Selective PCI for high-risk non-ischemic lesions: a viable strategy with long-term benefit
H Xuan, K H YiuAbstract
Background
Current guidelines recommend deferring percutaneous coronary intervention (PCI) for angiographically intermediate coronary lesions without functional ischemia (FFR >0.80). However, the long-term safety of this strategy and the potential role of preventive PCI in high-risk anatomical subsets remain uncertain.
Objectives
This study aimed to compare long-term vessel-level outcomes between PCI and medical therapy (MT) for functionally non-ischemic intermediate lesions, identify anatomical predictors of events under MT, and evaluate the net clinical benefit of preventive PCI.
Methods
In this single-center, retrospective cohort study, we analyzed 550 functionally non-ischemic intermediate lesions from 410 patients with chronic coronary syndrome. Lesions were managed by either PCI plus MT or MT alone based on clinician preference, and angiography-derived FFR was computed retrospectively. The primary endpoint was the vessel-oriented composite endpoint (VOCE), a composite of vessel-specific myocardial infarction and ischemia-driven target vessel revascularization.
Results
During a median follow-up of 9 years, PCI did not reduce the risk of VOCE in the overall cohort compared with MT (9.1% vs. 13.3%; HR 0.635, 95% CI 0.379-1.057, P=0.081). However, significant heterogeneity was observed. Among lesions with high-risk anatomical features (stenosis ≥70%, multivessel disease, and left anterior descending artery involvement), PCI was associated with a significantly lower risk of VOCE (9.4% vs. 28.2%; HR 0.297, 95% CI 0.164-0.535, P<0.0001). The number needed to treat to prevent one VOCE event in this high-risk subgroup was 4 at 9 years, with a favorable number needed to harm of 9, indicating a positive net clinical benefit.
Conclusions
A uniform strategy of deferring PCI for all functionally non-ischemic intermediate lesions may not be optimal in the long term, and lesions with high-risk anatomic features may still benefit from PCI.Kaplan-Meier curves for clinical outcomeFor image description, please refer to the figure legend and surrounding text.Benefits and harms of PCIFor image description, please refer to the figure legend and surrounding text.