Computed Tomography Angiography or Standard Care After Left Main PCI?
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D'Ascenzo Fabrizio, Cerrato Enrico, De Filippo Ovidio, Gaido Luca, Franzè Alfonso, Iannaccone Mario, Wańha Wojciech, Santarelli Andrea, Guiducci Vincenzo, Barbero Umberto, Fernandez Pereira Carlos, Gatti Marco, Tebaldi Matteo, Giammaria Massimo, Boccuzzi Giacomo, Wojakowski Wojciech, di Pietro Gianluca, Placido Roberto, Gili Sebastiano, Depaoli Alessandro, Biondi Zoccai Giuseppe, Tomassini Francesco, Bruno Francesco, Zugna Daniela, Faletti Riccardo, Biscaglia Simone, Caglioni Serena, Varbella Ferdinando, de Ferrari Gaetano Maria, Campo Gianluca
Аннотация
OBJECTIVES: The authors evaluated whether CCTA-guided follow-up improves clinical outcomes vs symptoms- or ischemia-driven care after LM PCI.
METHODS: PULSE was a prospective, multicenter, open-label randomized trial. A total of 606 patients treated with second-generation drug-eluting stents were enrolled (October 2019 to September 2024) and randomized 1:1 to CCTA at 6 months (experimental) or standard care (control). The primary endpoint was a composite of all-cause death, spontaneous myocardial infarction (MI), unstable angina, or definite or probable stent thrombosis at 18 months. Secondary endpoints included target-lesion revascularization (TLR) and each primary endpoint component.
RESULTS: CCTA was completed in 272/303 experimental patients (89.8%) after a median of 200 days (IQR: 181-270 days). The primary endpoint occurred in 36/303 experimental patients vs 38/303 control patients (11.9% vs 12.5%; HR: 0.97; 95% CI: 0.76-1.23; P = 0.80). Compared with the control arm, the CCTA arm showed a reduced risk of spontaneous MI (0.9% vs 4.9%; HR: 0.26; 95% CI: 0.07-0.91; P = 0.004) and an increased risk of imaging-triggered TLR (4.9% vs 0.3%; HR: 7.7; 95% CI: 1.70-33.7; P = 0.001), whereas clinically driven TLR rates were similar (5.3% vs 7.2%; HR: 0.74; 95% CI: 0.38-1.41; P = 0.32).
CONCLUSIONS: Routine CCTA after LM PCI did not reduce the composite primary endpoint, but was associated with fewer spontaneous MIs and more imaging-triggered revascularizations. Future trials to clarify its value in complex anatomic subsets appear to be warranted. (Angiographic Control vs Ischemia-Driven Management of Patients Treated With PCI on Left Main With Drug-Eluting Stents [PULSE; NCT04144881]).