Angiography Is the Gold Standard and Objective Evidence of Myocardial Ischemia Is Mandatory If Lesion Severity Is Questionable - Indication of PCI for Angiographically Significant Coronary Artery Stenosis Without Objective Evidence of Myocardial Ischemia (Pro) -

Abstract

Circulation Journal Official Journal of the Japanese Circulation Society http://www. j-circ.or.jp t present, coronary artery disease (CAD) remains the biggest cause of death. While the mortality rate of acute coronary syndrome (ACS) has declined in recent years, mortality due to stable CAD has been unchanged over the last decades. 1 Medical treatment for CAD aims at stabilization of plaque and prevention of progression, as well as prevention of plaque rupture and subsequent future events, while treating the symptoms and sequelae of the disease. On the other hand, revascularization by either coronary artery bypass surgery or percutaneous coronary intervention (PCI) aims to re-establish effective coronary blood flow, leading to improvement of myocardial ischemia and its manifestations. The indications for PCI have expanded due to recent advances in techniques and the development of new devices. Especially since the approval of drug-eluting stents (DES), use of PCI has expanded for both complex lesions and for mild to moderate stenosis 2 (Figure 1). Recent rapid advances of diagnostic modalities such as coronary CT angiography are likely to contribute to this trend for increased use of PCI. 3,4 Although the data have not been reported, it is speculated that the number of PCI procedures for coronary artery stenosis documented by coronary CT angiography has dramatically increased ( Figure 2). As a result, the appropriateness of current indications for PCI has been called into question, particularly its use in patients lacking documentation of ischemia by noninvasive testing prior to the procedure. Here, I will discuss the importance of evaluating the extent of CAD and the indications for PCI in CAD patients. Coronary Angiography (CAG) Is the Gold Standard for Evaluation of LesionsCAG has long been the gold standard for evaluation of CAD. However, the limitations of CAG have also been clearly demonstrated by intravascular ultrasound studies and autopsy studies. 5-7 Because angiographic assessment is based on visualizing the vessel lumen, complex lesions (such as diffuse lesions, bifurcation lesions, and slit-like lesions) are not ideal for evaluation of severity by CAG. These lesions are difficult to visualize angiographically, even if multiple projections are employed. Therefore, the clinical importance of physiological assessment as an adjunct to CAG for evaluation of The indications for percutaneous coronary intervention (PCI) have expanded, especially after the approval of drugeluting stents, for both complex lesions and those with intermediate stenosis.Because recent randomized trials have demonstrated the non-inferiority of optimal medical treatment for stable angina compared with coronary revascularization, and the benefits of PCI guided by coronary pressure measurement have been shown in another trial, the appropriateness of current indications for PCI has been called into question. In the evaluation of coronary artery stenosis, inter- and intraobserver variabilities can be problematic. Therefore, the use of P...

Clinical significance of optical coherence tomography‑guided angioplasty on treatment selection

“…Although CAG is widely considered the gold standard for the diagnosis of CAD as well as a primary examination for guiding PCI procedures and judging coronary intervention success ( 5 , 27 , 28 ), studies have suggested that its use alone may miss important information. Such studies have claimed that treatment strategies would be modified if the OCT examination was used with or instead of CAG ( 27 , 29 ).…”

“…Recent advances in interventional cardiology have highlighted the importance of a detailed understanding of the tissue characteristics of coronary atherosclerotic lesions, including the identification of plaque stability, estimation of lesion covering, and tearing degree pre- and post-PCI ( 3 , 4 ). Coronary angiography (CAG) has been considered to be the gold standard diagnostic method for CAD and is widely accepted as a firm basis for determining treatment strategies for PCI ( 5 ). However, previous evidence indicated that CAG may not provide accurate images in certain cases and may fail to reflect specific critical characteristics of atherosclerotic lesions or vessel-stent associations in high-risk cases ( 5 – 7 ).…”

“…Coronary angiography (CAG) has been considered to be the gold standard diagnostic method for CAD and is widely accepted as a firm basis for determining treatment strategies for PCI ( 5 ). However, previous evidence indicated that CAG may not provide accurate images in certain cases and may fail to reflect specific critical characteristics of atherosclerotic lesions or vessel-stent associations in high-risk cases ( 5 – 7 ). Therefore, novel techniques that fully reflect lesion and stent features have been developed in interventional cardiology.…”

Coronary Calcium Scoring and Modifiable Coronary Risk Factors

“…Conventional coronary angiography is a gold standard for the diagnosis of coronary artery narrowing but it has a disadvantage of being an invasive procedure with a life threatening complication rate of one per thousand. [11] A study suggested that calcium scores can be used to stratify risk factor in asymptomatic patient and is a strong predictor of predictive information beyond the traditional risk factors in different ethnic group. [2] However, in this study having risk factors did not increase calcium score in most cases so it may be hypothesized that coronary calcium score and traditional risk factors might be independent risk factors.…”

PCI in Post Thrombolysis Stable STEMI Patients: A Timeline in Question

“…Medical management and thrombolysis focuses on symptomatic treatment as well as plaque stabilization, prevention of progression of subsequent future events. But revascularization by either PCI or coronary artery bypass grafting (CABG) aims to re-establish coronary artery flow leading to improvement of ischemia and its manifestations [12]. The Urgency of the treatment is based on various pathologic changes in the myocardium following STEMI, which is illustrated in Figure 2.…”