ESC Congress 2016 - 27

Your FREE access to ESC Congress content all year long www.escardio.org/365 Stress myocardial perfusion imaging with magnetic resonance imaging, CT, or PET can accurately rule out hemodynamically significant CAD [Takx R et al. Circ Cardiovasc Imaging. 2015]. Current European Society of Cardiology guidelines recommend the use of anatomical or functional cardiac imaging, or a hybrid of the 2, for the diagnosis of CAD [ESC Taskforce. Eur Heart J. 2014]. The primary goal of the PACIFIC trial was to establish the accuracy CCTA, SPECT, and PET imaging in a headto-head fashion for the diagnosis of CAD compared with FFR. A secondary purpose was to explore the incremental diagnostic value of hybrid cardiac imaging compared with stand-alone imaging. The study included stable patients (aged > 40 years) with suspected but no prior history of CAD, an intermediate pretest likelihood and normal left ventricular function on echocardiography who presented for a clinically referred invasive coronary angiography. PACIFIC was a prospective trial involving 208 stable patients all of whom underwent invasive coronary angiography, followed by CCTA, SPECT, and PET as well as some hybrid combinations of PET and CCTA or SPECT and CCTA designed to combine functional and anatomical assessments. Obstructive CAD was defined as ≥ 50% stenosis. The primary endpoint of the study was a hemodynamically significant stenosis in ≥ 1 coronary artery as indicated by a FFR ≤ 0.80 or stenosis > 90% if FFR was lacking. The McNemar test was used to compare the sensitivity, specificity, and diagnostic accuracy of the imaging modalities. Patients were mean age 58 years; 64% were men. About half of the participants had a family history of CAD (51%), 48% used tobacco, 40% had hypercholesterolemia, and 46% were hypertensive (46%). The use of aspirin (87% of patients), statins (77%), and ß-blockers (64%) was high. The pretest likelihood of CAD was deemed intermediate in 90% of patients. Coronary angiography showed 44.2% of patients to have hemodynamically significant CAD. When compared against the results of coronary angiography, the diagnostic accuracy of PET was significantly better (85%) than either CCTA (74%; P = .003) or SPECT (77%; P = .02). Diagnostic accuracy was not improved by either hybrid CCTA/SPECT (76%; P = NS) or CCTA/PET (84%; P = NS) but resulted in an increase in false-negatives and a decrease in false-positive results for each modality alone (P < .001). In this first prospective head-to-head comparative trial, PET exhibited a higher accuracy for diagnosis of myocardial ischemia compared with SPECT or CCTA. Furthermore, a combined anatomical and functional assessment (hybrid imaging) did not add incremental diagnostic value and increases the risk of poor clinical decision-making. ESC CONGRESS 2016 IN REVIEW PRAGUE-18: No Difference in Outcomes Between Prasugrel and Ticagrelor in Patients With AMI Treated With PCI Written by Maria Vinall The PRAGUE-18 study [Motovska Z et al. Circulation. 2016] is a direct comparison of prasugrel and ticagrelor in patients with acute myocardial infarction (AMI) treated with immediate or primary percutaneous coronary intervention (PCI). In his presentation of the 1-month results from PRAGUE-18, Petr Widimsky, MD, Charles University, Prague, Czech Republic, reported no difference in outcome between the groups. The study was prematurely terminated for futility. The PRAGUE-18 study was designed as a head-tohead comparison of prasugrel and ticagrelor in patients with either STEMI or high-risk NSTEMI undergoing PCI. The primary endpoint was a composite of death, re-infarction, stroke, major bleeding, or urgent repeat revascularization of the infarct-related artery (IRA) at 7 days (or discharge if earlier). The key secondary endpoint was a composite of cardiovascular death, nonfatal myocardial infarction, or stroke at 30 days. The study included elderly patients and patients in all Killip classes (5% Killip class III-IV) with STEMI (NSTEMI with ongoing ischemia) and emergent coronary angiography with planned PCI. Eligible patients (mean age, 62 years; mostly men) were randomized immediately after arrival at the PCI center to either prasugrel (n = 634; 60 mg orally followed by 10 mg/d for 1 year [5 mg/d if > 75 years or < 60 kg]) or ticagrelor (n = 596; 180 mg orally followed by 90 mg BID for 1 year). At 7 days there was no significant difference between treatments for primary endpoint of death, re-infarction, stroke, major bleeding, and urgent IRA repeat revascularization (prasugrel 4.0% and ticagrelor 4.1%; OR, 0.98; 95% CI, 0.55 to 1.73; P = .939). Results for the key secondary endpoint at 30 days were also not significantly different (prasugrel 2.7%; ticagrelor 2.5%; OR, 1.06; 95% CI, 0.53 to 2.15; P = .864). The majority of patients continued on treatment drugs after discharge (prasugrel 74%; ticagrelor 64%) beyond day 30 or until death. There were no significant differences for any of the other prespecified outcomes at 7 days (urgent repeat target-vessel revascularization, serious bleeding requiring transfusion or prolonged hospital stay, TIMI-3 flow after primary PCI) or 30-days (all-cause mortality, re-infarctionn, stroke/TIA, or definite stent thrombosis). Official Peer-Reviewed Highlights From ESC Congress 2016 27 http://www.escardio.org/365

Table of Contents for the Digital Edition of ESC Congress 2016