Percutaneous Revascularization In Patients Research Articles

Comparison of Complete Versus Incomplete Percutaneous Revascularization in Patients With Chronic Total Occlusion: A Systematic Review and Meta-Analysis.

The optimal extent of revascularization in patients with chronic total occlusion (CTO) undergoing percutaneous coronary intervention (PCI) remains debated. This meta-analysis aimed to compare the clinical outcomes of complete versus incomplete revascularization in CTO patients. A systematic search of EMBASE, PubMed, and Web of Science was conducted up to July 6, 2024. Studies reporting outcomes in CTO patients undergoing PCI with complete or incomplete revascularization were included. The primary outcomes were major adverse cardiovascular events (MACE), all-cause mortality, and cardiovascular mortality. Eight studies with a total of 7,067 patients (4,854 complete and 2,213 incomplete revascularization) were included. Complete revascularization was associated with a significantly lower risk of MACE (RR: 0.57, 95% CI: 0.43-0.77), all-cause mortality (RR: 0.54, 95% CI: 0.37-0.78), and cardiovascular mortality (RR: 0.46, 95% CI: 0.29-0.75) compared to incomplete revascularization. There was no significant difference in the risk of recurrent myocardial infarction between the two groups (RR: 0.60, 95% CI: 0.20-1.80). In patients with CTO undergoing PCI, complete revascularization is associated with significantly better clinical outcomes, including lower risks of MACE, all-cause mortality, and cardiovascular mortality, compared to incomplete revascularization. These findings suggest that achieving complete revascularization should be prioritized when feasible in CTO patients.

Complete vs. incomplete percutaneous revascularization in patients with chronic total coronary artery occlusion.

There is current controversy surrounding the benefits of percutaneous coronary intervention (PCI) of chronic total coronary occlusions (CTO). We aimed to evaluate the impact of complete percutaneous revascularization on major adverse cardiovascular events (MACE) in patients with CTO. A retrospective observational study was conducted of consecutive patients referred for invasive coronary angiography at a single center between January 2018 and December 2019 and at least a CTO. The patients were divided into two groups according to the result of the procedure: complete revascularization of CTO (CR-CTO) versus incomplete revascularization (ICR-CTO) (patients with at least one non-recanalized CTO). Short- and mid-term clinical outcomes were evaluated. The primary endpoint was a composite of MACE that included all-cause death, non-fatal myocardial infarction, non-fatal stroke, or unplanned revascularization. In total, 359 patients with CTO were included. The median age was 68 years [interquartile range (IQR) 60-77 years], 66 (18%) were women and 169 (47.3%) had diabetes mellitus. In all, 167 (46.5%) patients received complete revascularization. After a median follow-up of 42 months (IQR 46-50 months), the primary endpoint occurred in 39 (23.4%) patients in the CR-CTO group and in 75 (39.1%) in the ICR-CTO group (HR 0.50, 95% CI 0.34-0.74; p < 0.001). This association remained significant in an inverse probability weighted model considering prognostic factors (adjusted HR 0.61, 95% CI 0.41-0.92; p = 0.018) and was driven by lower rates of all-cause death (adjusted OR 0.50, 95% CI 0.23-0.84; p = 0.01). Complete revascularization of CTO was associated with a lower risk of MACE in the midterm follow up.

Illusion of revascularization: does anyone achieve optimal revascularization during percutaneous coronary intervention?

This Perspective article is a form of 'pastiche', inspired by the 1993 review by Lincoff and Topol entitled 'Illusion of reperfusion', and explores how their concept continues to apply to percutaneous revascularization in patients with coronary artery disease and ischaemia. Just as Lincoff and Topol argued that reperfusion of acute myocardial infarction was facing unresolved obstacles that hampered clinical success in 1993, we propose that challenging issues are similarly jeopardizing the potential benefits of stent-based angioplasty today. By analysing the appropriateness and efficacy of percutaneous coronary intervention (PCI), we emphasize the limitations of relying solely on visual angiographic guidance, which frequently leads to inappropriate stenting and overtreatment in up to one-third of patients and the associated increased risk of periprocedural myocardial infarction. The lack of optimal revascularization observed in half of patients undergoing PCI confers risks such as suboptimal physiology after PCI, residual angina and long-term stent-related events, leaving an estimated 76% of patients with an 'illusion of revascularization'. These outcomes highlight the need to refine our diagnostic tools by integrating physiological assessments with targeted intracoronary imaging and emerging strategies, such as co-registration systems and angiography-based computational methods enhanced by artificial intelligence, to achieve optimal revascularization outcomes.

