In A Nutshell: The Hottest Developments In The Field Of Cardiology In 2020. Section 5. Coronary Artery Disease

Coronary Artery Disease Management

Coronary artery disease (CAD) management is undoubtedly the most impactful arena of interventional cardiology. This year we witnessed several important trials that redefined the drug management as well as interventions for CAD. There was the ATPCI trial that explored the benefit of trimetazidine in post PCI setup, Tailor PCI, TICO, TWILIGHT COMPLEX, ALPHEUS, and COMPARE CRUSH trials will serve as landmarks for future guidelines for antiplatelet therapy in CAD.

The extended outcome of the PRECOMBAT trial sheds more light on the ever-debatable CABG vs. PCI for left main disease while DEFINITION II has supported DK crush for complex PCI lesions. Finally, COMPARE ACUTE supported the role of FFR in complete revascularisation during the index procedure in STEMI setting.

1. ATPCI Trial

Efficacy and Safety of Trimetazidine in Patients Having Been Treated by Percutaneous Coronary Intervention

Long term trimetazidine is safe but not preventative of angina or adverse outcome after PCI.

The ATPCI trial followed 6007 patients receiving either trimetazidine or a placebo, following successful percutaneous coronary intervention (PCI). After a median follow-up of 47.5 months, trimetazidine did not improve either the outcome or the occurrence of angina.

The event rate in this trial was lower than expected and may have contributed to the null finding.

"It is the first study to test the value of increasing the energy status of the ischemic myocyte with trimetazidine in terms of hard end points such as cardiac death and hospitalization. This is particularly relevant considering that a recent study with ranolazine (RIVER-PCI trial), another piperazine derivative, in a similar patient setting failed to show a benefit" noted Roberto Ferrari, MD Department of Cardiology and LTTA Centre University Hospital of Ferrara ITALY (study author).

Source: The Lancet Journal: Ferrari R, Ford I, Fox K, et al. Efficacy and safety of trimetazidine after percutaneous coronary intervention (ATPCI): Lancet 2020;396:830-8.

2. The Tailor PCI Trial

Tailored Antiplatelet Initiation to Lessen Outcomes due to Decreased Clopidogrel Response After Percutaneous Coronary Intervention

A genotype-guided strategy was not superior at reducing adverse cardiovascular events compared with standard therapy after PCI.

Patients undergoing primary PCI for stable or unstable coronary artery disease were randomized to a genotype-guided strategy (n = 2,652) versus standard therapy (n = 2,650).

The primary analysis was between 903 subjects with a loss of function allele (*2 or *3) in the genotype-guided group compared with 946 subjects in the standard therapy group with a loss of function allele.

Among patients who underwent PCI for stable or unstable coronary artery disease, a genotype-guided strategy was not beneficial compared to standard therapy. The primary outcome of major adverse cardiovascular events and bleeding were similar between treatment groups at 12 months.

"Although these results fell short of the effect size that we predicted, they nevertheless provide a signal that offers support for the benefit of genetically guided therapy, with approximately one-third fewer adverse events in the patients who received genetically guided treatment compared with those who did not," said Naveen L. Pereira, MD, of Mayo Clinic, Rochester, Minnesota, co-principal investigator of the study, who presented the results.

Source: JAMA cardiology: Pereira NL, Farkouh ME, So D, et al. The TAILOR-PCI Randomized Clinical Trial. JAMA 2020;324:761-71.

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