Clinical Pearls & Morning Reports

Posted by Carla Rothaus

Published May 3, 2023


How does factitious disorder differ from malingering?

How did intravascular imaging–guided PCI compare with angiography-guided PCI for the management of complex coronary-artery lesions in the trial by Lee et al.? Read the NEJM Original Article here.

Clinical Pearls

Q: What are complex coronary-artery lesions?

A: Complex coronary-artery lesions in this trial were defined as true bifurcation lesions according to the Medina classification system with a side-branch diameter of at least 2.5 mm; a chronic total occlusion; unprotected left main coronary artery disease; long coronary-artery lesions that would involve an expected stent length of at least 38 mm; multivessel PCI involving at least two major epicardial coronary arteries being treated at the same time; a lesion that would necessitate the use of multiple stents (at least three planned stents); a lesion involving in-stent restenosis; a severely calcified lesion; or ostial lesions of a major epicardial coronary artery.

Q: What have prior trials shown regarding the use of imaging–guidance for PCI?

A: Previous randomized clinical trials have consistently shown a lower risk of clinical events after intravascular ultrasonography–guided PCI than after angiography-guided PCI. However, these trials enrolled too few patients for the evaluation of hard clinical end points, focused on a narrow group of lesion subsets, or were limited to short-term follow-up. Although a few observational studies and meta-analyses have included large numbers of patients, the criteria that were used to define stent optimization were heterogeneous and the inclusion of patients who had been treated with first-generation drug-eluting stents made it unclear that the results would be applicable to contemporary clinical practice. Two randomized, controlled trials have shown similar clinical outcomes with intravascular ultrasonography–guided PCI and with OCT-guided PCI; however, data on long-term clinical outcomes after OCT-guided PCI are limited.

Morning Report Questions

Q: How did intravascular imaging-guided PCI compare with angiography-guided PCI for the management of complex coronary-artery lesions in the trial by Lee et al.?

A: The trial showed that, at a median follow-up of 2.1 years, intravascular imaging–guided PCI for complex coronary-artery lesions was associated with a lower incidence of a composite of death from cardiac causes, target-vessel–related myocardial infarction, or clinically driven target-vessel revascularization than angiography-guided PCI. A primary end-point event had occurred in 76 of 1092 patients in the intravascular imaging group and in 60 of 547 patients in the angiography group (cumulative incidence at 3 years, 7.7% vs. 12.3%; hazard ratio, 0.64; 95% confidence interval [CI], 0.45 to 0.89; P = 0.008). The risk of target-vessel failure without procedure-related myocardial infarction appeared to be lower in the intravascular imaging group than in the angiography group (cumulative incidence, 5.1% vs. 8.7%; hazard ratio, 0.59; 95% CI, 0.39 to 0.90).

Q: What were some of the other findings of this trial?

A: The cumulative incidence of target-vessel–related myocardial infarction or death from cardiac causes was 5.3% in the intravascular imaging group and 8.5% in the angiography group (hazard ratio, 0.63; 95% CI, 0.42 to 0.93). The cumulative incidence of definite stent thrombosis was 0.3% in the overall trial population and was 0.1% in the intravascular imaging-guided group and 0.7% in the angiography group (hazard ratio, 0.25; 95% CI, 0.02 to 2.75). There were no apparent between-group differences in the incidence of procedure-related safety events. More than half the trial population was enrolled at a single center, and the trial included only East Asian patients, which might limit the generalizability of the trial results.

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