Large Differences between Focal and Diffuse Patterns of Stable CAD

PCI is far more successful at reducing ischemia when treating focal stable coronary artery disease (CAD). However, there were no differences in symptoms between both types of CAD. 

Physiological assessment with pressure wire pullback can be used to distinguish focal vs diffuse CAD, even though the relevance of this distinction has not been looked at closely. 

Using the ORBITA database, researchers tested PCI efficacy against placebo in both types of CAD patterns (focal vs diffuse). They observed the impact of these patterns on stress echocardiography ischemia and symptom end points. 

164 patients were assessed with iFR pullback before randomization. Focal CAD was defined as iFR drop >0.03 within 15 mm. Greater distances were defined as diffuse CAD. 

Of the 85 patients in the ORBITA PCI branch, 48 showed focal lesions and 37 diffuse CAD. IN the placebo arm (n=79) 35 had focal lesions and 44 diffuse CAD.

Focal stenosis was associated with significantly lower FFR and iFR vs. diffuse pattern patients (mean FFR and iFR, focal 0.60±0.15 and 0.65±0.24, diffuse 0.78±0.10 and 0.88±0.08, respectively, p<0.0001).

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Stress echocardiography ischemia saw significantly greater reduction with PCI when patients showed a focal pattern, vs. a diffuse pattern (p<0.05). 

PCI did not show significant variation in exercise time pre and post randomization. This continued to be true after stratifying patients according to CAD pattern. 

PCI was superior to placebo when using the Seattle Angina Questionnaire both in frequency and freedom from symptoms. However, these differences continued to be true and similar when stratifying patients into focal and diffuse CAD. 

Conclusion

PCI achieve greater ischemia reduction with focal CAD vs. diffuse. There were no differences in symptom end points. 

Original Title: Placebo-Controlled Efficacy of Percutaneous Coronary Intervention for Focal and Diffuse Patterns of Stable Coronary Artery Disease.

Reference: Christopher A Rajkumar et al. Circ Cardiovasc Interv. 2021 Aug 3;CIRCINTERVENTIONS120009891. Online ahead of print. doi: 10.1161/CIRCINTERVENTIONS.120.009891.

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