Asymptomatic Cardiac Ischemia Pilot (ACIP) Study Two-Year Follow-Up, Outcomes of Patients Randomized to Initial Strategies of Medical Therapy Versus Revascularization

Department of Medicine, University of Ottawa (Ontario) Heart Institute, Canada.
Circulation (Impact Factor: 14.43). 04/1997; 95(8):2037-43. DOI: 10.1161/01.CIR.95.8.2037
Source: PubMed


Patients with ischemia during stress testing and ambulatory ECG monitoring have an increased risk of cardiac events, but it is not known whether their prognosis is improved by more aggressive treatment with anti-ischemic drugs or revascularization.
The Asymptomatic Cardiac Ischemia Pilot study randomized 558 such patients who had coronary anatomy suitable for revascularization to three treatment strategies: angina-guided drug therapy (n=183), angina plus ischemia-guided drug therapy (n=183), or revascularization by angioplasty or bypass surgery (n=192). Two years after randomization, the total mortality was 6.6% in the angina-guided strategy, 4.4% in the ischemia-guided strategy, and 1.1% in the revascularization strategy (P<.02). The rate of death or myocardial infarction was 12.1% in the angina-guided strategy, 8.8% in the ischemia-guided strategy, and 4.7% in the revascularization strategy (P<.04). The rate of death, myocardial infarction, or recurrent cardiac hospitalization was 41.8% in the angina-guided strategy, 38.5% in the ischemia-guided strategy, and 23.1% in the revascularization strategy (P<.001). Pairwise testing revealed significant differences between the revascularization and angina-guided strategies for each comparison.
A strategy of initial revascularization appears to improve the prognosis of this population compared with angina-guided medical therapy. A larger long-term study is needed to confirm this benefit and to adequately test the potential of more aggressive drug therapy.

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    • "The revascularization of patients with objective evidence of ischemia can improve functional status and outcomes [1] [2] [3], and fractional flow reserve (FFR) is a proven physiologic tool for assessment of lesion specific ischemia. FFR-guided percutaneous coronary intervention (PCI) can improve the event free survival, and reduce health care costs [3] [4] [5]. "
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    ABSTRACT: The role of resting pressure parameters, i.e. instantaneous wave-free ratio (iFR), and resting distal coronary pressure/aortic pressure (Pd/Pa) in assessing functionally significant stenosis remains controversial. We sought to assess the diagnostic performance of iFR and resting whole-cycle Pd/Pa in Asian patients. In this study, 238 consecutive lesions (no total occlusions) in which fractional flow reserve (FFR) was measured with both intravenous and intracoronary adenosine administration were included. Coded resting pressure data were sent to the core laboratory in which iFR was calculated in a blinded fashion. FFR and iFR had unimodal distributions and the correlation was r=0.77 (95% confidence interval, 0.71 to 0.82). In a receiver-operating-characteristic curve analysis, iFR had an area under the curve (AUC) of 0.9 at FFR≤0.80. The best cut-off value for iFR was 0.90 with a sensitivity, specificity, positive and negative predictive values, and diagnostic accuracy of 76%, 86%, 82% and 80%, and 82%, respectively. The resting whole-cycle Pd/Pa cut-off of 0.91 demonstrated a diagnostic accuracy of 82% (AUC 0.9). However, iFR had higher discriminatory power than the resting whole-cycle Pd/Pa. Both iFR and resting whole-cycle Pd/Pa showed good diagnostic performance to define the functionally significant stenosis in an independent Asian cohort distributed unimodally and without total occlusions. However, further validation is needed to explore the areas of disagreement between different physiologic parameters prior to adoption of resting pressure parameters into routine clinical practice.
    International journal of cardiology 07/2013; 168(4). DOI:10.1016/j.ijcard.2013.07.030 · 4.04 Impact Factor
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    • "Treatment strategies in managing stable CHD patients are controversial and still discussed in several studies (49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71). "Table 6" shows the results of comparisons of two main strategies (medical therapy versus revascularization) and two revascularization techniques including PCI and CABG. "
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    12/2011; 20(3):75-93. DOI:10.4274/MIRT.33
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    • "Recently, new 2010 European Society of Cardiology guidelines for PCI have classified FFR-guided treatment as Class I with level of evidence A. This update has been driven from the Fractional Flow Reserve Versus Angiography for Multivessel Evaluation (FAME) study, which demonstrated improved outcomes at 1 year in patients with multivessel coronary disease whose coronary intervention was guided by FFR measurement rather than by angiography alone [4]. It has been established to perform PCI for patients with coronary stenotic lesions which induce myocardial ischemia and successful PCI improves the outcome [5]. In recent years, especially after the introduction of drug-eluting stents (DES), PCI has increased [6] and tends to be performed on angiographically intermediate stenotic lesions which may not be proven as real myocardial ischemia. "
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