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CARDIOLOGY

New progress in coronary intervention research in 2019, have you got it?

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Percutaneous coronary intervention (PCI) research focuses on optimizing treatment strategies, developing new devices and drug therapies to improve outcomes, and focusing on the identification of risk stratification and high-risk patients who will be emerging from the emerging atherosclerotic evolutionBenefit from therapy.Recently, Eur Heart J summarized the key findings of PCI published in 2019 and discussed their impact on clinical practice.The COACT study of revascularization in patients with cardiac arrest or acute coronary syndrome is a landmark study that has changed the management of patients with cardiac arrest who successfully resuscitated without ST-elevation myocardial infarction (STEMI).The results of this study suggest that immediate angiography does not improve survival in patients with out-of-hospital cardiac arrest (with cardiopulmonary resuscitation but unconsciousness) without STEMI signs compared with delayed angiography.In contrast, the Complete study confirms the value of active revascularization in patients with STEMI.The results of the study showed that the primary endpoint (cardiovascular death and recurrent myocardial infarction) in patients with complete revascularization had a lower incidence (7.8% vs. 10.5%) compared to patients who only interfered with the offender’s blood vessels.However, the prognostic value of complete revascularization in non-STEMI patients has not been fully studied.Revascularization and Drug Therapy for Chronic Coronary Syndrome Although there is strong evidence to support the prognostic significance of complete revascularization in STEMI patients, the value of PCI in improving the prognosis of patients with chronic coronary syndrome is not relevant.One.A retrospective analysis showed that for patients with ischemic load> 5% to 10%, early surgery or percutaneous revascularization can improve the prognosis.However, post hoc analysis of the clinical results of COURAGE did not confirm these findings.The study after 7.9 years of follow-up found that compared with the best drug treatment, PCI combined with the best drug treatment did not improve the prognosis; more importantly, there was no difference between the degree of ischemia or CAD and the treatment strategy (ie conservative and PCI).interaction.The ISCHEMIA study was designed to compare the efficacy and safety of conventional interventional therapy (based on the best drug therapy) with the best drug therapy alone in patients with stable ischemic heart disease with moderate to severe myocardial ischemia.During a follow-up of 3.3 years, there was no significant difference in the incidence of major composite endpoint events between the two groups (15.5% vs. 13.8%, P = 0.34).Studies have shown that interventional therapy based on this does not benefit patients with stable coronary heart disease with moderate to severe myocardial ischemia compared with the best medication alone.However, an important limitation of the study is the high crossover rate (28%) between conservative and invasive treatments, which may affect the reported results.A recent post hoc analysis of the STICH study failed to demonstrate that the presence or absence of myocardial survival has an impact on the survival benefit of patients undergoing surgical revascularization.The REVIVED trial is currently investigating the safety and effectiveness of PCI in improving the prognosis of patients with heart failure.Patient management in different disease categories 1. Surgical revascularization of the left main trunk with three vascular lesions is currently the recommended treatment strategy for patients with multiple coronary lesions with diabetes. PCI is recommended for patients with SYNTAX score ≤ 22 and SYNTAX score is>22 patients are not recommended.These recommendations are consistent with the results of a follow-up study from FREEDOM, which showed that the PCI group had a higher mortality at 8 years of follow-up compared to the surgical revascularization group (24.3% vs. 18.3%, P = 0.010).In contrast, a non-inferiority study comparing PCI (first-generation paclitaxel-eluting stent) and coronary artery bypass grafting (CABG) of the three branches of the coronary artery and the left main lesion was compared with the SYNTAX study.All-cause mortality showed no significant difference (27% vs. 24%, P = 0.092).CABG has certain advantages in patients with three branches of disease, but left main disease does not.However, both studies have limitations: patients in the PCI group used the first-generation therapeutic drug-eluting stent (DES), which is no longer used, and they only reported all-cause mortality, not patient-specificGuided cardiovascular endpoint.The EXCEL trial overcomes these limitations, selecting a second-generation DES and using all-cause death, myocardial infarction, or stroke as the composite endpoint.At 5-year follow-up, there was no difference in composite endpoints between the PCI and CABG treatment groups.Similar to the situation reported in the SYNTAX study, there were no differences in outcomes between the two treatment strategies for patients with diabetes and non-diabetes at 3- and 5-year follow-up.2. Left main bifurcation lesions. In 2019, the 3-year follow-up results of the DKCRUSH-V trial were announced.The results showed that the failure rate of target lesions in the DK Crush technology group was 8.3%, which was significantly lower than the single stent group’s 16.9%.This is mainly because DK Crush technology reduces target vessel myocardial