Abstract 19028: Revascularization in Ischemic Cardiomyopathy With Left Ventricular Systolic Dysfunction- Percutaneous Intervention (PCI) vs Medical Therapy

Background: The benefits of percutaneous revascularization in patients with reduced Left Ventricular (LV) systolic function secondary to stable coronary artery disease (CAD) is still ambiguous. We aim to compare the survival benefits of PCI in patients with Ischemic cardiomyopathy with reduced LV Ejection Fraction (LVEF &lt;35%) compared to Medical Therapy (MT) alone. Methods: A systematic search was conducted in PubMed, Google Scholar, and Cochrane databases from inception to 5 th June 2023. Among 108 results from the systematic search, a total of 4 studies (2080 patients) were included. Our outcome of interest was all-cause mortality in patients undergoing PCI vs. medical therapy. We used random-effects models to aggregate data and to calculate pooled incidence and relative risk (RR) with 95% confidence intervals (CIs). Results: Of 1082 patients undergoing revascularization with PCI and 998 patients in the medical therapy arm, the outcome of all-cause mortality occurred in 168 patients (15.5%) in the PCI group and in 200 patients (20.0%) in the medical therapy group (Hazard ratio, 0.88; 95% confidence interval [CI], 0.71 to 1.09; P=0.25). However, a non-statistical trend toward lower mortality was noted in the PCI arm. Low heterogenicity was noted between the studies. Conclusions: In patients with ischemic cardiomyopathy with reduced LV systolic function (EF &lt;35%), revascularization with PCI is associated with similar all-cause mortality compared to medical therapy.

Comparison of mid-term mortality after surgical, supported or unsupported percutaneous revascularization in patients with severely reduced ejection fraction: A direct and network meta-analysis of adjusted observational studies and randomized-controlled

IntroductionThe optimal revascularization strategy in patients with heart failure with reduced ejection fraction (HFrEF) remains to be elucidated. The aim of this paper is to compare the mid-term mortality rate among patients with severely reduced ejection fraction (EF) and complex coronary artery disease who underwent coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI) with Impella support, or without. MethodsRandomized control trials and propensity-adjusted observational studies including patients with ischemic cardiomyopathy (ICM) and severe EF reduction undergoing revascularization were selected. Different revascularization strategies (CABG, supported PCI, and PCI without Impella) were compared in pairwise and network meta-analysis. The primary endpoint was mid-term mortality (within the first year after revascularization). ResultsFifteen studies, mostly observational (17,841 patients; 6779 patients treated with CABG, 8478 treated with PCI without Impella, and 2584 treated with Impella-supported PCI) were included in this analysis. The median age was 67.8 years (IQR 65–70.1), 21.2% (IQR 16.4–26%) of patients were female sex, and a high prevalence of cardiovascular risk factors was noted across the entire population. At pairwise analysis, CABG and PCI without Impella showed similar one-year all-cause mortality (10.6% [IQR 7.5–12.6%] vs 12% [IQR 8.4–11.5%]) RR 0.85 CI 0.67–1.09, while supported PCI reduced one-year all-cause mortality compared to PCI without Impella (9.4% [IQR 5.7–12.5%] vs 10.6% [IQR 8.9–10.7%]) RR 0.77 CI 0.6–0.89. At network meta-analysis, supported PCI showed better results (RR 0.75, 95% CI 0.59–0.94) compared to CABG. ConclusionOur analysis found that supported PCI may have a benefit over standard PCI in patients in direct comparison, and over CABG from indirect comparison, and with HFrEF undergoing revascularization. Further RCTs are needed to confirm this result. (PROSPERO CRD42023425667).

