Clinical impact of functional testing strategy among stented and non-stented patients: insights from the ROSETTA Registry.

UNLABELLED: The clinical utility of routine functional testing following percutaneous coronary intervention (PCI) among patients with and without coronary stenting is unclear. We established an international registry to evaluate the functional testing strategies following successful PCI. Among patients treated with stents, adverse cardiovascular outcomes were similar between those who underwent routine or clinically-driven functional testing. Conversely, among those who were not treated with stents, the rate of death, myocardial infarction or unstable angina was lower than those who underwent routine functional testing (14.8% vs. 6.6%; P=0.033). Our study suggests that routine functional testing may be beneficial to patients not treated with stents. BACKGROUND: The role of routine functional testing following successful PCI is unclear. By improving patient outcomes with coronary stenting, the value of such a strategy may diminish. HYPOTHESIS: To determine the clinical utility of routine functional testing following PCI between patients with and without stenting. METHODS: The routine versus selective exercise testing after angioplasty (ROSETTA) Registry was established to evaluate the utilization of functional testing following PCI. Use of functional testing, either routine or selective (clinically-driven), was left to the discretion of the attending physician. RESULTS: Of 791 patients enrolled, 462 (58%) underwent coronary stenting. Stented patients were less likely to suffer from concomitant diseases but had more complex angiographic morphological characteristics. Between the groups of patients with and without stents, there was no difference in the proportion of patients undergoing routine functional testing (24% vs. 36%) or subsequent cardiac procedures (18.4% vs. 16.0%). Among patients with stents, outcomes at 6 months were similar between the groups undergoing routine and selective functional testing, including death (0% vs. 1.7%), myocardial infarction (0.9% vs. 2.0%), unstable angina (9.9% vs. 13.7%), repeat angiography (16.2% vs. 16.9%) and revascularization procedures (11.7% vs. 10.8%). However, among non-stented patients, selective functional testing was associated with a higher occurrence of death, myocardial infarction or unstable angina (14.8% vs. 6.6%; P=0.033). There was also no difference in the rates of repeat coronary angiography or revascularization procedures between these two strategies. CONCLUSION: Although routine functional testing has little impact on outcomes among patients treated with coronary stents, non-stented patients may derive particular benefit.

Medical therapy in patients undergoing percutaneous coronary intervention: results from the ROSETTA registry.

BACKGROUND: Previous studies have examined medication use among patients with coronary artery disease who have suffered an acute myocardial infarction (MI). However, little is known about medication use among patients with coronary artery disease who undergo percutaneous coronary intervention (PCI). OBJECTIVE: To examine the patterns of use of medical therapy among patients who undergo PCI; and to examine the determinants of medical therapy in these patients. METHODS: The Routine versus Selective Exercise Treadmill Testing after Angioplasty (ROSETTA) registry is a prospective multicentre study examining the use of functional testing after PCI. The medication use was examined among 787 patients who were enrolled in the ROSETTA registry at 13 clinical centres in five countries. RESULTS: Most patients were men (mean age 61+/-11 years, 76% male) who underwent single vessel PCI (85%) with stent implantation (58%). At admission, discharge and six months, rates of acetylsalicylic acid use were 77%, 96% and 93%, respectively (discharge versus six months, P<0.0001). Rates of use of other oral antiplatelet agents were 11%, 59% and 2% (P=0.02). For individual anti-ischemic medications, rates of use were as follows: beta-blockers 49%, 58% and 59% (P<0.0001); calcium antagonists 34%, 43% and 42% (P<0.0001); and nitrates 42%, 56% and 43% (P<0.0001). Rates of use of combination anti-ischemic medications were as follows: triple therapy 7%, 9% and 9% (P<0.0001); double therapy 34%, 47% and 38% (P<0.0001); monotherapy 36%, 36% and 41% (P<0.0001); and no anti-ischemic therapy 23%, 8% and 12% (P<0.0001). Rates of use of angiotensin-converting enzyme inhibitors were 25%, 33% and 32% (P<0.0001), and rates of use of lipid lowering agents were 41%, 52% and 61% (P<0.0001). CONCLUSIONS: Trials and guidelines statements have favourably affected the rates of use of acetylsalicylic acid and other antiplatelet agents after PCI. However, in spite of patients undergoing a successful revascularization procedure, physicians do not reduce the use of anti-ischemic medical therapy.

Six-month outcomes of percutaneous transluminal coronary angioplasty in hypertensive patients: results from the ROSETTA registry. Routine Versus Selective Exercise Treadmill Testing After Angioplasty.

PURPOSE: Hypertension is an important risk factor for coronary artery disease. However, the impact of hypertension on the outcomes of patients undergoing percutaneous transluminal coronary angioplasty (PTCA) is unknown. Our purpose was to evaluate the association between hypertension and adverse outcomes and repeat cardiac procedures during the 6-month period after PTCA. METHODS: We studied 791 patients who were enrolled in the Routine Versus Selective Exercise Treadmill Testing After Angioplasty (ROSETTA) registry. This registry is a prospective multicenter study examining the use of functional testing after a successful PTCA. RESULTS: We compared 411 hypertensive patients (mean age 60.1 +/- 10 years, 31.1% female) with 380 normotensive patients (mean age 59.1 +/- 12 years, 16.2% female). Patients with hypertension had a higher 6-month rate of composite clinical events (unstable angina, myocardial infarction, death) than did normotensive patients (16.5% vs 10.5%, P =.017). In addition, there was a trend for hypertensive patients to have higher rates of cardiac procedures (angiography, repeat PTCA, coronary artery bypass graft surgery) compared with normotensive patients (19.8% vs 14.9%, P =.074). However, functional testing after PTCA was lower among hypertensive subjects (44.4% vs 54.0%, P =.008). Among the 411 hypertensive patients, a regression analysis showed that several variables were independently associated with increased 6-month adverse event rates, including pre-PTCA Killip class III-IV (odds ratio [OR] 5.7, 95% CI 1.7-19.0), Canadian Cardiovascular Society angina class III-IV (OR 2.1, 95% CI 1.1-4.2), unstable angina as the reason for PTCA (OR 2.3, 95% CI 1.2-4.3), peripheral vascular disease (OR 3.2, 95% CI 1.5-6.4), PTCA of a bypass graft (OR 3.1, 95% CI 1.2-7.6), and calcium antagonist usage at admission for the index PTCA (OR 1.9, 95% CI 1.1-3.4). CONCLUSIONS: During the 6-month period after a successful PTCA, patients with hypertension have significantly higher adverse event rates than do those without hypertension. Several clinical variables may help identify which hypertensive patients are at higher risk for clinical events.