The edition · Cardiology
Imaging-guided PCI across 28 trials, and why exercise echo alone misses HFpEF
A meta-analysis of 24,634 patients found fewer deaths, infarcts and stent thromboses with intracoronary imaging. Separately, exercise echocardiography picked up only 55–60% of invasively proven HFpEF until left atrial strain was added.
The edition in brief
An updated meta-analysis of 28 randomised trials (24,634 patients) found that intracoronary imaging-guided PCI lowered target lesion failure (RR 0.72), cardiac death (RR 0.73), myocardial infarction (RR 0.86), stent thrombosis (RR 0.55) and all-cause death (RR 0.82) compared with angiography guidance; heterogeneity was largely explained by geography and lesion characteristics. A post hoc look at the OCTOBER bifurcation trial found that two-stent PCI as actually delivered carried more events at two years than one stent (13.9% v 9.0%), but planned strategy made no difference, and angiography-guided double-kissing crush did worse than OCT-guided crush. In a multicentre study of 482 patients with unexplained breathlessness who had invasive exercise testing, current HFpEF scores plus exercise echocardiography detected only 55–60% of cases; adding resting left atrial compliance with separate rule-in and rule-out thresholds halved the need for invasive testing. A small prospective study found sotatercept reduced right ventricular contractility in step with lower afterload while free-wall strain and right atrial function improved, so a falling TAPSE on treatment may not signal harm. The pearl covers natriuretic peptides in obesity. There was no FDA activity for this desk today.
Exercise echo alone missed four in ten cases of invasively proven HFpEF
Do not treat a normal exercise echo as excluding HFpEF; add left atrial strain and refer indeterminate cases for invasive testing.
In true bifurcations, the second stent tracked with more events, not the plan for one
Plan bifurcation PCI by anatomy, and use intracoronary imaging when a two-stent crush technique is needed.
Sotatercept lowered RV contractility in step with afterload while strain improved
On sotatercept, do not read a lower TAPSE alone as right ventricular deterioration.
A low natriuretic peptide in obesity does not rule out HFpEF
Interpret a borderline natriuretic peptide in obesity cautiously and keep HFpEF on the list when the history fits.
Across 28 trials, imaging-guided PCI cut deaths, infarcts and stent thrombosis
Use intracoronary imaging to guide complex PCI, and change the procedure on what it shows.
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