Background: The clinical value of physiological assessment after percutaneous coronary intervention (PCI) remains uncertain. We evaluated clinical outcomes associated with post-PCI physiology and temporal trends in its adoption. Methods: PROPHET-FFR (NCT05056662) is an ambispective observational study of patients undergoing invasive physiological assessment of intermediate coronary stenoses. Patients were categorized into three strategies: deferred revascularization based on non-ischemic physiology (deferred PCI), PCI for ischemic lesions without post-PCI physiological assessment (conventional PCI), and physiology-guided PCI with post-PCI assessment and optimization when indicated (post-PCI physiology). Temporal trends in the use of post-PCI physiology and physiology-guided optimization were evaluated, together with the incidence of 12-month major adverse cardiovascular events (MACE), comprising cardiovascular death, spontaneous myocardial infarction, and target-vessel revascularization (TVR). Propensity score matching between conventional PCI and post-PCI physiology was performed to confirm the primary findings. Results: Among 1,986 patients, 1,307 underwent deferred PCI, 331 conventional PCI, and 348 post-PCI physiology. At 12 months, MACE occurred in 4.1%, 7.6%, and 3.4%, respectively (p=0.011). Compared with conventional-PCI, post-PCI physiology had lower MACE (3.4% vs 7.6%; p=0.019), primarily driven by reduced TVR (2.6% vs 5.4%; p=0.057), with consistent findings after propensity score matching (226 patients/group; 2.7% vs 8.0%; p=0.0114). Post-PCI physiology increased from 11.8% to 22.8% across registry phases (p<0.001), with a numerical increase in physiology-guided optimization (11.6% vs 18.1%; p=0.08). Conclusions: In this observational study, post-PCI physiology appears to be associated with lower 12-month MACE compared with conventional PCI, with consistent findings after propensity score matching.
BACKGROUND: Myocardial infarction with nonobstructive coronary arteries (MINOCAs) and angina with nonobstructive coronary arteries (ANOCAs) present diagnostic and therapeutic challenges. We assessed the frequency of coronary microvascular disease (CMD) and its subtypes in MINOCA compared with ANOCA and evaluated long-term cardiovascular outcomes. METHODS: Patients with nonobstructive coronary arteries undergoing invasive coronary function testing from 2012 to 2022 were prospectively enrolled and retrospectively classified as MINOCA or ANOCA (reference group). Myocardial infarction due to atherothrombosis, myocarditis, and Takotsubo syndrome were excluded. Invasive provocation testing was performed. CMD was classified as endothelium-independent (coronary flow reserve <2.5 with adenosine) and endothelium-dependent (<50% increase in coronary blood flow with acetylcholine). Major adverse cardiovascular events (cardiac death, nonfatal myocardial infarction, heart failure hospitalization, urgent revascularization, stroke) were recorded over 8 years. RESULTS: Of 622 patients, 73 (12%) had MINOCA (69% female, median age 56 years) and 549 (88%) ANOCA (72% female, median age 53 years). CMD was common in both groups (71% versus 64%; P =0.271), while endothelium-independent CMD was more frequent in MINOCA (41% versus 21%; P <0.001). Over a median follow-up of 4.5 years, major adverse cardiovascular events occurred more often in MINOCA (40% versus 11%; adjusted hazard ratio, 2.4; P =0.001). CMD predicted higher major adverse cardiovascular events in both MINOCA (hazard ratio, 3.6 [95% CI, 1.1–12.0]; P =0.038) and ANOCA (hazard ratio, 7.9 [95% CI, 2.9–21.8]; P <0.001). CONCLUSIONS: CMD is common in both MINOCA and ANOCA. The higher prevalence of endothelium-independent CMD in MINOCA suggests a potential mechanistic role in infarction. Patients with MINOCA have a worse prognosis than ANOCA, particularly when CMD is present.
