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08-07-2024 | Acute Coronary Syndrome | Editor's Choice | News

Routine stress testing provides no protection from recurrent risks in ACS after PCI

Author: Dr. Jonathan Smith

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medwireNews: Routine surveillance stress testing is no more beneficial than standard care alone in preventing recurrent events in patients with acute coronary syndrome (ACS) who have undergone percutaneous coronary intervention (PCI), a secondary analysis of the POST-PCI trial has found.

“The findings of this analysis address a clinically important gap in the evidence base necessary to guide decisions about the follow-up strategy of patients with ACS undergoing PCI,” write Duk-Woo Park (University of Ulsan College of Medicine, Seoul, South Korea) and colleagues in JAMA Cardiology.

The trial enrolled 1706 patients from South Korea who had undergone successful PCI involving contemporary drug-eluting stents, bioabsorbable scaffolds, or drug-coated balloons. Eligible participants had at least one high-risk factor for ischemic or thrombotic events, including coronary artery disease (CAD), medically treated diabetes, or chronic kidney failure.

The patients were a mean of 64.7 years old and 79.5% were men. A total of 526 (30.8%) of the patients had ACS, of whom 62.9% had myocardial infarction with or without ST-segment elevation and 37.1% had unstable angina.

After PCI, 251 of the patients with ACS were randomly assigned to receive routine functional testing at 12 months and 275 to receive standard care alone. The patients without ACS were also randomly assigned, with 598 receiving routine functional testing and 582 standard care. Routine functional testing involved cardiac stress testing, including exercise electrocardiography, nuclear stress testing, and stress echocardiography. The standard care group only received stress testing if clinically indicated.

The patients’ baseline characteristics were mostly similar across the treatment groups for those with and without ACS. Patients with ACS were more likely to be smokers and have a lower left ventricular ejection fraction than those without ACS, but they were less likely to have comorbidities and high-risk factors for ischemic or thrombotic events.

Despite having fewer high-risk factors, patients with ACS had a significant 55% greater risk than those without ACS for the primary outcome, a composite of death from any cause, myocardial infarction, or hospitalization for unstable angina, at 2 years following randomization, with respective rates of 7.6% and 5.0%.

Park et al also found that patients with versus without ACS were significantly more likely to need rehospitalization due to cardiac causes (17.2 vs 12.7%) at 2 years and had higher rates of death or myocardial infarction (5.0 vs 3.4%), although not significantly so.

“These higher event rates at 2 years were driven by higher event rates in the first year before the 12-month intervention,” the researchers note.

Within the ACS group, the risk for the composite primary outcome at 2 years was similar between patients receiving routine functional testing and those receiving standard care, with respective rates of 6.6% and 8.5%. A similar pattern was observed in patients without ACS, with corresponding rates of 5.1% and 4.9%.

A prespecified landmark analysis assessing the incidences of invasive coronary angiography and repeat revascularization among the patients showed that rates were higher among patients receiving functional testing than those receiving standard care, but only significantly for those without ACS.

Park and colleagues remark that “given the heightened risk for recurrent events across the coronary tree after ACS, one might anticipate a protective benefit of active follow-up surveillance with routine stress testing 12 months following PCI in the ACS setting. However, the findings in this prespecified analysis from the POST-PCI trial do not support this concept.”

They also point out that “the overall event rates in the cohorts both with and without ACS in this trial were quite low and most likely reflect adherence to guideline recommendations for medical therapy after PCI for patients presenting with ACS or chronic CAD.”

The study has some limitations, the investigators acknowledge, including the lack of adjustment for multiple testing, meaning that the results should be treated as “hypothesis-generating.” They add that the study was “based on an Asian cohort and women were underrepresented,” limiting the generalizability of the findings.

medwireNews is an independent medical news service provided by Springer Healthcare Ltd. © 2024 Springer Healthcare Ltd, part of the Springer Nature Group

JAMA Cardiol 2024; doi:10.1001/jamacardio.2024.1556

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