IN-HOSPITAL MORTALITY AFTER INCOMPLETE PERCUTANEOUS REVASCULARIZATION IN PATIENTS WITH MULTIVESSEL CORONARY ARTERY DISEASE PRESENTING WITH ACUTE CORONARY SYNDROME

Objectives: Patients with significant multi-vessel coronary artery disease (CAD) are approximately one-half to two-thirds of patients presenting with acute coronary syndrome (ACS). Therefore, this study aimed to evaluate the in-hospital mortality of incomplete percutaneous revascularization in a patient with multi-vessel CAD presenting with ACS at a single tertiary care hospital in Karachi, Pakistan. Methodology: This descriptive study with 282 included consecutive patients from March 22, 2021, to September 21, 2021, fulfilling the inclusion criteria of aged between 18 and 75 years and of any gender, diagnosed with ACS, multi-vessel diseases, and undergone percutaneous revascularization of culprit artery only. Patients with pre-existing chronic kidney disease or cardiogenic shock at presentation were excluded. All patients were kept under observation during the hospital stay for up to one week, and in-hospital mortality was recorded. Results: Mean age was 55.7±10.8 years with 185 (65.6%) male patients. Types of ACS were noted as ST-elevation myocardial infarction (STEMI) in 109 (38.7%), 117 (41.5%) non-STEMI, while unstable angina was noted in 56 (19.9%) patients. Three-vessel disease was noted in 126 (44.7%), 108 (38.3%) were diabetics, 164 (58.2%) were hypertensive, and 128 (45.4%) were smokers. In-hospital mortality was documented in 22 (7.8%) patients. Conclusion: A significant proportion of in-hospital mortality was observed after incomplete percutaneous revascularization in ACS patients with multi-vessel CAD.

Complete Percutaneous Revascularization in Patients Aged ≥85 Years With Acute Coronary Syndrome and Multivessel Coronary Artery Disease

Multivessel coronary disease is frequent in older patients who underwent coronary angiography for acute coronary syndrome. Whether a complete revascularization or a culprit-only approach is preferable in these patients is still debated. We included consecutive patients aged ≥85years, presenting with acute coronary syndrome and showing multivessel coronary disease at coronary angiography. Patients were grouped according to complete (residual SYNTAX score [RSS] 0 to 8) or incomplete (RSS &gt;8) revascularization. Primary end point was the rate of major adverse cardiovascular events (MACEs, the composite of cardiovascular death, re-myocardial infarction [re-MI], clinically driven percutaneous coronary intervention, and rehospitalization because of cardiac disease) at 2years follow-up. A total of 166 patients met the criteria for enrollment; 108 patients had a final RSS 0 to 8 (complete revascularization) and 58 patients had a final RSS &gt;8 (incomplete revascularization). The rate of MACE was reduced in patients who underwent complete revascularization (35.2% vs 51.7%, p=0.039, adjusted hazard ratio 0.60, 95% confidence interval 0.37 to 0.98, p=0.04), a difference mainly driven by a reduction in re-MI (8.3% vs 19.0%, p=0.045), clinically driven percutaneous coronary intervention (2.8% vs 19.0%, p &lt;0.001), and rehospitalization for cardiac disease (9.3% vs 24.1%, p=0.009). Other independent predictors of MACE were active malignancy, previous MI, left ventricle ejection fraction &lt;35% (increasing risk of events), and radial access (reducing risk of events). In conclusion, in patients aged ≥85years, a complete revascularization is associated with a better prognosis, especially in terms of nonfatal events.

Comparison of SYNTAX and Gensini Scores in the Decision of Surgery or Percutaneous Revascularization in Patients With Multivessel Coronary Artery Disease.

