Should Ischemia Be the Main Target for PCI Strategy?
Should Ischemia Be the Main Target for PCI Strategy?
As evidence builds to support an ischemia-driven interventional strategy to achieve both symptomatic and prognostic benefits from CAD in stable and unstable patients, it is our belief that this approach will be increasingly adopted by all Interventional Cardiologists and will become frequent, if not, routine practice across the world.
Ongoing studies investigating the validity and predictive value of the pressure wire in determining clinical outcomes are expected to support its use for individual lesions in ACSs. This may include designated nonculprit vessels in ST elevation infarcts and multivessel lesions in presentations where a single culprit is not easily identified.
Studies which are already in progress are also expected to show that use of the pressure wire as a routine investigative tool for those patients undergoing coronary angiography as part of a diagnostic work up process will be a critical factor in changing management strategy and may well become routine practice in assessment of individual lesion and patients assessment for both PCI and bypass surgery. The SYNTAX score, (which is a lesion distribution and anatomical severity/complexity score) may well be superseded by an FFR adjusted 'SYNTAX' type score in which a multidisciplinary team discussion between cardiologists and cardiothoracic surgeons will be guided by the number and distribution of ischemic stenoses rather than by anatomy alone.
This could well shift the balance of revascularization strategy toward or away from a percutaneous strategy on an individual case basis.
A further future development which has potential to revolutinize the diagnostic work up and future management of patients with possible or known CAD is the advent of a reliable noninvasive FFR calculation from coronary CT angiography that correlates reliably with ischemia and clinical outcomes. It could be foreseen that such a development could lead to a single CT examination resulting in an assessment both anatomically and functionally for an individual patient would negate the need for an invasive test entirely. This is an exciting prospect indeed.
Furthermore, it could possibly be foreseen that ischemia assessment may become a 'recommended practice' in all patients considered for any form of revascularization. Large bodies such as the AHA, ESC and NICE in the UK, may well seek to review the current and future evidence and we would welcome the outcome of such an appraisal.
Expert Commentary & Five-year View
As evidence builds to support an ischemia-driven interventional strategy to achieve both symptomatic and prognostic benefits from CAD in stable and unstable patients, it is our belief that this approach will be increasingly adopted by all Interventional Cardiologists and will become frequent, if not, routine practice across the world.
Ongoing studies investigating the validity and predictive value of the pressure wire in determining clinical outcomes are expected to support its use for individual lesions in ACSs. This may include designated nonculprit vessels in ST elevation infarcts and multivessel lesions in presentations where a single culprit is not easily identified.
Studies which are already in progress are also expected to show that use of the pressure wire as a routine investigative tool for those patients undergoing coronary angiography as part of a diagnostic work up process will be a critical factor in changing management strategy and may well become routine practice in assessment of individual lesion and patients assessment for both PCI and bypass surgery. The SYNTAX score, (which is a lesion distribution and anatomical severity/complexity score) may well be superseded by an FFR adjusted 'SYNTAX' type score in which a multidisciplinary team discussion between cardiologists and cardiothoracic surgeons will be guided by the number and distribution of ischemic stenoses rather than by anatomy alone.
This could well shift the balance of revascularization strategy toward or away from a percutaneous strategy on an individual case basis.
A further future development which has potential to revolutinize the diagnostic work up and future management of patients with possible or known CAD is the advent of a reliable noninvasive FFR calculation from coronary CT angiography that correlates reliably with ischemia and clinical outcomes. It could be foreseen that such a development could lead to a single CT examination resulting in an assessment both anatomically and functionally for an individual patient would negate the need for an invasive test entirely. This is an exciting prospect indeed.
Furthermore, it could possibly be foreseen that ischemia assessment may become a 'recommended practice' in all patients considered for any form of revascularization. Large bodies such as the AHA, ESC and NICE in the UK, may well seek to review the current and future evidence and we would welcome the outcome of such an appraisal.
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