What are the current treatment options for adult patients with cardiovascular disease, including coronary artery disease, heart failure, or structural heart disease, based on recent interventional cardiology trials?

Recent Interventional Cardiology Trials: Current Treatment Options

Coronary Artery Disease

Revascularization Strategy Selection

For patients with multivessel coronary artery disease, particularly those with diabetes mellitus, proximal LAD involvement, or left ventricular dysfunction, CABG remains the preferred revascularization strategy over PCI. 1

• Left main coronary artery disease requires careful anatomic assessment: PCI with drug-eluting stents is appropriate for ostial or midshaft lesions, prohibitively high surgical risk (EuroSCORE >10%), or patients with serious comorbidities including chronic lung disease, advanced age, or limited life expectancy 2
• CABG is superior for complex left main disease with distal bifurcation lesions requiring two-stent techniques, severe calcification, concomitant diffuse multivessel disease, or severely compromised left ventricular function 2
• Distal left main bifurcation lesions treated with PCI have restenosis rates up to 42% and target lesion revascularization rates up to 38%, significantly higher than ostial or midshaft lesions 2

Contemporary Stent Technology

Drug-eluting stents demonstrate significantly superior outcomes compared to bare-metal stents, with restenosis rates of 6% versus 22% and target lesion revascularization rates of 2% versus 16%. 2

• Current practice utilizes newer-generation DES with thinner struts, improved polymer biocompatibility (both durable and biodegradable), and optimized antiproliferative drug delivery 3
• Over 30 different DES designs are commercially available in Europe, each with unique characteristics affecting thromboresistance, neointimal coverage speed, and completeness of healing 3
• IVUS assessment is mandatory for most left main stenting cases to ensure optimal stent deployment and is reasonable for angiographically indeterminate left main disease 2

Antiplatelet Therapy Requirements

Dual antiplatelet therapy with aspirin plus clopidogrel must be continued for at least 12 months after drug-eluting stent placement. 2

• Aspirin 81 mg daily is preferred over higher maintenance doses 2
• Premature discontinuation dramatically increases stent thrombosis risk, which is catastrophic in left main locations 2
• GP IIb/IIIa inhibitors used adjunctively with PCI for unstable angina/NSTEMI have resulted in more favorable outcomes 1

Lesion-Specific Management

For healed coronary lesions with less than 50% stenosis, medical management is the standard of care without need for revascularization. 4

• Lesions with 40-70% stenosis require functional assessment with FFR or iFR to determine hemodynamic significance before considering intervention 4
• Only stenoses >90% reliably predict hemodynamic relevance (96% correct classification) 4
• Visual angiographic assessment alone correlates poorly with hemodynamic significance 4

Structural Heart Disease

Transcatheter Aortic Valve Replacement (TAVR)

TAVR has expanded beyond high-risk patients to include intermediate and lower-risk cohorts based on recent trial data. 1

• Initial assessment must confirm severe aortic stenosis through echocardiographic measures and exclude symptoms from other causes 1
• Coronary angiography is mandatory in all TAVR candidates, as coronary artery disease is present in 40-75% of patients 1
• The Heart Valve Team must decide on coronary revascularization before TAVR case-by-case, as post-hoc analysis of PARTNER 2A showed no increased risk of death or disabling stroke at 2 years with concurrent revascularization 1

Low flow (stroke volume index <35 mL/m²) predicts poor outcomes post-TAVR regardless of ejection fraction and should be considered in patient selection. 1

• Both stroke volume index and ejection fraction must be evaluated, as patients with low flow have poor outcomes regardless of management strategy 1
• Moderate-to-severe mitral regurgitation is present in approximately 20% of TAVR candidates; secondary MR tends to improve following TAVR in many patients 1
• Primary mitral valve disease, atrial fibrillation, pulmonary hypertension, and reduced ejection fraction predict poor outcomes in patients with significant MR undergoing TAVR 1

Mitral Valve Interventions

Transcatheter edge-to-edge repair (TEER) is indicated for severely symptomatic patients with primary mitral regurgitation at high or prohibitive surgical risk, and for secondary mitral regurgitation based on COAPT trial criteria. 1

• Understanding the pathophysiologic differences between primary and secondary mitral regurgitation is essential for appropriate patient selection 1
• Recent-generation TEER devices have expanded initial morphologic considerations for successful intervention 1
• Multidisciplinary team evaluation is critical for optimal patient selection and device choice 1

Cardiac Resynchronization Therapy (CRT)

CRT should be expanded to mildly symptomatic heart failure patients (NYHA class I-II) to prevent disease progression, based on MADIT-CRT and REVERSE trial results. 1

• Current guidelines limiting CRT to NYHA class III-IV patients may exclude those who would benefit from preventing progression rather than reversing severe heart failure 1
• CRT is not recommended for heart failure patients with narrow QRS complex based on ESTEEM-CRT and RethinQ trial results 1
• Atrial fibrillation does not preclude CRT benefit; both sinus rhythm and atrial fibrillation patients show significant improvement in NYHA class, LVEF, and long-term survival 1

Heart Failure Management

Medical Therapy Optimization

Exercise training should be implemented for all stable outpatients with chronic heart failure who can participate in conditioning protocols, used in conjunction with drug therapy. 1

• Formal programs requiring gradual achievement of 40-70% maximal effort for 20-45 minutes, 3-5 times weekly for 8-12 weeks produce comparable benefits to pharmacological interventions 1
• Exercise training reduces neurohormonal activation, attenuates ventricular remodeling, and in one long-term study reduced hospitalization and death risk 1
• Benefits are additive to ACE inhibitors and beta-blockers 1

Implantable Cardioverter-Defibrillators (ICDs)

ICDs are highly effective in preventing death from ventricular tachyarrhythmias but require careful patient selection and programming to avoid complications. 1

• ICDs can aggravate heart failure and have been associated with increased heart failure hospitalizations, potentially from right ventricular pacing producing dyssynchronous contraction 1
• Frequent ICD shocks reduce quality of life; amiodarone may be added for recurrent discharges, and catheter ablation considered for refractory ventricular tachycardia 1
• Before implantation, patients must be fully informed of cardiac prognosis, ICD efficacy and risks, shock-related morbidity, and the process for potential future deactivation 1

Medication Adherence and Prescribing

Medication underuse—defined as omission of potentially beneficial therapy or inadequate dose/duration—has been demonstrated for aspirin and beta-blockers post-MI, antihypertensives, ACE inhibitors in heart failure, and anticoagulation in atrial fibrillation. 1

• Policy interventions lowering out-of-pocket expenses reduce but do not eliminate nonadherence to cardiovascular medications 1
• Older adults may prioritize quality of life, functional independence, and adverse event avoidance over delayed potential benefits, requiring different engagement strategies 1
• Shared decision-making tools and patient engagement require provider training, information system support, and process reengineering to overcome barriers 1