Introduction: Many scoring systems have been developed to determine the extent of coronary artery disease (CAD) in patients with multi-vessel disease. The most widely used of these are Synergy between percutaneous coronary intervention with Taxus and cardiac surgery (SYNTAX) and Gensini scoring. Gensini scoring system can successfully show coronary plaque burden. In our study, we aimed to test the predictive power of SYNTAX and Gensini scores for surgical or percutaneous intervention decisions made by the cardiac team in patients with three-vessel disease.Methods: A total of 476 patients without ST-elevation myocardial infarction with the three-vessel disease were included in the study. SYNTAX and Gensini scores of the patients were calculated from their coronary angiographies. Receiver operating characteristic curve (ROC-curve) analysis was performed using both scores.Results: Both the SYNTAX score and Gensini score were able to predict heart team decisions (AUC: 0.759, 0.680; p<0.001). Diabetes and smoking were more common in patients who were decided to have surgery (p<0.001).Conclusion: In the light of our study results, the decisions to be made with the SYNTAX score will be closer to the decisions of the heart team than the Gensini score.

Can Fetuin A Be Utilized in the Evaluation of Elderly Patients with Acute Myocardial Infarction?

Background: Lower baseline Fetuin-A (FA) is associated with left ventricular remodeling and cardiovascular death (CVD) at 4 months after acute myocardial infarction (AMI). However, the association between FA levels, incomplete ST segment resolution (STR) following primary percutaneous coronary intervention (PCI) and early mortality in AMI has not been previously studied. Methods: We enrolled 100 patients with AMI, which we divided in two groups: 21 patients who suffered sudden cardiac death (SCD) in the first 7 days after PCI and 79 controls. We measured FA, NT-proBNP and troponin levels and correlated them with the occurrence of death in the first week after revascularization. We also tested the cut-off value of FA to determine STR at 90 min after PCI. Results: SCD was most frequently caused by pump failure (n = 10, 47.6%) and ventricular arrhythmias (n = 9, 42.5%). Plasma FA levels correlated with NT-proBNP values (r = −0.47, p = 0.04) and were significantly lower in patients presenting SCD (115 (95–175) vs. 180 (105–250) ng/mL, p = 0.03). Among all three biomarkers, FA was the only one associated with incomplete STR after PCI on the multivariate logistic regression (cut-off value of 175 ng/mL, Se = 74%, Sp = 61.1%). Death rate was highest (n = 16/55, 30%) in patients with FA levels below the cut-off value of 175 ng/mL. Conclusion: Lower FA is associated with higher early mortality and incomplete STR after primary percutaneous revascularization in patients with AMI. Measurement of FA levels in addition to NT-proBNP, troponin and STR might enable more accurate identification of high-risk patients.

Long-Term Survival After Surgical or Percutaneous Revascularization in Patients With Diabetes and Multivessel Coronary Disease

BackgroundThere remains a paucity of real-world observational evidence comparing percutaneous coronary intervention (PCI) with coronary artery bypass grafting (CABG) in patients with diabetes and multivessel coronary artery disease (CAD). ObjectivesThis study compared early and long-term outcomes of PCI versus CABG in patients with diabetes. MethodsClinical and administrative databases in Ontario, Canada were linked to obtain records of all patients with diabetes with angiographic evidence of 2- or 3-vessel CAD who were treated with either PCI or isolated CABG from 2008 to 2017. A 1:1 propensity score match was performed to account for baseline differences. All-cause mortality and the composite of myocardial infarction, repeat revascularization, stroke, or death (termed major cardiovascular and cerebrovascular events [MACCEs]) were compared between the matched groups using a stratified log-rank test and Cox proportional hazards model. ResultsA total of 4,519 and 9,716 patients underwent PCI and CABG, respectively. Before matching, patients who underwent CABG were significantly younger (age 65.7 years vs. 68.3 years), were more likely to be men (78% vs. 73%) and had more severe CAD. Propensity score matching based on 23 baseline covariates yielded 4,301 well-balanced pairs. There was no difference in early mortality between PCI and CABG (2.4% vs. 2.3%; p = 0.721) after matching. The median and maximum follow-ups were 5.5 and 11.5 years, respectively. All-cause mortality (hazard ratio [HR]: 1.39; 95% CI: 1.28 to 1.51) and overall MACCEs (HR: 1.99; 95% CI: 1.86 to 2.12) were significantly higher with PCI compared with CABG. ConclusionsIn patients with multivessel CAD and diabetes, CABG was associated with improved long-term mortality and freedom from MACCEs compared with PCI.

