Coronary computed tomography angiography (CCTA) following PCI for unprotected left main disease did not reduce the composite primary endpoint of all-cause death, spontaneous myocardial infarction (MI), unstable angina, or definite or probable stent thrombosis at 18 months, based on findings from the PULSE trial presented at ESC Congress 2025 and simultaneously published in JACC. However, researchers said CCTA was associated with fewer spontaneous MIs and more imaging-triggered revascularizations.

"Detrimental complications, such as stent restenosis, and recurrent ischemic events can occur after left main PCI; however, the optimal surveillance strategy remains a subject of debate," said Ovidio De Filippo, MD, when presenting the findings.

PULSE enrolled 606 patients treated with second-generation drug-eluting stents and randomized them to receive CCTA at six months or stand care. In addition to the primary composite endpoint, researchers looked at target-lesion revascularization (TLR) and a breakdown of each composite endpoint component.

In overall findings, the primary endpoint occurred in nearly 12% of patients (36/303) assigned to CCTA compared with 12.5% of patients (38/303) assigned to standard care. Secondary endpoint results showed a reduced risk of spontaneous MI and an increased risk of imaging-triggered TLR among patients in the CCTA group compared with standard care (0.9% vs. 4.9% and 4.9% vs. 0.3%, respectively). However, clinically driven TLR rates were similar between the two groups (5.3% vs. 7.2%, respectively).

"Systematic 6-month CCT-based follow-up did not result in a reduction in 18-month all-cause death, spontaneous MI, unstable angina and stent thrombosis," said Fabrizio D'Ascenzo, MD, lead author of the paper. "While universal CCT-based follow-up may not be useful, the marked reduction in spontaneous MI and identification of obstructive lesions requiring repeat PCI suggest this approach may be worth investigating further in selected patients with complex anatomies and over longer follow-up."