Pragmatic Trial Comparing Symptom-Oriented Versus Routine Stress Testing in High-Risk Patients Undergoing Percutaneous Coronary Intervention - POST-PCI

Mar 11, 2024
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Author/Summarized by Author:
Anthony A. Bavry, MD, MPH, FACC
Summary Reviewer:
Deepak L. Bhatt, MD, MPH, MBA, FACC; Kim A. Eagle, MD, MACC
Trial Sponsor:
CardioVascular Research Foundation and Daewoong Pharmaceutical
Date Presented:
08/28/2022
Date Published:
03/01/2024
Date Updated:
03/11/2024
Original Posted Date:
08/28/2022
References

Contribution To Literature:

Highlighted text has been updated as of March 11, 2024.

The POST-PCI trial failed to show that routine functional testing after PCI prevents adverse cardiovascular events.

Description:

The goal of the trial was to evaluate functional testing compared with standard of care among patients who underwent percutaneous coronary intervention (PCI) and had high-risk characteristics.

Study Design

  • Randomization
  • Parallel

Patients who underwent PCI and had high-risk clinical or anatomical characteristics were randomized to functional testing (n = 849) versus standard of care (n = 857).

In the functional testing group, subjects could undergo nuclear stress testing or stress echocardiography at 12 months. Exercise electrocardiography was permissible but discouraged due to high rate of false-positive results.

  • Total number of enrollees: 1,706
  • Duration of follow-up: 24 months
  • Mean patient age: 65 years
  • Percentage female: 22%
  • Percentage with diabetes: 39%

Inclusion criteria:

  • Patients who underwent PCI and had high-risk clinical or anatomical characteristics.
  • High-risk anatomical characteristics included left main disease, bifurcation disease, ostial lesion, chronic total occlusion, multivessel PCI, re-stenotic lesion, diffuse lesion (i.e., stent length >32 mm)
  • High-risk clinical characteristics included diabetes mellitus, chronic renal failure (serum creatinine level ≥2.0 mg/dL or hemodialysis), and acute coronary syndrome

Exclusion criteria:

  • Cardiogenic shock
  • Treated with bare-metal stents or balloon angioplasty alone
  • Pregnancy
  • Limited life expectancy
  • Participation in another investigational study

Other salient features/characteristics:

  • Stable angina: 70%
  • Unstable angina: 11%
  • Non–ST-segment elevation myocardial infarction: 12%
  • ST-segment elevation myocardial infarction: 7%

Principal Findings:

The primary outcome, all-cause mortality, myocardial infarction, or hospitalization for unstable angina at 2 years, occurred in 5.5% of the functional testing group compared with 6.0% of the standard care group (p = 0.62).

Secondary outcomes:

  • Invasive coronary angiography at 2 years: 12.3% of the functional testing group compared with 9.3% of the standard care group (p = 0.62)
  • Repeat revascularization at 2 years: 8.1% of the functional testing group compared with 5.8% of the standard care group (p = not significant)

Outcomes in diabetic patients:

  • Among diabetic patients, the primary outcome was 7.1% in the functional testing group compared with 7.5% in the standard care group (p = 0.82)
  • Among nondiabetic patients, the primary outcome was 4.6% in the functional testing group compared with 5.1% in the standard care group (p = 0.68; p for interaction = 0.91)

Interpretation:

Among patients who underwent PCI and had high-risk anatomical or clinical characteristics, routine functional testing at 12 months was not beneficial. Routine functional testing was associated with a numerical increase in invasive coronary angiography and repeat revascularization at 24 months; however, this did not reduce the incidence of adverse cardiovascular events. Results were similar regardless of diabetes status. While routine functional testing is common among patients with coronary artery disease, this practice is not recommended.

References:

Kim H, Kang DY, Lee J, et al. Routine stress testing in diabetic patients after percutaneous coronary intervention: the POST-PCI trial. Eur Heart J 2024;45:653-65.

Editorial Comment: Senior R, Khattar RS. To test or not to test for ischemia routinely after percutaneous coronary intervention in diabetic patients: is the jury still out? Eur Heart J 2024;45:666-8.

Park DW, Kang DY, Ahn JM, et al., on behalf of the POST-PCI Investigators. Routine Functional Testing or Standard Care in High-Risk Patients After PCI. N Engl J Med 2022;387:905-15.

Editorial: Tamis-Holland JE. Surveillance Stress Testing “POST-PCI” — A Future Class III Recommendation? N Engl J Med 2022;387:941-2.

Presented by Dr. Duk-Woo Park at the European Society of Cardiology Congress (ESC 2022), Barcelona, Spain, August 28, 2022.

Clinical Topics: Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging

Keywords: Diabetes Mellitus, Diagnostic Tests, Routine, ESC22, Percutaneous Coronary Intervention


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