The Combination of Oral Anticoagulant and Antiplatelet Therapies: Stay One Step Ahead.

Antithrombotic drugs, which include antiplatelets and anticoagulants, are effective in prevention and treatment of many cardiovascular disorders such as acute coronary syndromes, stroke, and venous thromboembolism and are among the drugs most commonly prescribed worldwide. The advent of direct oral anticoagulants, which are safer alternatives to vitamin K antagonists and do not require laboratory monitoring, has revolutionized the treatment of nonvalvular atrial fibrillation and venous thromboembolism. The combination of oral anticoagulant and antiplatelet therapy is required in many conditions of great clinical impact such as the coexistence of atrial fibrillation and coronary artery disease, with indication to percutaneous coronary intervention. However, strategies that combine anticoagulant and antiplatelet therapies lead to a significant increase in bleeding rates and it is crucial to find the right combination in the single patient in order to optimize the ischemic and bleeding risk. The aim of this review is to explore the evidence and controversies regarding the optimal combination of anticoagulant and antiplatelet therapy through the consideration of past dogmas and new perspectives from recent clinical trials and to propose a tailored therapeutic approach, according to specific clinical scenarios and individual patient characteristics. In particular, we separately explored the clinical settings of stable and acute coronary syndromes and percutaneous revascularization in patients with atrial fibrillation.

Towards a Saphenous Vein Graft Moratorium.

Atherosclerosis develops and rapidly progresses in saphenous veins grafts after coronary bypass surgery. In contrast to native coronary artery, percutaneous revascularization does not impede the progression of saphenous vein atherosclerosis and saphenous vein graft failure commonly ensues. The protracted patency of arterial grafts is likely to account for most of the long-term superiority of coronary artery bypass surgery over percutaneous revascularization in patients with complex coronary artery disease. Long-lasting, complete coronary revascularization may be best achieved by combining surgical arterial grafting of diseased coronary arteries to percutaneous revascularization with drug-eluting stents than by the continued use of saphenous vein grafts.

Antithrombotic therapy after percutaneous revascularization in patients on chronic oral anticoagulation treatment

Antithrombotic therapy after percutaneous revascularization in patients on chronic oral anticoagulation treatment

Guidewire fracture during orbital atherectomy for peripheral artery disease: Insights from the Manufacturer and User Facility Device Experience database.

Orbital atherectomy (OA) is routinely being used for plaque modification to facilitate percutaneous revascularization in patients with peripheral arterial disease (PAD) and arterial calcification. Guidewire fracture (GWF) during OA, though anecdotally described, has not been studied in a systematic manner. We conducted a review of the Manufacturer and User Facility Device Experience (MAUDE) database to study the reports of wire fracture and its management and consequences. We queried the MAUDE database for all events involving the current generation of the OA device: "Diamondback 360 Peripheral Orbital Atherectomy System", and "Stealth 360° Orbital PAD System". We identified 62 reports of GWF during OA for PAD. The superficial femoral artery was the most commonly involved atherectomy site. The wire fractured at the soft tip in a majority of cases (68%). Embolized wire fragments were left in the patient in 36 cases (58%), retrieved percutaneously in 10 cases (16%), and trapped by a stent against the arterial wall in eight cases (13%). Lastly, eight patients (13%) underwent surgery for removal of the wire fragment. This is the first published report to study the complication of GWF during peripheral OA. GWF is an uncommon but has significant procedural and clinical consequences. It results in a high rate of ancillary rescue procedures (including surgery) and is associated with a higher risk of arterial thrombosis and complications from wire retrieval attempts. The risk of wire fracture may be avoided with carefully adherence to the IFU.

