Screening for and Treating Asymptomatic Extracoronary Disease No Help in High-risk CAD

ROME, Italy—Systematically looking for asymptomatic atherosclerotic disease throughout the body to treat in patients who have high-risk CAD along with implementing other proactive strategies does not improve outcomes compared with a more conventional approach involving the treatment of symptomatic coronary and extracoronary lesions, the randomized AMERICA trial shows.

By 2 years, roughly 47% of patients in each group had had a primary endpoint event, including death, an ischemic event leading to hospitalization, or organ failure (HR 1.03; 95% CI 0.80-1.34), Jean-Philippe Collet, MD, PhD (Hôpital Pitié-Salpêtrière, Paris, France), reported here at the European Society of Cardiology Congress 2016. There were no differences for any of the secondary outcomes either.

“Our study does not support the routine detection of asymptomatic multisite artery disease even in very high-risk coronary patients [like] those recruited in the trial,” Collet said, noting that aggressive secondary preventive therapies were applied in both groups.

Commenting for TCTMD, Athena Poppas, MD (Rhode Island Hospital, Providence), said the study confirms “that aggressive guideline-directed therapy for secondary prevention is important.”

As for looking for asymptomatic extracoronary disease in a secondary prevention setting, “I think we’ve moved so far in being very aggressive with these patients to prevent disease that it’s not surprising it didn’t change the outcomes,” said Poppas, a former chair of the American College of Cardiology Scientific Sessions.

Avoiding Extra Tests ‘Could Benefit Patients’

The trial included 521 patients enrolled at 28 French centers. All were considered high risk either by virtue of having been diagnosed with three-vessel disease in the past 6 months or by being at least 75 years old with a recent ACS.

The proactive strategy evaluated in the study started with screening via whole-body vascular Doppler ultrasound and complemented by other imaging tests as determined by the treating physicians. It also involved assessment of ankle-brachial index; measurement of creatinine clearance, fasting glycemia, and LDL cholesterol every 6 months; and use of aggressive medical therapy, smoking cessation, and rehabilitation programs.

The control group received clinically guided treatment of symptomatic coronary and extracoronary disease along with medical therapy.

Asymptomatic extracoronary disease was identified in just 23% of patients in the proactive group, and few underwent additional revascularization procedures in response to the findings.

Poppas noted that clinicians currently don’t perform the level of screening evaluated in the trial. Thus, “it is positive in that it’s reassuring for people that they don’t have to go the extra effort or put patients through additional testing, some of which has some false-positive results that can lead people down a different path.”

So avoiding that additional testing “could be cost-saving and could benefit patients,” she said.

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