See also Coronary Stent Thrombosis, STEMI, ACS, Antithrombotic Therapy after PCI in Atrial Fibrillation.

PCI

REVIVED (2022) - PCI in ischemic HFrEF

REVIVED (in NEJM August 2022) randomized 700 patients with severe LV systolic dysfunction (LVEF <= 35%) from ischemic heart disease in whom revascularization may be reasonable (extensive CAD amenable to PCI, and demonstrable myocardial viability) to PCI+GDMT vs GDMT alone.

There was NO significant difference over 41 months of followup iwith regards to the primary outcome of all-cause mortality + heart failure hospitalization. There was no difference at 6 and 12 months with regards to LVEF. There was no difference in QOL at 24 months.

SUMMARY: Among patients with severe ischemic left ventricular systolic dysfunction who received optimal medical therapy, revascularization by PCI did not result in a lower incidence of death from any cause or hospitalization for heart failure.

PCI vs CABG

EXCEL (2009)

CABG likely preferred in the setting of LMCA disease. Due to decreased all-cause death and decreased ischemia-driven revascularization.

  1. No significant difference between PCI vs CABG for the primary outcome of death, stroke, MI at 5 years
  2. Increased all-cause deaths in the PCI group (13% vs 9.5%).
  3. Ischemia-driven revascularization within 5 years was performed more frequently after PCI than after CABG.

FREEDOM (2012)

In patients with Diabetes Mellitus and multivessel disease, CABG is preferred due to large and significant effect size of composite outcome of decreased death, MI, and stroke. Driven by decreased death or MI independently. However, increased risk of stroke (5.2% vs 2.4%).

  1. PCI inferior to CABG for primary outcome (26.6% vs 18.7%), with risk divergence at 2 yrs and widening with time
  2. Increased death or MI in PCI compared to CABG
  3. Decreased strokes with PCI compared to CABG (1/2 the risk)