mean of 3,5 years. PCI guided by non-invasive assessment of ischemia entailed a reduced risk of myocardial infarction compared with OMT (HR 0.61:0.37-0.94, CI 95%). This strategy ranked best in preventing CV death. In addition, PCI guided by ischemia defined either invasively or not was associated with a reduced risk of MACE as compared with OMT. iFR and FFR guided approaches showed the highest probability of performing best. Finally, physiology guided PCI ranked best in reducing subsequent urgent revascularizations. Conclusions For patients with CCS, ischemia-guided PCI, either by invasive or noninvasive assessment, resulted in a reduced risk of MACE as compared with OMT. PCI guided by a non-invasive assessment of ischemia reduced risk of myocardial infarction compared to OMT, while PCI guided by iFR or FFR showed the highest probability of reducing the need of subsequent revascularization. These strategies showed the highest probability of reducing MACE and CV death.
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Giacobbe et al. (2023) conducted a meta-analysis in Chronic coronary syndrome (CCS) (n=17,512). Percutaneous coronary intervention (PCI) guided by angiography, non-invasive ischemia assessment, or coronary physiology (FFR or iFR) vs. Optimal medical therapy (OMT) was evaluated on Major adverse clinical events (MACE), as defined by each included trial.
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