Related Article Overview

Authors:
Haseeb Rahman

Presented:
ACI 2019

Published:
January 2019

Article Title:
Young Investigator Award 2019 – Mechanisms of myocardial ischaemia in the absence of obstructive coronary disease

Mechanisms of myocardial ischaemia in the absence of obstructive coronary disease

Dr Haseeb Rahman, BHF Clinical Research Fellow St Thomas’ Hospital, King’s College London and winner of the BCIS Young Investigator Award 2019, presents his work on the mechanisms of ischaemia in the absence of obstructive epicardial coronary disease.

Related Article Overview

Authors:
Haseeb Rahman

Presented:
ACI 2019

Published:
January 2019

Article Title:
DEBATE – Cardiac Arrest without ST elevation – Who should go to the cath lab immediately?

Mechanisms of myocardial ischaemia in the absence of obstructive coronary disease

Dr Haseeb Rahman, BHF Clinical Research Fellow St Thomas’ Hospital, King’s College London and winner of the BCIS Young Investigator Award 2019, presents his work on the mechanisms of ischaemia in the absence of obstructive epicardial coronary disease.

Related Article Overview

Authors:
SL Chen, JJ Zhang

Published:
November 2017

Journal:
J Am Coll Cardiol

Article Title:
DOUBLE KISSING CRUSH VERSUS PROVISIONAL STENTING FOR LEFT MAIN DISTAL BIFURCATION LESIONS DKCRUSH-V RANDOMIZED TRIAL

DOI:
http://dx.doi.org/10.1016/j.jacc.2017.09.1066

A Literature Review by BCIS R&D Group

There are varying PCI techniques for unprotected distal left main (ULM) disease including single stent strategy, provisional T-stenting (PS), crush technique, or culotte. No trial had previously compared DK crush with PS in the context of ULM disease. The DKCRUSH-V randomized trial was a prospective, randomised, international, multicentre study of 482 patients with distal ULM disease scheduled to undergo PCI to evaluate the comparative outcomes of DK crush with PS. The main inclusion criteria were silent ischemia, stable or unstable angina, MI>24 hours before treatment, distal left lesion (Medina 1,1,1 or 0,1,1) with >50% stenosis of both the ostial Cx and LAD by visual assessment.

The primary end point was target lesion failure defined as the composite of cardiac death, target vessel MI, or clinically driven target lesion revascularization at 1 year follow-up. Secondary end point included all cause death, all MI, periprocedural troponin I release, clinically driven revascularization, angina, and in-stent restenosis. In this study, DK crush was associated with a significantly lower primary end point (5% vs. 10.7%; p=0.02). DK crush was also associated with lower rates of target vessel MI (0.4% vs. 2.9%; p=0.03). Clinically driven target vessel revascularization (3.8% vs. 7.9%; p=0.06) and angiographic restenosis (7.1% vs. 14.6%; p=0.1) were numerically lower with DK crush.

In this randomised trial, DK CRUSH was associated with a superior outcome compared to PS in LM PCI.

Related Article Overview

Authors:
Rasha Al-Lamee, Kare Tang, John Davies, David Thompson, Hakim-Moulay Dehbi, Thomas Keeble

Published:
January 2018

Journal:
The Lancet

Article Title:
Percutaneous Coronary Intervention In Stable Angina (ORBITA): A Double-Blind, Randomised Controlled Trial

DOI:
http://dx.doi.org/10.1016/S0140-6736(17)32714-9

A Literature Review by BCIS R&D Group

In patients with stable angina, PCI has been associated with a reduction in the relief of angina but no placebo-controlled trials have been undertaken in this patient population. The ORBITA trial was a multicentre, randomised study of 230 patients designed to assess the effects of PCI versus placebo on exercise time. Key inclusion criteria were patients aged 18-85 years with angina, at least one angiographically significant lesion (≥70% on visual assessment). After enrolment, the study consisted of two consecutive phases: first 6-weeks consisting of optimizing anti-anginal therapy and the second 6 weeks during which patients underwent follow-up assessment including Canadian Cardiovascular Society angina severity, cardiopulmonary exercise testing, dobutamine stress echocardiography, blood pressure and heart rate monitoring. At enrolment, patients completed SAW and EQ-5D-5L questionnaire. In all patients, a research invasive FFR and iFR was also undertaken in the PCI group. Of note, the values of the FFR and iFR were not available to the operator making the PCI arm an angiography guided procedure & were negative in some cases.

The primary end point of the study was the difference in exercise time increment between the groups. Secondary end points included peak VO₂, change in exercise time to 1 mm ST segment depression, angina severity, physical limitation, angina stability and angina frequency. ORBITA demonstrated no significant difference in exercise time increment between the two groups (PCI minus placebo=16.6 seconds; 95% CI:-8.9-42; p=0.2). Similarly, there were no differences between the PCI arm and the placebo arm in any components of the secondary end point.  Interestingly, the exercise time did increase significantly in the PCI arm and not in the medical arm, but this was not the prespecified endpoint.

The conclusion was that “in patients with medically treated angina and severe coronary stenosis, PCI did not increase exercise time by more than the effect of a placebo procedure”.

The debate rages about the trial design but employing a sham arm makes this a powerful study.