infarction and target lesion revascularization (TLR).In addition, exact or probable intra-stent thrombosis is also less common in the DK Crush technology group than in the single-stent group.It is worth noting that DK Crush technology is even better for patients with complex lesions or at high risk.However, the 14th consensus document recently released by the European Bifurcation Club advocates the use of temporary T-stent technology for the treatment of bifurcation lesions, and suggests that only when the lesions have an anatomical complex structure that is difficult to enter the collaterals, or where the collateral entrance has> 5 mmTwo stent strategies are used only when the bulge or calcification increases.In the case of the double-stent strategy, the European Forking Club recommends using the culotte technique or the TAP technique, and when considering the squeeze technique, it is recommended to use the DK Crush technique.3. Chronic total occlusive disease According to the ESC myocardial revascularization guidelines, combined with the results of randomized controlled studies, the European CTO Club recommends that despite the best drug treatment, CTO recanalization should be performed in the presence of symptoms; for asymptomatic patientsIt is recommended to perform an ischemic load assessment, and if there is evidence of an increase in ischemic load (≥10% of left ventricular mass), CTO revascularization is recommended.The results of the recently published DECISION-CTO study support this recommendation again.The study followed up for 4 years and found no difference in the composite endpoints and quality of life for death, myocardial infarction, stroke, or revascularization between the CTO-PCI group and the non-CTO-PCI group.Studies have shown that in multivessel disease, it is recommended to consider revascularization of non-CTO lesions and re-evaluation of ischemia and patient symptoms before using CTO.4. Small vessel disease and in-stent restenosis Small vessel disease has a higher incidence of TLR due to major adverse cardiovascular events (MACE) and in-stent restenosis during PCI.The 3-year follow-up data from the BIO-RESORT study showed that, in terms of mortality, incidence of target vascular myocardial infarction, and stent thrombosis, the ultra-thin stent Orsiro and the ultra-thin stent Synergy had no statistical difference compared to the thin-stent RESOLUTE INTEGRITY;In terms of TLR, the ultra-thin stent Orsiro excels.These findings highlight the effect of stent thickness on the prognosis of small vessel disease in the DES era, and are consistent with the results of previously reported studies of bare metal stents.In-stent restenosis is the most common cause of stent treatment failure. The two most effective treatment strategies currently are drug-coated balloon angioplasty or DES implantation.The DAEDALUS study published in 2019 analyzed the differences in anti-restenosis efficacy between DES and drug-coated balloons.The results showed a higher incidence of paclitaxel-coated balloon angioplasty TLR compared to DES implantation.However, the composite endpoint of death, myocardial infarction, or target lesion thrombosis did not differ between the two groups.Existing and emerging interventional devices 1. DES and bioabsorbable stents The ESC Myocardial Revascularization Guidelines recommend the use of second-generation DES in clinical practice.The COMFORTABLE-AMI late follow-up study further demonstrated the superiority of DES in STEMI patients compared to bare metal stents.The BIOSTEMI study found that compared with Xience, patients treated with ultra-thin Orsiro had lower clinically indicated target lesion revascularization rates, leading to differences in TLF.In contrast, the TALENT study concluded that the clinical efficacy of the ultra-thin sirolimus-eluting stent Supraflex is not significantly different from the clinical efficacy of Xience.The introduction of bioabsorbable stents overcomes the limitations of DES and improves long-term efficacy.However, the increased incidence of these devices during short- and medium-term follow-up has raised concerns about their safety and is not currently recommended for routine clinical use.A recent meta-analysis comparing the results of a randomized study of resorbable biostents (BVS) and everolimus-eluting stents found that the incidence of TLF in BVS was higher during a 5-year follow-up (14.9% vs. 11.6%,P = 0.030).Another landmark analysis showed a higher incidence of events in the Absorb BVS group within 0–3 years of follow-up.However, during the follow-up period of 3-5 years, the incidence of cardiogenic death, target vascular myocardial infarction, ischemic TLR and device thrombosis was similar between the two groups in patients who had not experienced an event in the first 3 years.These findings provide the basis for the timing of adverse events in bioabsorbable stents for the first time, and indicate that the incidence of long-term events after complete absorption is low.2. Assisted interventional devices In recent years, intravascular lithotripsy (IVL) has become an effective alternative method for the treatment of calcified lesions.The technology uses sound pressure waves emitted by neatly arranged small lithotripters to break calcified lesions in blood vessels, and the surrounding soft tissues are not affected by them.The DISRUPT CAD study is the first study to systematically evaluate the safety and effectiveness of IVL.The study included 60 patients with severe calcification and a length of 32 mm or less.The results showed that the operation was successful in all lesions, the acute lumen obtained was 1.7 mm, and the residual stenosis was 12.2%.The