ReACT: Routine Angiographic Follow-up After PCI Does Not Lower Clinical Events

WASHINGTON, DC—The routine use of angiographic follow-up after PCI failed to reduce the risk of clinical events among a group of “all comer” patients treated for coronary disease, according to the results of a new study.

In ReACT, a Japan-based study where coronary angiography is still used routinely during follow-up of patients treated with PCI, there was no significant reduction in the risk of death, MI, stroke, hospitalization for ACS, or hospitalization for heart failure with follow-up angiography when compared with patients followed clinically.

Target lesion revascularization within the first year after the index PCI was performed more frequently among patients who underwent follow-up angiography compared with those who received clinical follow-up (7.0% vs 1.7%; P < 0.001). Any coronary revascularization within the first year after the index PCI was also significantly higher among patients randomized to angiographic follow-up. However, by 5 years, the incidence of target lesion revascularization and any revascularization was similar among patients followed clinically and with angiography.

Hiroki Shiomi, MD (Kyoto University Graduate School of Medicine, Japan), presented the results of the study during today’s first report investigation session at TCT 2016. Despite the negative results, he said he’s not sure if the study will impact clinical practice in Japan.

“This trial truncated the number of patients enrolled,” he commented during a morning press conference, noting his research group had initially intended to enroll 3,300 patients. “Unfortunately, the result of this trial was underpowered to

definitively address the role of routine angiography after PCI, especially after high-risk PCI, such as left main disease or multivessel disease,” Shiomi said.

ReACT included 349 patients who underwent angiographic follow-up between 8 and 12 months after the initial PCI and 351 patients who received clinical follow-up only. In a subgroup analysis, the researchers saw no benefit for routine angiographic follow-up among patients with diabetes, left main coronary artery disease, chronic total occlusions, bifurcated lesions, multivessel disease, or long lesions.

Jeffrey Popma, MD (Beth Israel Deaconess Medical Center, Boston, MA), said when the initial PCI studies were conducted, routine angiographic follow-up performed by Japanese physicians changed interventional cardiologists’ understanding of pathology. “For example, we never understood negative remodeling that happened to cause restenosis,” said Popma. “We always thought it was due to tissue growth.”

The ReACT study, however, provides a snapshot of how well the current-generation stents perform. Popma told TCTMD that physicians did follow-up with angiography in certain patients after PCI. “We used to before we had durable stent results,” he said. “Five years ago, if you did a complex left main, we would schedule them back for their 6-month follow-up to make sure it was OK, but with the durability of the devices now we haven’t been.”

Popma suspects that had this study been performed 10 years ago with less durable stents, “it would have a very different outcome.”

To TCTMD, George Dangas, MD (Mount Sinai Medical Center, New York, NY), said routine angiography has been discarded in the US. In fact, the 2011 PCI guidelines from the American College of Cardiology, American Heart Association, and Society for Cardiovascular Angiography and Interventions even abandoned routine follow-up angiography after PCI for left main disease. In Europe, the European Society of Cardiology European Association for Cardiothoracic Surgery guidelines state that routine follow-up angiography after high-risk PCI (and left main PCI) is a class IIb recommendation (level of evidence C).

Dangas said CT angiography, which is less invasive, provides good images if physicians need to see the left main artery after PCI. Angiography had value when physicians had more imperfect devices, although it’s still important for assessing futility, he said.