Daily Cardiology Research Analysis
Analyzed 146 papers and selected 3 impactful papers.
Summary
Three high-impact cardiology studies this cycle: (1) FAITAVI shows physiology-guided PCI using FFR before TAVI reduces 12-month MACCE, mainly mortality, versus angiography guidance. (2) A prespecified landmark analysis of NEO-MINDSET finds early (0–30 days) ischemic excess with aspirin-free potent P2Y12 monotherapy after ACS PCI, but similar ischemic risk and less bleeding thereafter. (3) The nationwide HONEST S-ICD cohort refines long-term real-world safety/effectiveness, identifies predictors of inappropriate shocks, and shows SMART Pass filtering reduces inappropriate shocks.
Research Themes
- Physiology-guided revascularization in TAVI candidates
- Early vs late risk balance of aspirin-free P2Y12 monotherapy after ACS PCI
- Long-term real-world safety and programming strategies for S-ICD therapy
Selected Articles
1. Physiology vs angiography-guided percutaneous coronary intervention in transcatheter aortic valve implantation: the FAITAVI trial.
In this multicenter randomized trial of TAVI candidates with intermediate coronary lesions, FFR-guided PCI reduced 12-month MACCE versus angiography-guided PCI (8.5% vs 16.0%; HR 0.52), driven by lower all-cause mortality (HR 0.31). Findings support physiology-based revascularization in elderly, frail TAVI populations.
Impact: This is the first RCT in TAVI patients showing outcome benefit of FFR-guided revascularization, suggesting a practice-shifting approach to coronary management before TAVI.
Clinical Implications: Adopt FFR-guided decision-making for intermediate lesions in TAVI candidates to reduce MACCE and mortality at 12 months; integrate invasive physiology into pre-TAVI planning.
Key Findings
- FFR-guided PCI lowered 12-month MACCE vs angiography-guided PCI (8.5% vs 16.0%; HR 0.52; P=0.047).
- All-cause mortality was significantly reduced with FFR guidance (HR 0.31; 95% CI 0.10–0.96).
- Trial included very elderly patients (median age 86) with low SYNTAX burden (median 7).
Methodological Strengths
- Multicenter randomized superiority design with blind adjudication of events
- Intention-to-treat primary analysis and clinical outcomes endpoint (MACCE)
Limitations
- Open-label design may introduce performance bias
- Modest sample size with borderline P value; generalizability beyond elderly TAVI population uncertain
Future Directions: Confirm in larger, international RCTs; assess cost-effectiveness and optimal timing of physiology-guided PCI in the TAVI pathway.
2. Prasugrel or ticagrelor monotherapy vs dual antiplatelet treatment after percutaneous coronary intervention in acute coronary syndromes: a landmark analysis from the NEOMINDSET trial.
Among 3410 ACS patients, potent P2Y12 monotherapy increased early (0–30 days) ischemic events versus DAPT (3.3% vs 1.8%) but reduced bleeding; from 31–365 days, ischemic risks were similar (3.8% each) and bleeding remained lower with monotherapy (1.3% vs 3.5%).
Impact: Clarifies the time-dependent trade-off of aspirin-free strategies after ACS PCI, informing guideline updates and clinical protocols on when to de-escalate from DAPT.
Clinical Implications: Avoid early aspirin withdrawal in the first 30 days after ACS PCI due to higher ischemic risk; consider de-escalation to potent P2Y12 monotherapy after 30 days to reduce bleeding while maintaining ischemic protection.
Key Findings
- 0–30 days: higher ischemic composite with monotherapy (3.3%) vs DAPT (1.8%); lower bleeding (0.6% vs 1.5%).
- 31–365 days: ischemic events similar (3.8% each), but bleeding remained lower with monotherapy (1.3% vs 3.5%).
- Prespecified landmark analysis in a large RCT of DES-treated ACS patients.
Methodological Strengths
- Large randomized sample with prespecified landmark analysis
- Clinically meaningful co-primary endpoints (ischemia composite and BARC 2/3/5 bleeding)
Limitations
- Open-label antiplatelet assignment may affect care patterns
- Heterogeneity between prasugrel and ticagrelor monotherapy not separately powered
Future Directions: Define optimal early-phase strategies (e.g., very short DAPT) and patient subgroups for safe aspirin withdrawal; harmonize de-escalation protocols with bleeding and ischemic risk tools.
3. Long-term outcomes of subcutaneous implantable cardioverter defibrillators: the French nationwide HONEST study.
In 4,924 unselected S-ICD recipients with 5-year follow-up, inappropriate shocks occurred in 13.8%, infections in 2.4%, lead dysfunction in 1.5%, and device extraction in 8.4%. SMART Pass filtering reduced inappropriate shocks (HR 0.67), and predictors of inappropriate shocks included male sex, obesity, ARVC, and concomitant pacemaker.
Impact: Provides robust, industry-independent, nationwide long-term data on S-ICD performance and complications, directly informing device selection, programming (SMART Pass), and patient counseling.
Clinical Implications: Use SMART Pass filtering to reduce inappropriate shocks; recognize higher-risk subgroups (male, obesity, ARVC, pacemaker) for intensified follow-up; counsel patients on 5-year risks including reoperation and extraction.
Key Findings
- Five-year cumulative incidence: inappropriate shocks 13.8%, early battery depletion 10.8%, infections 2.4%, lead dysfunction 1.5%, extraction 8.4%.
- SMART Pass filtering reduced inappropriate shocks (HR 0.67; 95% CI 0.50–0.89).
- Predictors of inappropriate shocks: male sex (HR 1.29), obesity (HR 1.35), ARVC (HR 1.70), pacemaker presence (HR 2.20).
Methodological Strengths
- Nationwide, near-complete capture (≈98%) with central adjudication and 5-year follow-up
- Industry-independent academic registry reflecting real-world practice
Limitations
- Observational design susceptible to residual confounding and device-generation effects
- Programming and practice patterns evolved over study years, potentially influencing outcomes
Future Directions: Prospective evaluation of programming strategies (including SMART Pass) by indication; comparative effectiveness vs transvenous ICD in defined subgroups; interventions to reduce early battery depletion.