In a nutshell: The hottest developments in the field of cardiology in 2020. Section 5. Coronary artery disease - Page 5
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
Coronary artery disease (CAD) management id undoubtedly the most impactful arena of interventional cardiology. This year we witnessed several important trials that redefined the drug management as well as interventions for CAD. There was ATPCI trial that explored the benefit of trimetazidine in post PCI setup, Tailor PCI, TICO, TWILIGHT COMPLEX, ALPHEUS and COMPARE CRUSH trials will serve as landmarks for future guidelines for antiplatelet therapy in CAD.
The extended outcome of PRECOMBAT trial sheds more light on ever-debatable CABG vs. PCI for left main disease while DEFINITION II has supported DK crush for complex PCI lesions. Finally, COMPARE ACUTE supported the role of FFR in complete revascularisation during the index procedure in STEMI setting.
Page 1: ATPCI and TAILOR-PCI trials
Page 2. TICO and TWILIGHT COMPLEX trials
Page 3. ALPHEUS and COMPARE-CRUSH trials
Page 4. HOST REDUCE POLYTECH ACS and PRECOMBAT trials
Page 5. DEFINITION II, COMPARE ACUTE and ONTIME 3 trials
Long term trimetazidine is safe but not preventative of angina or adverse outcome after PCI.
The ATPCI trial followed 6007 patients receiving either trimetazidine or a placebo, following successful percutaneous coronary intervention (PCI). After a median follow-up of 47.5 months, trimetazidine did not improve either the outcome or the occurrence of angina.
The event rate in this trial was lower than expected and may have contributed to the null finding.
"It is the first study to test the value of increasing the energy status of the ischemic myocyte with trimetazidine in terms of hard end points such as cardiac death and hospitalization. This is particularly relevant considering that a recent study with ranolazine (RIVER-PCI trial), another piperazine derivative, in a similar patient setting failed to show a benefit" noted Roberto Ferrari, MD Department of Cardiology and LTTA Centre University Hospital of Ferrara ITALY (study author).
Source: The Lancet Journal: Ferrari R, Ford I, Fox K, et al. Efficacy and safety of trimetazidine after percutaneous coronary intervention (ATPCI): Lancet 2020;396:830-8.
2. The Tailor PCI (Tailored Antiplatelet Initiation to Lessen Outcomes due to Decreased Clopidogrel Response After Percutaneous Coronary Intervention) trial
A genotype-guided strategy was not superior at reducing adverse cardiovascular events compared with standard therapy after PCI.
Patients undergoing primary PCI for stable or unstable coronary artery disease were randomized to a genotype-guided strategy (n = 2,652) versus standard therapy (n = 2,650).
The primary analysis was between 903 subjects with a loss of function allele (*2 or *3) in the genotype-guided group compared with 946 subjects in the standard therapy group with a loss of function allele.
Among patients who underwent PCI for stable or unstable coronary artery disease, a genotype-guided strategy was not beneficial compared to standard therapy. The primary outcome of major adverse cardiovascular events and bleeding were similar between treatment groups at 12 months.
"Although these results fell short of the effect size that we predicted, they nevertheless provide a signal that offers support for the benefit of genetically guided therapy, with approximately one-third fewer adverse events in the patients who received genetically guided treatment compared with those who did not," said Naveen L. Pereira, MD, of Mayo Clinic, Rochester, Minnesota, co-principal investigator of the study, who presented the results.
Source: JAMA cardiology: Pereira NL, Farkouh ME, So D, et al. The TAILOR-PCI Randomized Clinical Trial. JAMA 2020;324:761-71
