The impact of stress testing to guide PCI in patients with chronic coronary disease

Garry W Hamilton; Anoop N Koshy; Diem Dinh; Angela Brennan; Julian Yeoh; Matias B Yudi; Mark Horrigan; Christopher M Reid; Dion Stub; William Chan; Ernesto Oqueli; Melanie Freeman; Chin Hiew; Andrew Ajani; Omar Farouque; David J Clark

doi:10.1016/j.carrev.2024.08.010

The impact of stress testing to guide PCI in patients with chronic coronary disease

Cardiovasc Revasc Med. 2024 Aug 15:S1553-8389(24)00623-7. doi: 10.1016/j.carrev.2024.08.010. Online ahead of print.

Authors

Affiliations

¹ Department of Cardiology, Austin Health, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia.
² Centre of Cardiovascular Research and Education in Therapeutics (CCRET), Monash University, Melbourne, Australia.
³ Centre of Cardiovascular Research and Education in Therapeutics (CCRET), Monash University, Melbourne, Australia; School of Population Health, Curtin University, Perth, Australia.
⁴ Centre of Cardiovascular Research and Education in Therapeutics (CCRET), Monash University, Melbourne, Australia; Department of Cardiovascular Medicine, Alfred Hospital, Melbourne, Australia.
⁵ Department of Cardiology, Grampians Health, Ballarat, Australia; School of Medicine, Faculty of Health, Deakin University, Geelong, Australia.
⁶ Department of Cardiology, Box Hill Hospital, Melbourne, Australia.
⁷ Department of Cardiology, University Hospital Geelong, Australia.
⁸ Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia.
⁹ Department of Cardiology, Austin Health, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia; Centre of Cardiovascular Research and Education in Therapeutics (CCRET), Monash University, Melbourne, Australia. Electronic address: david.clark@austin.org.au.

PMID: 39174434
DOI: 10.1016/j.carrev.2024.08.010

Abstract

Background: Guidelines and international appropriate use criteria increasingly endorse non-invasive stress testing to evaluate patients with suspected chronic coronary disease (CCD). We sought to review the real-world utilisation of non-invasive stress testing and investigate whether their use prior to PCI associates with outcomes in patients with CCD.

Methods: Consecutive patients from a multicentre registry who underwent PCI for CCD between 2006 and 2018 were included. Clinical characteristics and outcomes were stratified according to whether stress testing was performed prior to PCI (stress vs no-stress groups). The primary outcome was 3-year all-cause mortality.

Results: Among the 8251 patients included, 4970 (60.2 %) underwent pre-PCI stress testing and this proportion increased over time (p-for-trend<0.001). The stress group had a lower prevalence of prior revascularization, myocardial infarction, or heart failure, and a lower incidence of triple vessel disease, in stent re-stenosis, and ACC/AHA class B2/C lesions (all p < 0.001). When comparing post-procedural outcomes, the stress group had lower rates of arrhythmia (1.5 % vs 2.6 %, p = 0.001), new heart failure (0.2 % vs 0.8 %, p = 0.001), renal impairment, and a shorter length of stay (1.6 vs 2.1 days, p < 0.001). Mortality at 3-years was lower in those undergoing PCI following stress testing (5.8 % vs 8.8 %, p < 0.001). After adjusting for key clinical variables, stress guided revascularization was associated with a significantly lower risk of 3-year mortality (adjusted Hazard Ratio 0.77, 95 % CI 0.64-0.92).

Conclusions: In patients with CCD, PCI guided by non-invasive stress testing is increasingly utilized and associated with improved survival. Further studies are necessary to investigate whether this results from differences in patient characteristics, optimized patient selection, or refined choice of target vessel.

Keywords: Chronic coronary disease; Chronic coronary syndrome; Coronary artery disease; Functional ischemia; Mortality; Percutaneous coronary intervention; Stable ischemic heart disease; Stress testing.