TCT-636 Multivessel Disease in STEMI patients: A Meta-analysis comparing the timing (index vs. staged) of achieving complete revascularization

Current guidelines for percutaneous revascularization in patients with ST elevation myocardial infarction (STEMI) and multivessel disease (MVD) advise restricting intervention to the culprit vessel at the index procedure. However, recent data, suggests that complete revascularization (CR) is

Retrograde Access Facilitates Percutaneous Revascularization in Patients with Complex Infra-inguinal Arterial Occlusive Disease

Retrograde Access Facilitates Percutaneous Revascularization in Patients with Complex Infra-inguinal Arterial Occlusive Disease

Percutaneous revascularization in patients treated with thoracic radiation for cancer

To assess coronary revascularization outcomes in patients with previous thoracic radiation therapy (XRT). Previous chest radiation has been reported to adversely affect long term survival in patients with coronary disease treated with percutaneous coronary interventions (PCI). Retrospective, single center cohort study of patients previously treated with thoracic radiation and PCI. Patients were propensity matched against control patients without radiation undergoing revascularization during the same time period. We identified 116 patients with radiation followed by PCI (XRT-PCI group) and 408 controls. Acute procedural complications were similar between groups. There were no differences in all-cause and cardiac mortality between groups (all-cause mortality HR 1.31, P=.078; cardiac mortality 0.78, P=.49). Patients with prior thoracic radiation and coronary disease treated with PCI have similar procedural complications and long term mortality when compared to control subjects.

Impact of Incomplete Percutaneous Revascularization in Patients With Multivessel Coronary Artery Disease: A Systematic Review and Meta-Analysis.

BackgroundUp to half of patients undergoing percutaneous coronary intervention have multivessel coronary artery disease (MVD) with conflicting data regarding optimal revascularization strategy in such patients. This paper assesses the evidence for complete revascularization (CR) versus incomplete revascularization in patients undergoing percutaneous coronary intervention, and its prognostic impact using meta‐analysis.Methods and ResultsA search of PubMed, EMBASE, MEDLINE, Current Contents Connect, Google Scholar, Cochrane library, Science Direct, and Web of Science was conducted to identify the association of CR in patients with multivessel coronary artery disease undergoing percutaneous coronary intervention with major adverse cardiac events and mortality. Random‐effects meta‐analysis was used to estimate the odds of adverse outcomes. Meta‐regression analysis was conducted to assess the relationship with continuous variables and outcomes. Thirty‐eight publications that included 156 240 patients were identified. Odds of death (OR 0.69, 95% CI 0.61‐0.78), repeat revascularization (OR 0.60, 95% CI 0.45‐0.80), myocardial infarction (OR 0.64, 95% CI 0.50‐0.81), and major adverse cardiac events (OR 0.63, 95% CI 0.50‐0.79) were significantly lower in the patients who underwent CR. These outcomes were unchanged on subgroup analysis regardless of the definition of CR. Similar findings were recorded when CR was studied in the chronic total occlusion (CTO) subgroup (OR 0.65, 95% CI 0.53‐0.80). A meta‐regression analysis revealed a negative relationship between the OR for mortality and the percentage of CR.Conclusion CR is associated with reduced risk of mortality and major adverse cardiac events, irrespective of whether an anatomical or a score‐based definition of incomplete revascularization is used, and this magnitude of risk relates to degree of CR. These results have important implications for the interventional management of patients with multivessel coronary artery disease.

Assessment of Inducible Myocardial Ischemia, Quality of Life, and Functional Status After Successful Percutaneous Revascularization in Patients With Chronic Total Coronary Occlusion

The benefits of chronic total coronary occlusion (CTO) revascularization are not well established. In this prospective cohort study, 47 consecutive patients with successful percutaneous recanalization of CTO underwent adenosine stress cardiac magnetic resonance (CMR), 6-minute walk test (6MWT), and the Short Form-36 Health Survey before and 6 months after the procedure. Successful recanalization of a CTO was followed by significant improvement of (1) global physical and mental health status; (2) the distance walked in the 6MWT; (3) the incidence of chest pain at the end of the 6MWT; and (4) the score of a novel CMR ischemic burden index on the basis of the characteristics of adenosine stress perfusion defects (extension, persistence, transmurality, and induced contractile regional dysfunction). Patients with greater CMR ischemic index before percutaneous revascularization showed better improvement in the 6MWT. In conclusion, successful recanalization of a CTO leads to a concurrent improvement in ischemic burden, exercise tolerance, angina frequency, and quality of life scores. Patients with a high ischemic CMR score before CTO recanalization showed the better improvement in exercise tolerance.

