Yeonwoo Choi, Do-Yoon Kang, Hoyun Kim, Jinho Lee, Sangyong Jo, Jung-Min Ahn, Nayoung Kim, Yong-Hoon Yoon, Seung-Ho Hur, Cheol Hyun Lee, Won-Jang Kim, Se Hun Kang, Chul-Su Park, Bong-Ki Lee, Jung-Won Suh, Jae Woong Choi, Kee-Sik Kim, Su Nam Lee, Seung-Jung Park, Duk-Woo Park
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引用次数: 0
Abstract
Objective: The optimal follow-up strategy for high-risk patients who underwent imaging-guided or physiology-guided percutaneous coronary intervention (PCI) remains uncertain. We investigated whether routine surveillance stress testing after PCI provides clinical benefit when the procedure is guided by intravascular ultrasonography (IVUS) or fractional flow reserve (FFR).
Methods: In the Pragmatic Trial Comparing Symptom-Oriented vs Routine Stress Testing in High-Risk Patients Undergoing PCI randomised trial, 1706 high-risk patients who underwent PCI were assigned to either routine functional testing at 1 year or standard care alone. In this prespecified subgroup analysis, patients were subsequently categorised according to whether IVUS or FFR was used at the index procedure. The primary outcome was a composite of death, myocardial infarction or hospitalisation for unstable angina over 2 years.
Results: Among the randomised population, 74% underwent IVUS-guided intervention and 36% underwent FFR-guided intervention. At 2 years, rates of the primary outcome were similar between routine testing and standard care both in patients treated with IVUS guidance (5.3% vs 6.7%; HR 0.79; 95% CI 0.50 to 1.24) and without IVUS guidance (5.7% vs 3.8%; HR 1.52; 95% CI 0.63 to 3.68; interaction p=0.21). Comparable results were observed in patients with FFR guidance (2.6% vs 3.9%; HR 0.65; 95% CI 0.26 to 1.58) and without FFR guidance (7.0% vs 7.1%; HR 0.99; 95% CI 0.63 to 1.55; interaction p=0.59). Routine functional testing was consistently associated with higher use of invasive coronary angiography and repeat revascularisation, without improvement in clinical outcomes.
Conclusions: Among high-risk patients who underwent PCI, routine surveillance stress testing did not reduce the risk of death, myocardial infarction or unstable angina, regardless of the use of IVUS or FFR at the index procedure. Routine functional testing increased downstream invasive procedures without clinical benefit. These findings support guideline recommendations against routine surveillance testing after PCI.
目的：高危患者行影像引导或生理引导下经皮冠状动脉介入治疗（PCI）的最佳随访策略尚不确定。我们研究了在血管内超声（IVUS）或分数血流储备（FFR）指导下，PCI术后常规监测压力测试是否能提供临床益处。方法：在一项比较高危PCI患者症状导向与常规压力测试的随机试验中，1706例高危PCI患者被分配到1年常规功能测试或单独标准治疗。在这个预先指定的亚组分析中，随后根据IVUS或FFR在索引程序中是否使用对患者进行分类。主要结局是死亡、心肌梗死或不稳定型心绞痛住院超过2年。结果：在随机人群中，74%的患者接受了ivus引导的干预，36%的患者接受了ffr引导的干预。2年时，接受IVUS指导的患者（5.3% vs 6.7%; HR 0.79; 95% CI 0.50 ~ 1.24）和未接受IVUS指导的患者（5.7% vs 3.8%; HR 1.52; 95% CI 0.63 ~ 3.68；交互作用p=0.21），常规检测和标准治疗的主要转归率相似。在有FFR指导的患者（2.6% vs 3.9%; HR 0.65; 95% CI 0.26 ~ 1.58）和没有FFR指导的患者（7.0% vs 7.1%; HR 0.99; 95% CI 0.63 ~ 1.55；相互作用p=0.59）中观察到类似的结果。常规功能检查始终与侵入性冠状动脉造影和重复血运重建的高使用率相关，而临床结果没有改善。结论：在接受PCI的高危患者中，无论在指标程序中使用IVUS或FFR，常规监测压力测试都不能降低死亡、心肌梗死或不稳定心绞痛的风险。常规功能测试增加了下游侵入性手术，但没有临床益处。这些发现支持PCI术后常规监测检测的指南建议。试验注册号：NCT03217877。
期刊介绍：
Heart is an international peer reviewed journal that keeps cardiologists up to date with important research advances in cardiovascular disease. New scientific developments are highlighted in editorials and put in context with concise review articles. There is one free Editor’s Choice article in each issue, with open access options available to authors for all articles. Education in Heart articles provide a comprehensive, continuously updated, cardiology curriculum.
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