Population-based study of the use of cardiac stress imaging and referral for coronary angiography and repeated revascularization after coronary artery bypass graft surgery

Surveillance Stress Testing After Percutaneous Intervention for Patients With Multivessel or Left Main Coronary Disease

BACKGROUND

The optimal surveillance strategy after percutaneous coronary intervention (PCI) for high-risk patients with multivessel or left main coronary artery disease (CAD) remains uncertain.

OBJECTIVES

This study aims to determine the prognostic role of routine functional testing in patients with multivessel or left main CAD who underwent PCI.

METHODS

The POST-PCI (Pragmatic Trial Comparing Symptom-Oriented Versus Routine Stress Testing in High-Risk Patients Undergoing Percutaneous Coronary Intervention) trial randomized high-risk PCI patients to routine functional testing at 1 year or standard care alone during follow-up. This analysis focused on participants with multivessel or left main CAD. The primary outcome was a composite of death from any cause, myocardial infarction, or hospitalization for unstable angina at 2 years.

RESULTS

Among 1,706 initially randomized patients, 1,192 patients with multivessel (n = 833) or left main (n = 359) were identified, with 589 in the functional testing group and 603 in the standard care group. Two-year incidences of primary outcome were similar between the functional testing group and the standard care group (6.2% vs 5.7%, respectively; HR: 1.09; 95% CI: 0.68-1.74; P = 0.73). This trend persisted in both groups of multivessel (6.2% vs 5.7%; HR: 1.09; 95% CI: 0.62-1.89; P = 0.78) and left main disease (6.2% vs 5.7%; HR: 1.09; 95% CI: 0.46-2.56; P = 0.85) (P for interaction = 0.90). Routine surveillance functional testing was associated with increased rates of invasive angiography and repeat revascularization beyond 1 year.

CONCLUSIONS

In high-risk patients with multivessel or left main CAD who underwent PCI, there was no incremental clinical benefit from routine surveillance functional-testing compared with standard care alone during follow-up. (Pragmatic Trial Comparing Symptom-Oriented Versus Routine Stress Testing in High-Risk Patients Undergoing Percutaneous Coronary Intervention [POST-PCI]; NCT03217877).

Routine stress testing in diabetic patients after percutaneous coronary intervention: the POST-PCI trial

BACKGROUND AND AIMS

The optimal follow-up surveillance strategy for high-risk diabetic patients with had undergone percutaneous coronary intervention (PCI) remains unknown.

METHODS

The POST-PCI (Pragmatic Trial Comparing Symptom-Oriented versus Routine Stress Testing in High-Risk Patients Undergoing Percutaneous Coronary Intervention) study was a randomized trial comparing a follow-up strategy of routine functional testing at 1 year vs. standard care alone after high-risk PCI. Randomization was stratified according to diabetes status. The primary outcome was a composite of death from any cause, myocardial infarction, or hospitalization for unstable angina at 2 years.

RESULTS

Among 1706 randomized patients, participants with diabetes (n = 660, 38.7%) had more frequent comorbidities and a higher prevalence of complex anatomical or procedural characteristics than those without diabetes (n = 1046, 61.3%). Patients with diabetes had a 52% greater risk of primary composite events [hazard ratio (HR) 1.52; 95% confidence interval (CI) 1.02-2.27; P = .039]. The 2-year incidences of the primary composite outcome were similar between strategies of routine functional testing or standard care alone in diabetic patients (7.1% vs. 7.5%; HR 0.94; 95% CI 0.53-1.66; P = .82) and non-diabetic patients (4.6% vs. 5.1%; HR 0.89; 95% CI 0.51-1.55; P = .68) (interaction term for diabetes: P = .91). The incidences of invasive coronary angiography and repeat revascularization after 1 year were higher in the routine functional-testing group than the standard-care group irrespective of diabetes status.

CONCLUSIONS

Despite being at higher risk for adverse clinical events, patients with diabetes who had undergone high-risk PCI did not derive incremental benefit from routine surveillance stress testing compared with standard care alone during follow-up.

