Routine functional testing after percutaneous coronary intervention (PCI) remains common in contemporary clinical practice—despite limited supportive randomized controlled trial data.¹ Whereas current European guidelines give a class IIb recommendation for surveillance stress testing after PCI, United States guidelines offer no specific recommendations for or against this practice.^2,3 In the absence of robust data, strong differences of opinion remain as to whether this practice benefits patients, clinicians, both, or neither. Enter the POST-PCI (Pragmatic Trial Comparing Symptom-Oriented versus Routine Stress Testing in High-Risk Patients Undergoing Percutaneous Coronary Intervention).

In the 2022 POST-PCI, Park et al. randomized 1,706 patients with high-risk anatomical characteristics (left main disease [21%], bifurcation disease [43.5%], ostial lesion [14.9%], chronic total occlusion [20%], multivessel disease [69.8%], restenotic lesion [11.4%], diffuse long lesion [70.1%]) or clinical characteristics (diabetes mellitus [38.7%], chronic renal failure [5.1%], acute coronary syndrome [30.8%]) treated with PCI to undergo either routine functional testing (nuclear stress testing, exercise electrocardiography, or stress echocardiography [n = 949]) at 1 year or to receive "standard care" (n = 857), with stress testing performed only for specific clinical indications.⁴ At 2 years, the incidence of the primary composite of all-cause death, myocardial infarction (MI), or hospitalization for unstable angina did not differ between the functional-testing group and the standard-care (control) group (5.5% vs. 6%; hazard ratio [HR], 0.9; 95% confidence interval [CI], 0.61-1.35). There were also no differences for the individual components of the primary outcome. A landmark analysis of the functional-testing versus standard-care groups performed between 1 and 2 years after randomization showed a higher incidence of coronary angiography (8.2% vs. 3.3%; HR, 2.47; 95% CI, 1.62-4.09) and coronary revascularization (5.8% vs. 2.4%; HR, 2.44; 95% CI, 1.43-4.16) in the functional-testing group, with no significant between-group differences in the rates of death or MI.

Overall, the POST-PCI failed to show that routine functional testing after PCI (in the absence of other clinical signs or symptoms suggestive of recurrent ischemia) prevented adverse cardiovascular events, and further demonstrated no value to routine functional testing above and beyond standard care in patients at high risk. The trial did not examine cost-effectiveness or assess impact on quality of life. So how do clinicians apply this data to daily practice? The trial findings suggest that follow-up after PCI in patients without symptoms should focus on optimizing heart-healthy lifestyle habits, guideline-based medical therapy, and regular physical exercise, and on assessing the presence or absence of symptoms, rather than on routinely stress-testing patients without symptoms (even those with high-risk anatomical and clinical features post PCI).

References

1. Bagai A, Eberg M, Koh M, et al. Population-based study on patterns of cardiac stress testing after percutaneous coronary intervention. Circ Cardiovasc Qual Outcomes 2017;Oct:[ePub ahead of print].
2. Neumann FJ, Sousa-Uva M, Ahlsson A, et al.; ESC Scientific Document Group. 2018 ESC/EACTS guidelines on myocardial revascularization. Eur Heart J 2019;40:87-165.
3. Lawton JS, Tamis-Holland JE, Bangalore S, et al.; Writing Committee Members. 2021 ACC/AHA/SCAI guideline for coronary artery revascularization: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2022;79:e21-e129.
4. Park DW, Kang DY, Ahn JM, et al.; POST-PCI Investigators. Routine functional testing or standard care in high-risk patients after PCI. N Engl J Med 2022;387:905-15.

Clinical Topics: Acute Coronary Syndromes, Cardiovascular Care Team, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Atherosclerotic Disease (CAD/PAD), Interventions and ACS, Interventions and Coronary Artery Disease, Interventions and Imaging, Angiography, Nuclear Imaging

Keywords: ESC Congress, ESC22, Percutaneous Coronary Intervention, Coronary Artery Disease, Acute Coronary Syndrome, Quality of Life, Confidence Intervals, Follow-Up Studies, Random Allocation, Angina, Unstable, Coronary Angiography, Myocardial Infarction, Electrocardiography, Healthy Lifestyle, Hospitalization

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