Ischemia-Guided Percutaneous Revascularization

Submit Manuscript | http://medcraveonline.com The study of Hachamovitch et al. [3] emphasized the relationship between inducible ischemia on SPECT and the presence of shortterm survival benefits with early revascularization vs. medical therapy.Revascularization was associated with a reduction in mortality for patients having moderate to severe ischemia. The cut-off level of ischemic myocardium, assessed by summed stress scores, to predict lower mortality using revascularization was approximately 10-12.5% [3]. Kim et al. [4] supported the benefit of ischemia-guided revascularization with myocardial perfusion imaging for patients with multivessel coronary artery disease. The outcomes of ischemia-guided revascularization were retrospectively compared with those of non ischemiaguided revascularization in a registry of 5,340 patients with multivessel coronary disease comprising 2,587 percutaneous coronary interventions (PCIs) with drug-eluting stents and 2,753 coronary artery bypass graft (CABG) surgeries. The incidence of major adverse cardiac and cerebrovascular events (MACCE) was significantly lower in the ischemia-guided than in the non ischemia-guided group, primarily driven by the lower repeat revascularization rate. Subgroup analysis showed that ischemiaguided reduced the risk of MACCE in PCI but not in CABG patients [4]. Several diagnostic modalities are available for use as tools to establish the initial diagnosis, assess disease severity, and select the appropriate treatment strategy in symptomatic patients suspected of having SCAD. In relation to this point, a multicenter study performed in Japan hypothesise that the choice of the initial diagnostic test might influence the treatment strategy. They showed that patients receiving initial SPECT had a lower rate of revascularization than those receiving coronary angiography [5]. In relation to invasive methods assessing ischemia, fractional flow reserve (FFR) is considered nowadays the elective way for invasive assessment of physiological stenosis significance and a decisive tool for decision making in coronary revascularization. The recently published ESC guidelines on the management of stable coronary artery disease endorse the use of FFR for risk stratification. FFR is calculated as the ratio of distal coronary pressure to aortic pressure measured during maximal hyperaemia. A normal value for FFR is 1.0. Stenoses with a FFR >0.80 are hardly ever associated with exercise-induced ischaemia [6]. The principal utility of FFR is in certain situations when it is not clear whether an intermediate angiographic lesion causes ischemia. The use of FFR in the catheterization laboratory accurately identifies which lesions should be revascularized and improves the outcome in most elective clinical and angiographic conditions, as compared with the situation where revascularization decisions are simply made on the basis of angiographic appearance of the lesion [7]. The DEFER study evaluated the 5-year outcomes in 325 patients assigned to 3 groups: deferred group (FFR ≥0.75 without PCI), PCI group (FFR ≥0.75 with PCI), and a control group (FFR <0.75 with PCI). 5-year event-free survival rates were similar in the deferred and PCI groups, with a risk of cardiac death or MI in patients with normal FFR inferior to 1% per year [8]. FAME study evaluated angio-guided versus FFR-guided percutaneous revascularization in patients with multivessel disease. Routine measurement of FFR in patients with multivessel coronary artery disease who were undergoing PCI with drug-eluting stents significantly reduced the rate of the composite end point of death, nonfatal myocardial infarction, and repeat revascularization at one year of follow up [9]. The 2-year outcome report of the FAME study supported the safety of deferring PCI for non ischemic lesions [10]. Of interest, a sub analysis of the FAME study also showed that angiography is inaccurate in assessing the functional significance of a coronary stenosis when compared with the FFR in the 50% to 70% category but also in the 70% to 90% angiographic severity category [11]. The FAME-2 trial tested the benefits, for SCAD, of FFR-guided PCI plus optimal medical therapy with optimal medical treatment alone. PCI group had significant lower rate of primary endpoint event: death, MI, or urgent revascularization. Also there was a lower rate of urgent revascularization in the PCI group than in the medical therapy group [12].