results of the DISRUPT CAD II study are similar, showing that IVL can significantly increase the lumen area and improve the stent adherence, and no malignant arrhythmia was found.The ongoing DISRUPT CAD III study is expected to provide further evidence for the safety and effectiveness of IVL in the treatment of calcified lesions.The strategy and duration of antiplatelet therapy for adjuvant drugs in patients with PCI has been an area of ​​intensive research by scholars.The results of the TWILIGHT trial announced at the TCT Annual Meeting showed that patients who received PCI and placed DES were switched to ticagrelor monotherapy after 3 months of dual antiplatelet therapy (DAPT). Compared with continuing DAPT, the risk of bleeding was higher.Decreased without an increase in ischemic risk.However, the latest post hoc analysis results of the GLOBAL LEADERS study show that for patients after complex PCI, compared with standard antiplatelet therapy (1 year DAPT + 1 year aspirin), the long-term ticagrelor strategy (1 month DAPT)(Tegrelol alone) may be better.Another study also showed that prolonged DAPT treatment was associated with a lower incidence of ischemic events in patients with a lower risk of bleeding, especially in patients receiving complex PCI.In contrast, long-term use of DAPT in patients with high bleeding risk does not reduce the risk of ischemic events, but increases the risk of bleeding.Patients with AF after PCI have an increased risk of bleeding after receiving antiplatelet and anticoagulant therapy.In recent years, several large-scale randomized controlled studies have investigated the best treatment options for such patients.The results of the much-watched AUGUSTUS trial were announced at this year’s ACC annual meeting.Studies show that for patients with atrial fibrillation who have recently had ACS or received PCI, the risk of bleeding is significantly reduced with the dual antithrombotic regimen of apixaban + P2Y12 inhibitor compared with the triple therapy regimen of warfarin + DAPTThere was no significant difference in the incidence of ischemic events.The results of the ENTRUST-AF PCI study are similar.Studies have confirmed that dual antithrombotic therapy with edosaban + P2Y12 inhibitors is not inferior to VKA triple therapy in terms of primary study endpoints (major bleeding and clinically relevant non-major bleeding).A meta-analysis published this year also confirmed the findings, but patients receiving dual antithrombotic therapy had a higher risk of developing stent thrombosis.Invasive diagnostic tests 1. Coronary physiology tests Recent studies have shown that blood flow reserve fraction (FFR) and resting indicators, including instantaneous no-wave speed ratio (iwFR), can not only guide blood flow reconstruction, but also assessThe final results and predictive prognosis also have some value.However, there are occasional inconsistencies between high blood volume FFR and resting index.A subgroup analysis of the DEFINE-FLAIR study compared the prognosis of patients with left anterior descending branch disease with delayed vascular reconstruction based on FFR or iwFR assessment.The follow-up results showed that the 1-year event rate was lower in the iwFR group.In contrast, a post hoc analysis of a study of patients with diabetes showed no difference in prognosis between the FFR and iwFR groups; however, the iwFR group had a higher incidence of nonfatal myocardial infarction and a significant correlation with diabetes.While introducing resting indicators to assess the severity of intermediate lesion function, researchers are also working to explore computer-assisted coronary angiography or invasive imaging data to obtain FFR.In 2019, two new calculation-derived FFR solutions were proposed: one is to obtain the vessel geometry and estimate the pressure reduction at the lesion by three-dimensional quantitative coronary angiography; the other is to process OCT imaging data.The latter can be combined with morphological and physiological assessments of atherosclerotic lesions and surgical outcomes after PCI.Preliminary validation of these solutions shows good results; however, before they can be widely used in the clinical field, further evaluation of the efficacy on a large number of patients is needed.2. Multiple accumulated evidence for intravascular imaging has demonstrated the value of intravascular ultrasound (IVUS) in guiding PCI.A meta-analysis published this year highlighted IVUS-guided prognostic benefits, with a lower incidence of MACE, cardiac death, TLR, and clear / probable stent thrombosis in the IVUS-guided group compared to the angiographic-guided group.Consistent with the above findings, the 5-year follow-up analysis of the IVUS-XPL study showed that the incidence of MACE and TLR was lower in the IVUS-guided group, which brought benefits from long-term follow-up.These findings underscore the significance of IVUS in guiding the prognosis of revascularization and support its routine use to optimize surgical outcomes and improve short- and long-term outcomes after PCI.FFR is currently recommended to guide vascular reconstruction in patients with chronic coronary syndromes and moderate stenosis.The FORZA study compared the outcome and prognosis of FFR and optical coherence tomography (OCT) guided PCI.After 13 months of follow-up, it was found that the incidence and cost of vascular reconstruction caused by OCT-guided PCI were higher, but there was no difference between the two groups in all-cause death, myocardial infarction, the composite endpoint of target vascular reconstruction, and the incidence of MACE.In 2019, the European Society of Percutaneous Cardiovascular Interventions (EAPCI) published a consensus on clinical applications of intracoronary imaging.This consensus emphasizes the value of intravascular imaging, especially the value of OCT in criminal lesions that cannot be detected by coronary angiography and in the individualized treatment of ACS patients.At the same time, the consensus also emphasized the value of intravascular imaging in assessing ambiguous coronary angiography results, detecting embolism events and intramural hematomas, assessing lesions caused by external organ compression on the blood vessels, and summarizing their support in identifying vulnerableEvidence for a role in plaque and high-risk patients.3. Non-invasive imaging technology Non-invasive imaging technology plays an important role in the diagnosis of symptomatic obstructive CAD patients.MR-INFORM research shows that non-invasive imaging technology, especially cardiac magnetic resonance imaging (CMR), can be used not only for the diagnosis of CAD but also for guiding the revascularization.Similar results were obtained in the CROSS-AMI study, which compared the differences in revascularization between STAMI patients under angiography and echocardiography.A one-year follow-up found no differences in the primary endpoints of cardiogenic death, myocardial infarction, coronary revascularization, or rehospitalization due to heart failure between the two groups.However, one limitation of the CROSS-AMI study is the lack of ability to assess differences between groups.Therefore, it is necessary to further study the value of noninvasive imaging in guiding vascular reconstruction in patients with ACS.Detection of vulnerable plaques In short-term follow-up, the incidence of patients undergoing revascularization, especially in patients with ACS, is high.The emergence of new drug therapies seems to improve atherosclerotic plaques and inhibit disease progression, but its costs and side effects are high.Therefore, accurate risk stratification and identification of high-risk patients are expected to provide personalized active treatment for these patients to improve the prognosis of vulnerable groups.Large-scale prospective intravascular imaging studies have highlighted the value of IVUS in cardiovascular risk in detecting vulnerable plaques that may progress and cause events, as well as more accurate stratification of risks.The Lipid-Rich Plaque (LRP) and CLIMA studies published in 2019 evaluated for the first time the efficacy of near-infrared spectroscopy (NIRS) -IVUS and OCT in detecting vulnerable plaques.During the 2-year follow-up of the LRP study, it was found that the incidence of non-criminal MACE in patients with increased lipid load was higher than that in patients without lipid plaque, and maxLCBI4mm> 400 was an independent predictor of MACE.This study provided evidence for the prognostic impact of plaque components, but due to incomplete IVUS analysis, it was limited to maxLCBI at 4 mm segments and failed to study the synergistic value of NIRS and IVUS in predicting events.The CLIMA study found that the minimum lumen area is <3.5 mm2, the lipid arc is> 180 °, the thickness of the fiber cap is <75 μm, and macrophage accumulation is an independent predictor of end-stage cardiac death and target myocardial infarction.The incidence of events was higher in patients with all plaque-specific lesions than in other patients.In 2019, the combined IVUS-OCT catheter was first applied in the human body.In addition, the application of polarization-sensitive OCT imaging systems in the human body was proposed in 2019, and this method is expected to better describe plaque characteristics and evaluate their composition in more detail.Two more recent reports have examined the efficacy of attenuation compensation techniques.Attenuation compensation is a post-processing method that seems to enhance the depth of OCT imaging and more accurately assess the plaque burden in severely diseased segments.These reports highlight the potential of this approach in assessing the intrinsic vascular plaque area of ​​severe lesions, but also show the significant limitations of this technique.The effect of local hemodynamics on the progression and instability of atherosclerotic diseases cannot be ignored.IBIS-4 analysis shows that the shear stress distribution estimated using computational fluid dynamics analysis has added value in predicting the progression of atherosclerotic disease and changes in plaque morphology, and PROSPECT studies have shown that plaques are estimated by processing virtual histological IVUS imagesBlock stress can more accurately identify lesions that will cause events in the future.Conclusion STEMI patients should be actively treated with the goal of complete vascular reconstruction.In contrast, for patients with out-of-hospital cardiac arrest who have no clinical evidence of acute ischemia, the initial conservative treatment appears to be as effective as early invasive treatment.Strong evidence highlights the short- and long-term efficacy of DES, and advances in coronary physiology and the development of image-based FFR calculation methods are expected to expand its application in guiding revascularization.Cumulative data highlights the prognostic benefits of endovascular imaging in guiding PCI and assessing pathology of lesions, while advances in intravascular imaging and computational models are expected to better predict vulnerable lesions and at-risk patients who will benefit fromNew treatments for plaque evolution.These advances are expected to improve the surgical outcome and long-term prognosis of patients with coronary heart disease through personalized drug invasion strategies..

ouyangshaoxia

The author ouyangshaoxia