Interventional cardiology

Aussie data assists decision making for PCI in patients with stable IHD

Percutaneous coronary intervention (PCI) is safe and effective for symptom relief in patients with stable ischaemic heart disease (IHD) that is refractory to medical therapy, according to ‘real world’ data from an Australian registry.

While revascularisation does not improve prognosis in patients with stable IHD, Victorian clinicians says its benefits in improving symptoms and quality of life in appropriately selected cases should not be discounted, including in those with severe proximal left anterior descending (LAD) disease.

In a new study they report data for 9,421 PCI procedures in stable IHD conducted over a 14 year period, obtained from the Melbourne Interventional Group (MIG) registry, which they say shows “a high degree of procedural success and an excellent safety profile … despite increasing patient and procedural complexity.”

Led by Dr Garry Hamilton of the Department of Cardiology, Austin Health, Melbourne, the researchers reviewed outcomes for patients undergoing PCI for symptomatic stable IHD between 2005–2018.

They found that  over time, patients were increasingly co-morbid with conditions such as diabetes, COPD, be current smokers, and have a family history of coronary artery disease . Patients were also more likely to be older and had higher rates of AHA/ACC class B2/C lesions, ostial stenoses, bifurcation lesions, and chronic total occlusions.

Despite this, the in-hospital and 30-day outcomes were stably low over the 14 year study period, they noted.

Rates of peri-procedural adverse events were very low, with a reduction in major bleeding events over time from 1.1% to 0.3%.

There were only seven (0.07%) in-hospital deaths, and no change over time in 5-year mortality, which was 10.3% overall.

The major predictors of long term mortality were low renal function, low left ventricular ejection fraction, and COPD.

The study authors said the excellent safety outcomes could be explained by ongoing improvements in PCI techniques and technologies which may have offset increasingly complex lesions in higher risk patients.

“These include safer arterial access techniques and vessel closure devices, functional assessments of ischaemia, intracoronary imaging, and newer drug eluting stents,” they wrote

In a sub analysis of 1,551 patients who had proximal left anterior descending (LAD)  PCI the study showed that procedural success was higher than the non-proximal LAD group (97.1% vs 94.2%) and there were no differences found in in-hospital or 30-day outcomes, nor 5-year mortality.

“Coupled with the demonstrated safety in the primary analysis, these findings provide reassurance that patients with symptomatic stable IHD who have severe stenoses in the proximal LAD tolerate PCI well, despite the large area of myocardium at risk,” the study authors wrote.

The researchers noted that their data came from the era prior to the MBS Review Taskforce implementing changes to reimbursement for cardiac services to encourage more appropriate use of PCI in patients with stable IHD.

“Nonetheless, we demonstrated real-world safety which likely justifies intervention in carefully selected patients with symptoms refractory to medical therapy,” they wrote.

“The decision requires careful contemplation using a shared decision-making model involving patients and their families. This includes weighing up the risks of the procedure (including real-world data such as these) with the likely symptomatic benefit, in the context of RCT evidence lacking a prognostic advantage.”

“Our findings provide valuable real-world insights to complement RCT evidence and enhance such discussions,” they concluded.

The findings are published in Heart, Lung and Circulation (link here)

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