PCI before TAVR? In older CAD patients, deferral may be the best approach
When patients with coronary artery disease (CAD) undergo transcatheter aortic valve replacement (TAVR), they are often scheduled to undergo percutaneous coronary intervention (PCI) first. According to new data presented at ACC.26 in New Orleans, however, TAVR patients with CAD appear to have comparable outcomes whether they undergo PCI first or not. The study was simultaneously published in The Lancet.[1]
The PRO-TAVI trial included data from 466 TAVR patients who underwent treatment in the Netherlands from 2021 to 2024. The median age was 81 years old, and 64% were men. Voskuil emphasized that these were all high-risk patients due to their age and mix of comorbidities; this analysis was not powered to evaluate PCI deferral in younger TAVR patients.
Patients were randomized to either receive PCI prior to TAVR or only receive TAVR and then turn to PCI only if necessary. Overall, the study’s primary 12-month endpoint—a composite of all-cause mortality, myocardial infarction, stroke or moderate-to-severe bleeding events—occurred in 25.8% of PCI patients and 24.1% of deferred PCI patients. This confirmed to the authors that deferral was noninferior to performing PCI prior to TAVR.
In addition, the major bleeding rate was significantly higher among patients who underwent PCI (25.8%) than those with deferred PCI (24.1%). This is likely due to the antiplatelet therapy prescribed to patients after PCI.
Another key finding from the team’s study was the fact that just 11% of patients from the deferral group ultimately ended up undergoing PCI after their TAVR; this suggests many patients could skip the PCI initially and then only undergo treatment in the future as needed.
Michiel Voskuil, MD, PhD, an interventional cardiologist and professor at University Medical Center Utrecht in the Netherlands, presented his team’s data on the ACC.26 stage.
“For elderly TAVR patients with concomitant CAD, I think it’s safe to first do TAVR and see if patients will still have complaints about chest pain or tightness,” he explained. “We can wait and, if they still have complaints afterward, only then do PCI.”
Doing less, not more, a fresh approach for treating heart disease
Interventional cardiologist Wayne B. Batchelor, MD, president of Inova’s medicine service line, was on the stage at ACC.26 when these data were presented.
“These studies that look at strategies, and especially deferral strategies, are fascinating,” Batchelor said. “I think we need to do more of them in interventional cardiology. We tend to be driven by things that make us want to do more and not less. So I congratulate you and your investigators for thinking outside of the box a little bit in that regard.”
Batchelor added that this is an especially important topic because so many older patients have both CAD and severe aortic stenosis.
“I think this really adds incrementally to our knowledge base and it helps us reassure patients that it is actually probably okay in certain scenarios to defer and watch and wait,” he said.
Michael has more than 19 years of experience as a professional writer and editor. He has written at length about cardiology, radiology, artificial intelligence and other key healthcare topics.