Routine Functional Testing or Standard Care in High-Risk Patients after PCI

BACKGROUND

There are limited data from randomized trials to guide a specific follow-up surveillance approach after myocardial revascularization. Whether a follow-up strategy that includes routine functional testing improves clinical outcomes among high-risk patients who have undergone percutaneous coronary intervention (PCI) is uncertain.

METHODS

We randomly assigned 1706 patients with high-risk anatomical or clinical characteristics who had undergone PCI to a follow-up strategy of routine functional testing (nuclear stress testing, exercise electrocardiography, or stress echocardiography) at 1 year after PCI or to standard care alone. The primary outcome was a composite of death from any cause, myocardial infarction, or hospitalization for unstable angina at 2 years. Key secondary outcomes included invasive coronary angiography and repeat revascularization.

RESULTS

The mean age of the patients was 64.7 years, 21.0% had left main disease, 43.5% had bifurcation disease, 69.8% had multivessel disease, 70.1% had diffuse long lesions, 38.7% had diabetes, and 96.4% had been treated with drug-eluting stents. At 2 years, a primary-outcome event had occurred in 46 of 849 patients (Kaplan-Meier estimate, 5.5%) in the functional-testing group and in 51 of 857 (Kaplan-Meier estimate, 6.0%) in the standard-care group (hazard ratio, 0.90; 95% confidence interval [CI], 0.61 to 1.35; P = 0.62). There were no between-group differences with respect to the components of the primary outcome. At 2 years, 12.3% of the patients in the functional-testing group and 9.3% in the standard-care group had undergone invasive coronary angiography (difference, 2.99 percentage points; 95% CI, -0.01 to 5.99), and 8.1% and 5.8% of patients, respectively, had undergone repeat revascularization (difference, 2.23 percentage points; 95% CI, -0.22 to 4.68).

CONCLUSIONS

Among high-risk patients who had undergone PCI, a follow-up strategy of routine functional testing, as compared with standard care alone, did not improve clinical outcomes at 2 years. (Funded by the CardioVascular Research Foundation and Daewoong Pharmaceutical; POST-PCI ClinicalTrials.gov number, NCT03217877.).

Prognostic value of vasodilator stress perfusion CMR in patients with previous coronary artery bypass graft

AIMS 

The accuracy and prognostic value of stress perfusion cardiac magnetic resonance (CMR) are established in coronary artery disease (CAD) patients. Because myocardial contrast kinetics may be altered after coronary artery bypass graft (CABG), most studies excluded CABG patients. This study aimed to assess the prognostic value of vasodilator stress perfusion CMR in CABG patients.

METHODS AND RESULTS 

Consecutive CABG patients referred for stress CMR were retrospectively included and followed for the occurrence of major adverse cardiovascular events (MACE) including cardiovascular (CV) death or non-fatal myocardial infarction (MI). Cox regression analyses were performed to determine the prognostic association of inducible ischaemia and late gadolinium enhancement (LGE) by CMR. Of 866 consecutive CABG patients, 852 underwent the stress CMR protocol and 771 (89%) completed the follow-up [median (interquartile range) 4.2 (3.3-6.2) years]. There were 85 MACE (63 CV deaths and 22 non-fatal MI). Using Kaplan-Meier analysis, the presence of inducible ischaemia identified the occurrence of MACE [hazard ratio (HR) 3.52, 95% confidence interval (CI): 2.27-5.48; P < 0.001] and CV death (HR 2.55, 95% CI: 1.52-4.25; P < 0.001). In a multivariable stepwise Cox regression including clinical characteristics and CMR indexes, the presence of inducible ischaemia was an independent predictor of a higher incidence of MACE (HR 3.22, 95% CI: 2.06-5.02; P < 0.001) and CV death (HR 2.15, 95% CI: 1.28-3.62; P = 0.003), and the same was observed for LGE (both P = 0.02).

CONCLUSION 

Stress CMR has a good discriminative prognostic value in patients after CABG, with a higher incidence of MACE and CV death in patients with inducible ischaemia and/or LGE.