In a nutshell: The hottest developments in the field of cardiology in 2020. Section 5. Coronary artery disease

9. DEFINITION II (Two-Stent vs. Provisional Stenting Techniques for Patients With Complex Coronary Bifurcation Lesions) Trial

Two-stent strategy was superior to provisional stenting for complex bifurcation lesions.

Patients undergoing revascularization of a complex bifurcation lesion (defined as side branch lesion length ≥10 mm, and side branch diameter stenosis ≥70% for distal left main lesions or ≥90% for non-left main lesions) were randomized to a two-stent versus provisional stenting strategy. In the two-stent strategy, the DK-crush (or culotte technique) was strongly encouraged.

Among patients with a complex bifurcation lesion undergoing revascularization, a two-stent strategy was superior to provisional stenting.

The two-stent strategy was associated with a reduction in target lesion failure at 12 months. Benefit was due to reductions in target vessel myocardial infarction and target lesion revascularization. There was a numerical reduction in definite/probable stent thrombosis with the two-stent vs. provisional strategy.

Prior to the introduction of the DK-crush technique, a two-stent strategy was associated with inferior outcomes compared with provisional stenting. Accumulating data support DK-crush as the preferred technique for revascularization of complex bifurcation lesions. For simple bifurcation lesions, provisional stenting may still be considered.

Source: European Heart Journal: Zhang JJ, Ye F, Xu K, et al. The DEFINITION II trial. Eur Heart J 2020;Jun 26

FFR-guided complete revascularization during the index procedure was superior to infarct artery only revascularization.

STEMI patients undergoing primary PCI were randomized to FFR-guided complete revascularization (n = 295) versus infarct artery only revascularization (n = 590). All patients underwent FFR of nonculprit stenoses ≥50%.

The primary outcome, incidence of all-cause death, MI, cerebrovascular event, or any revascularization at 12 months, occurred in 7.8% of the complete group versus 20.5% of the infarct artery only group (p < 0.001).

There was no difference in mortality or MI. Benefit for complete revascularization was driven by a lower rate of future revascularization procedures. Adverse events among non-revascularized lesions tended to occur with FFR values <0.8.

Complete revascularization during the index procedure, which was mostly conducted in this trial, is the most efficient strategy and eliminates the need for future catheterization procedures.

Source: JACC Interventions. Piróth Z, Boxma-de Klerk BM, Omerovic E, et al. The Natural History of Nonculprit Lesions in STEMI: An FFR Substudy of the Compare-Acute Trial. JACC Cardiovasc Interv 2020;13:954-61.

11. ON-TIME 3 (Impact of opioids on P2Y12 receptor inhibition in patients with ST-elevation myocardial infarction who are pre-treated with crushed ticagrelor: Opioids aNd crushed Ticagrelor In Myocardial infarction Evaluation) Trial

Acetaminophen in patients with ST-elevation MI (STEMI) provides pain relief comparable to fentanyl comparable pain relief but with desirably higher blood levels of ticagrelor both immediately after primary percutaneous intervention and 1-hour post procedure.

The synthetic opioid fentanyl impairs gastrointestinal absorption of oral P2Y12 receptor antagonists such as ticagrelor. Opiates do so as well, whereas acetaminophen does not.

ON-TIME 3 was a multicenter, open-label, phase 4 clinical trial in which 195 STEMI patients with a self-reported pain score of at least 4 on a 0-10 scale received crushed ticagrelor in the ambulance along with either 1,000 mg of IV acetaminophen or fentanyl at 1-2 mcg/kg.

Ticagrelor blood levels were significantly higher in the IV acetaminophen group when measured just prior to primary PCI (151 ng/mL versus 60 ng/mL in the IV fentanyl group; immediately after PCI (326 versus 115 ng/mL), and 1-hour post PCI (488 versus 372 ng/mL).

Source: European Heart Journal: https://doi.org/10.1093/ehjcvp/pvaa095