Interventional Cardiology: Coronary
Percutaneous Coronary Intervention: Developments in the Last 12 Months Rhian E Davies, DO, and J Dawn Abbott, MD Division of Cardiology, Rhode Island Hospital, Brown Medical School, Providence, RI
Abstract In 2018, there were several studies that significantly added to the field of interventional cardiology. Research was focused on understanding the role of percutaneous coronary intervention (PCI) in various clinical syndromes, optimizing outcomes for high-risk lesion subsets, and building an evidence base for greater adoption of PCI guided by physiology and intracoronary imaging. In the area of innovation, novel and iterative developments in drug-eluting stents (DES) and scaffold platforms were compared with current generation DES. This article summarizes the research from last year which has had the most impact on PCI techniques and clinical care.
Keywords Angina, cardiogenic shock, drug-eluting stent, bifurcation, restenosis, intracoronary imaging, coronary physiology Disclosure: J Dawn Abbott has research grants with no direct compensation from SINOMED, Biosensors USA, Abbott Vascular, AstraZeneca and Bristol-Myers Squibb. RD has no conflicts of interest to declare. Received: January 16, 2019 Accepted: February 4, 2019 Citation: US Cardiology Review 2019;13(1):11–5. DOI: https://doi.org/10.15420/usc.2019.1.1 Correspondence: J Dawn Abbott, Department of Medicine, Division of Cardiology, Warren Alpert Medical School of Brown University, 593 Eddy Street, RIH APC814, Providence, RI 02903. E: JAbbott@Lifespan.org Open Access: This work is open access under the CC-BY-NC 4.0 License which allows users to copy, redistribute and make derivative works for non-commercial purposes, provided the original work is cited correctly.
Percutaneous Coronary Intervention for Clinical Syndromes Stable Angina The primary benefit of percutaneous coronary intervention (PCI) over medical therapy in patients with stable angina is the improved quality of life. The PCI in stable angina (ORBITA) trial was the first sham-controlled trial of PCI where 200 medically optimized patients with single vessel disease were randomized to PCI or placebo procedure.1 The trial failed to show a benefit of PCI at 6 weeks in the primary endpoint of exercise treadmill time or secondary endpoints of patient-centered outcomes. Limitations of the trial included high exercise time and low ischemic burden at baseline and a short follow-up period.1 The effect of medications and the uncertainty of stent treatment may have also influenced exercise time. The landmark trial, however, showed similar short-term outcomes in both study groups, and its findings support shared decision making and a conservative approach in patients with stable angina and similar risk profiles to those in the trial.
Cardiogenic Shock Holger et al. reported the 1-year outcomes of the randomized Culprit lesion only PCI versus multi-vessel PCI in Cardiogenic Shock (CULPRITSHOCK) trial.2 The primary endpoint at 30 days favored the culprit-only approach, with significantly lower rates of the composite of death or renal-replacement therapy (45.9% versus 55.4%, p=0.01).2 At 1 year follow-up, there was a trend towards lower risk of the composite of death and recurrent infarction in the culprit-only group (relative risk 0.87; 95% CI: 0.76–1.00) that did not reach statistical significance. In addition,
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rates of repeat revascularization (32.3% versus 9.4%; relative risk 3.44; 95% CI [2.39–4.95]), and rehospitalization for heart failure occurred more frequently in the culprit-only group.2 The 1-year results support a culprit-only approach in the acute setting for MI with cardiogenic shock, however, when patients stabilize and their risk of acute kidney injury is lower, ischemia-guided or complete revascularization to prevent subsequent unplanned revascularization or admissions may improve long-term outcomes in this high-risk patient cohort. Unloading the left ventricle (LV) with mechanical support before revascularization in acute ST segment elevation MI (STEMI) has also been under investigation. The theory is that unloading will limit infarct size and translate into lower mortality. The recent multi-center, prospective, randomized trial by Kapur et al. demonstrated feasibility of implantation of the Impella CP device (Abiomed) in STEMI with a mean longer door to balloon time of 25 minutes, with no difference in clinical outcomes or infarct size.3 A larger pivotal trial to compare pre-reperfusion unloading to the standard of care is needed before implementing a change in clinical practice.
Out-of-hospital Cardiac Arrest The optimal timing of cardiac catheterization in patients with outof-hospital cardiac arrest (OHCA) of presumed cardiac cause but without STEMI is unknown. The French Registry for OHCA evaluated the association between an immediate invasive strategy and survival in a cohort of 1,410 patients, according to their cardiac arrest hospital prognosis score.4 This score is calculated from: age, setting
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