Jurnal Reading physiology versus imaging

Journal Reading

1. JOURNAL READING FRIDAY 10 th MAY 2024

2. BACKGROUND it remains unclear whether intravascular imaging guidance or functional guidance is the best strategy to optimize outcomes and if the results are different in patients with vs without acute coronary syndromes (ACS)

3. OBJECTIVE To evaluate clinical outcomes with imaging-guided PCI or functionally guided PCI when compared with conventional angiography-guided PCI.

4. METHODS

5. Methods of Analysis

6. RESULTS

7. ELIGIBLE TRIALS Trial name, publication year Functional guidance Intravascular imaging guidance Purpose Cut-off (decision-making) Purpose Cut-off (decision-making) HOME DES IVUS, 2009 - - optimization - AVIO, 2013 - - optimization - RESET, 2013 - - optimization - DEFER-DES, 2015 decision-making 0.75 (FFR) - - DKCRUSH- Ⅵ , 2015 decision-making 0.80 (FFR) - - FAME, 2015 decision-making 0.80 (FFR) - - FAMOUS-NSTEMI, 2015 decision-making 0.80 (FFR) - - OCTACS, 2015 - - optimization - AIR-CTO, 2015 - - optimization - CTO-IVUS, 2015 - - optimization - Tan et al., 2015 - - optimization - DOCTORS, 2016 * - optimization - ROBUST, 2018 - optimization - Quintella et al., 2019 decision-making 0.75 (FFR) - - Liu et al., 2019 - optimization - FORZA, 2020 decision-making 0.80 (FFR) decision-making OCT: at least 1 of the following criteria was present: 1) area stenosis ≥75%; 2) area stenosis between 50% and 75% and minimal luminal area <2.5 mm2; and 3) area stenosis between 50% and 75% and plaque rupture. IVUS-XPL, 2020 - - optimization - ULTIMATE, 2020 - - optimization - OPTICO BVS, 2020 - - optimization - ILLUMIEN III, 2021 - - optimization - FLOWER-MI, 2021 decision-making 0.80 (FFR) - - iSIGHT, 2021 - - optimization - FUTURE, 2021 decision-making 0.80 £ (FFR) - - TARGET-FFR, 2021 optimization - - - FAVOR Ⅲ China, 2022 decision-making 0.80 (QFR) - - FLAVOUR, 2022 decision-making 0.80 (FFR) decision-making IVUS: minimal lumen area measuring either 3 mm 2 or less or measuring 3 mm 2 to 4 mm 2 with a plaque burden of more than 70%. EROSION III, 2022 - - optimization - RENOVATE-COMPLEX-PCI, 2023 - - optimization - Barauskas et al., 2023 decision-making 0.80 (QFR) - - FRAME-AMI, 2023 decision-making 0.80 (FFR) - - ILUMIEN IV, 2023 - - optimization - OCTOBER, 2023 - - optimization -

8. Risk of Bias All studies had low risk of bias on quality assessment There was no evidence of publication bias for any of the outcomes evaluated in this study (all the funnel plots for Primary and Secondary outcomes were symmetrical)

9. PRIMARY OUTCOME : MACE There was moderate heterogenity (I 2 = 25.8%;P = 0.086) and no significant inconsistency (P= 0.66) between direct and indirect comparisons

10. SECONDARY OUTCOME : All cause and Cardiovascular Death There was no evidence of heterogeneity (I² = 0%; P = 0.79) or inconsistency (P = 0.16) between direct and indirect comparisons in cardiovascular death There was no significant difference among the three strategies for all-cause death, with low heterogeneity (I² = 11.8%) and inconsistency (P = 0.33).

11. Secondary Outcome : Non-fatal MI, Stent Thrombosis & Target Lesion Revascularization

12. Ranking The Strategies Among the 3 strategies, Intravascular imaging-guided PCI was ranked first for decreasing MACE, cardiovascular death, stent thrombosis, and TLR

13. Subgroup Analysis : MACE The results in these cohorts were similar to the main analyses , with the magnitude of benefit similar or greater in the ACS trials compared with the non-ACS trials with intravascular-imaging guided PCI compared with the other strategies Intravascular imaging -guided PCI was ranked the best for most outcomes both for the ACS and non-ACS cohorts

14. Subgroup Analysis : All cause of death and Cardiovascular death

15. Subgroup Analysis : All cause of death and Cardiovascular death

16. Subgroup Analysis : All cause of death and Cardiovascular death

17. Sensitivity Analysis Five were categorized as first-generation DES trials and 27 were categorized as second-generation or newer DES trials The results of the analysis for only second-generation or newer DES trials were largely similar as the main analyses except for two findings: for the outcome of MI , both intravascular imaging -guided PCI and functionally guided PCI failed to reach statistical significance over angiography -guided PCI but were directionally similar to the main analysis for the outcome of TLR , intravascular imaging -guided PCI did not reach statistical significance over angiography -guided PCI, but was directionally similar to the main analysis Intravascular imaging-guided PCI was still ranked the best for most of the outcomes

18. DISCUSSION

19. Discussion These results were consistent in ACS vs non-ACS trials , with the benefits of intravascular imaging -guided PCI greater in patients with ACS . The results were consistent in a sensitivity analysis restricted to trials with second-generation or newer DES

20. Discussion : The Issues 22

21. 19

22. Discussion : The Issues

23. Study Limitations

24. SUMMARY In the present large-scale network meta-analysis , both intravascular imaging -guided PCI and functionally guided PCI were associated with superior outcomes compared with angiography-guided PCI. Intravascular imaging-guided PCI was ranked as the best modality for reduction in MACE, cardiovascular death, stent thrombosis, and TLR in both ACS and non-ACS cohorts.

25. THANK YOU