Giacobbe Federico, Valente Eduardo, Giannino Giuseppe, Yip Hiu Ching, De Filippo Ovidio, Bruno Francesco, Conrotto Federico, Iannaccone Mario, Zoccai Giuseppe Biondi, Gasparini Mauro, Escaned Javier, De Ferrari Gaetano Maria, D'Ascenzo Fabrizio
Division of Cardiology, Department of Medical Science, AOU Città della Salute e della Scienza di Torino, Turin, Italy.
Dipartimento di Scienze Matematiche, Politecnico di, Torino, Italy.
Catheter Cardiovasc Interv. 2025 Mar;105(4):761-771. doi: 10.1002/ccd.31331. Epub 2025 Jan 2.
In patients with chronic coronary syndromes (CCS), the benefit of percutaneous coronary intervention (PCI) added to optimal medical therapy (OMT) remains unclear. The indication to PCI may be driven either by angiographic evaluation or ischemia assessment, thus depicting different potential strategies which have not yet been thoroughly compared.
Randomized controlled trials (RCTs) comparing OMT versus PCI angio-guided or versus PCI non-invasive or invasive ischemia guided were identified and compared via network meta-analysis. Major adverse clinical events (MACE), as defined by each included trial, were the primary endpoint, while cardiovascular (CV) death, myocardial infarction (MI), and unplanned revascularization the secondary ones.
18 studies, encompassing 17,512 patients, were included, with a mean follow-up of 3.5 years. PCI guided by ischemia defined either invasively or not was associated with a reduced risk of MACE compared with OMT alone. Furthermore, PCI guided by non-invasive assessment of ischemia was associated with a reduced risk of MI compared with OMT (hazard ratio [HR]: 0.61 [95% confidence interval: 0.37-0.94). This strategy ranked best also in preventing CV death. Notably, iFR and FFR guided approaches showed the highest probability of performing best for reduction of subsequent revascularizations.
In patients with CCS, ischemia-guided PCI, either by invasive or non-invasive assessment, resulted in a reduced risk of MACE compared with OMT alone. The use of invasive or non-invasive tests influenced the benefit of ischemia-driven PCI: non-invasive tests significantly reduced risk of MI compared with OMT, while iFR or FFR showed the highest probability of reducing the need of subsequent revascularization.
在慢性冠状动脉综合征（CCS）患者中，经皮冠状动脉介入治疗（PCI）联合优化药物治疗（OMT）的获益仍不明确。PCI的适应证可能由血管造影评估或缺血评估决定，从而描绘出不同的潜在策略，但尚未进行充分比较。
通过网络荟萃分析，识别并比较了比较OMT与血管造影引导的PCI、非侵入性或侵入性缺血引导的PCI的随机对照试验（RCT）。各纳入试验定义的主要不良临床事件（MACE）为主要终点，心血管（CV）死亡、心肌梗死（MI）和非计划血管重建为次要终点。
纳入18项研究，共17512例患者，平均随访3.5年。与单纯OMT相比，侵入性或非侵入性缺血定义引导的PCI与MACE风险降低相关。此外，与OMT相比，非侵入性缺血评估引导的PCI与MI风险降低相关（风险比[HR]：0.61[95%置信区间：0.37 - 0.94]）。该策略在预防CV死亡方面也排名最佳。值得注意的是，iFR和FFR引导的方法在减少后续血管重建方面表现最佳的可能性最高。
在CCS患者中，与单纯OMT相比，侵入性或非侵入性评估的缺血引导PCI导致MACE风险降低。侵入性或非侵入性检查的使用影响了缺血驱动PCI的获益：与OMT相比，非侵入性检查显著降低了MI风险，而iFR或FFR在减少后续血管重建需求方面表现最佳的可能性最高。
