Escalation or de-escalation of antianginal medication was less common than treatment continuation without change after a chronic total occlusion rechanneling, with little variation according to the site. Further research is needed to identify patients who would benefit (or not) from these drugs and to develop strategies to adjust treatment during follow-up.

This work basically tells us that in successful rechanneling cases, most patients continued with the same medication even when dose reduction or even discontinuation could have been attempted. On the contrary, in failed rechanneling cases, some effort was put on the adjustment of the treatment aimed at relieving patient symptoms, once there was nothing further to offer to them.

Prior research had already shown that physicians infrequently adjust antianginal medications following a chronic total occlusion rechanneling attempt, whether successful or not.

Using information from the 12 sites involved in the OPEN CTO registry (Outcomes, Patient Health Status, and Efficiency iN Chronic Total Occlusion Hybrid Procedures), researchers assessed antianginal medication use at baseline and 6 months after the procedure.

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Treatment escalation was defined as any addition of a new drug or dose increase, whereas de-escalation was defined as any drug discontinuation or dose reduction.

Angina was assessed 6 months after the procedure using the Seattle Angina Questionnaire Angina Frequency domain. Potential factors associated with escalation (vs. no change) or de-escalation (vs. no change) were evaluated using a multivariate model.

Antianginal medication was escalated in 17.5% of cases and de-escalated in 39.0% of cases, but, for most patients, medication remained unchanged at 6 months (43.5%).

Patient characteristics associated with escalation included lung disease, ongoing angina, and periprocedural major adverse events.

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De-escalation was used among patients taking more medication at baseline, those treated with successful rechanneling, and patients who underwent treatment of other vessels with significant but patent lesions after the successful rechanneling procedure.

While the aforementioned factors (for both escalation and de-escalation) seem logical, almost half of the patients remained with the same treatment.

Conclusion

Drug/dose increase or drug discontinuation/dose reduction were relatively infrequent after chronic total occlusion rechanneling. Further research is needed to identify patients who will benefit from treatment escalation or de-escalation, but first we need to develop post-procedural follow-up strategies.

Original Title: Patient Characteristics Associated With Antianginal Medication Escalation and De-Escalation Following Chronic Total Occlusion Percutaneous Coronary Intervention Insights From the OPEN CTO Registry.

Reference: Taishi Hirai et al. Circulation: Cardiovascular Quality and Outcomes. 2019;12. Article in press.

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