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Surveillance Stress Testing After PCI
Quick Takes
- The incidences of the primary composite outcome of death from any cause, MI, or hospitalization for unstable angina at 2 years were similar between strategies of routine functional testing or standard care alone.
- Furthermore, the incidences of coronary angiography and revascularization were >2 times higher in the functional testing group than in the standard care group but did not translate into improved outcomes.
- Low-value health care services such as routine stress testing after PCI that provide little or no benefit to patients are commonly performed, potentially harmful, and expensive and there is a need for a multipronged approach to mitigate this overuse.
Study Questions:
What is the prognostic role of routine functional testing in patients with multivessel or left main coronary artery disease (CAD) who undergo percutaneous coronary intervention (PCI)?
Methods:
The investigators conducted the POST-PCI (Pragmatic Trial Comparing Symptom-Oriented Versus Routine Stress Testing in High-Risk Patients Undergoing Percutaneous Coronary Intervention) trial, which randomized high-risk PCI patients to routine functional testing at 1 year or standard care alone during follow-up. This analysis focused on participants with multivessel or left main CAD. The primary outcome was a composite of death from any cause, myocardial infarction (MI), or hospitalization for unstable angina at 2 years. Kaplan–Meier estimates of the cumulative incidence of primary and secondary outcomes by randomized follow-up strategy in the entire cohort and in each cohort of multivessel or left main disease were plotted in which the log-rank test was used to assess differences of outcomes.
Results:
Among 1,706 initially randomized patients, 1,192 patients with multivessel (n = 833) or left main (n = 359) were identified, with 589 in the functional testing group and 603 in the standard care group. Two-year incidences of the primary outcome were similar between the functional testing group and the standard care group (6.2% vs. 5.7%, respectively; hazard ratio [HR], 1.09; 95% confidence interval [CI], 0.68-1.74; p = 0.73). This trend persisted in both groups of multivessel (6.2% vs. 5.7%; HR, 1.09; 95% CI, 0.62-1.89; p = 0.78) and left main disease (6.2% vs. 5.7%; HR, 1.09; 95% CI, 0.46-2.56; p = 0.85) (p for interaction = 0.90). Routine surveillance functional testing was associated with increased rates of invasive angiography and repeat revascularization beyond 1 year.
Conclusions:
The authors report that in high-risk patients with multivessel or left main CAD who underwent PCI, there was no incremental clinical benefit from routine surveillance functional testing compared with standard care alone during follow-up.
Perspective:
This key subgroup analysis of the POST-PCI trial reports that the incidences of the primary composite outcome of death from any cause, MI, or hospitalization for unstable angina at 2 years were similar between strategies of routine functional testing or standard care alone. Furthermore, the incidences of coronary angiography and revascularization were >2 times higher in the functional testing group than in the standard care group but did not translate into improved outcomes. Low-value health care services such as routine stress testing after PCI that provide little or no benefit to patients are commonly performed, potentially harmful, and expensive and there is a need for a multipronged approach to mitigate this overuse.
Clinical Topics: Invasive Cardiovascular Angiography and Intervention, Atherosclerotic Disease (CAD/PAD), Interventions and Coronary Artery Disease, Interventions and Imaging
Keywords: Coronary Artery Disease, Exercise Test, Percutaneous Coronary Intervention
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