Routine stress testing did not offer benefit to high-risk patients after PCI
BARCELONA — Routine functional testing after percutaneous cardiac interventions (PCI) did not improve clinical outcomes at 2 years in high-risk patients, according to the POST-PCI trial.
The composite endpoint of death from any cause, myocardial infarction or hospitalization for unstable angina was observed in 5.5% of patients who underwent routine functional tests compared to 6.6% in the standard care group, for a relative risk of 0.90 (95% CI 0.61-1.35, P= 0.62), reported Duk-Woo Park, MD, PhD, of Asan Medical Center/Ulsan Medical University in Seoul.
Also at 2 years, 12.3% of patients in the functional test group underwent invasive coronary angiography compared to 9.3% in the standard care group for a nonsignificant difference, he said in a presentation to the Society. European Cardiology (ESC) Meeting. The results were published simultaneously in the New England Journal of Medicine (NEJM).
And there was no significant difference between the percentage of patients requiring repeat revascularization (8.1% versus 9.3%, respectively), according to Park and colleagues.
The authors pointed out that “the routine stress testing strategy appeared to be associated with more frequent invasive coronary angiography and repeat revascularization after 1 year, which did not lead to a significant reduction in major cardiovascular events or of mortality”.
The results appear to confirm recent clinical practice in the United States, explained B. Hadley Wilson, MD, vice president of the American College of Cardiology (ACC). “The standard of care in this study is guideline-directed medical treatment for patients with ischemic heart disease and those who have had high-risk PCI or who continue to follow patients with the best medical treatment and monitor them. to see if they develop any symptoms compared to what was traditional standard of care of stress testing at 1 year or 2 years in these high-risk patients.” He is in medical school at the University of North Carolina at Chapel Hill.
Wilson, who was not involved in the study, noted that these types of stress tests “place a huge burden on the healthcare system and [a drain] on patients too… this study… may change practice. We could see those routine stress tests melt away.”
Park and colleagues assigned 1,706 PCI patients with high-risk anatomical or clinical features who perform routine functional tests — such as nuclear stress testing, stress electrocardiography, or stress echocardiography — at 1 year after PCI or standard PCI care alone.
The average age of the patients was 64.7 years and more than three quarters were men. Of the patients, 21.0% had left main disease, 43.5% had bifurcation disease, 69.8% had multivessel disease, 70.1% had diffuse long lesions, 38.7% were diabetic and 96.4% had been treated with drug-eluting stents.
Park’s group acknowledged that “the observed number of primary outcome events was lower than expected. This discrepancy could be explained in part by differences in clinical or lesional characteristics, interventional practice, or race or group. Moreover, this may be due to advances in PCI methods and improvements in cardiovascular care over the past decade.”
In a NEJM accompaniement editorialJacqueline E. Tamis-Holland, MD, of the Icahn School of Medicine at Mount Sinai in New York City, pointed out that the low event rate may “reflect adherence to guideline recommendations“, such as those from the ACC/American Heart Association co-authored by Tamis-Holland.
Limitations of POST-PCI included that the follow-up strategy was not hidden from patients and investigators, so determination bias was a possibility. Additionally, women were underrepresented in the trial. Finally, “routine exercise testing included three different types of methods with diagnostic accuracy varying from test to test”, so “application of these different tests could result in inconsistent judgment of ischemic burden d ‘a patient and affect clinical responses,’ Park’s group said.
Still, Tamis-Holland pointed out that POST-PCI offers “compelling new evidence for a future Class III recommendation for routine surveillance testing after PCI. surveillance effort to our patients after PCI, in the absence of other clinical signs or symptoms suggestive of stent failure.”
POST-PCI was supported by the Cardiovascular Research Foundation (CRF) and Daewoong Pharmaceutical.
Park revealed his relationships with CRF and Daewoong Pharmaceutical.
Wilson did not disclose any relationship with the industry.
Tamis-Holland disclosed a relationship with Pfizer.