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PCI Versus Conservative Management Before TAVR in Patients With Significant Coronary Artery Disease : A Nationwide Instrumental Variable Analysis

Louca, Antros ; Petursson, Petur ; Sundström, Joakim ; Hagström, Henrik ; Rück, Andreas ; James, Stefan ; Koul, Sasha LU ; Skoglund, Kristofer ; Mohammed, Mohammed and Jeppsson, Anders , et al. (2026) In Circulation: Cardiovascular Interventions
Abstract

BACKGROUND: – The optimal management of coronary artery disease in patients undergoing transcatheter aortic valve replacement (TAVR) remains unclear, and evidence supporting routine percutaneous coronary intervention (PCI) beforehand is limited. This study aimed to evaluate whether PCI before TAVR provides clinical benefit compared with conservative management in patients with significant coronary artery disease, using nationwide Swedish registry data. METHODS: – This observational study included 2578 Swedish patients with significant coronary artery disease (≥50% angiographic stenosis or physiologically significant lesions) who underwent TAVR between 2008 and 2023. 1182 underwent PCI before TAVR, and 1396 were managed conservatively.... (More)

BACKGROUND: – The optimal management of coronary artery disease in patients undergoing transcatheter aortic valve replacement (TAVR) remains unclear, and evidence supporting routine percutaneous coronary intervention (PCI) beforehand is limited. This study aimed to evaluate whether PCI before TAVR provides clinical benefit compared with conservative management in patients with significant coronary artery disease, using nationwide Swedish registry data. METHODS: – This observational study included 2578 Swedish patients with significant coronary artery disease (≥50% angiographic stenosis or physiologically significant lesions) who underwent TAVR between 2008 and 2023. 1182 underwent PCI before TAVR, and 1396 were managed conservatively. The primary outcome was a composite of all-cause mortality, myocardial infarction, and urgent revascularization. Secondary outcomes included the individual components, cardiovascular mortality, any revascularization, stroke, and bleeding. The primary analysis used an instrumental variable approach based on each region’s quarterly PCI treatment preference to account for confounding. RESULTS: – PCI was not associated with a significant difference in the primary composite outcome (instrumental variable–adjusted hazard ratio, 0.98 [95% CI, 0.85–1.14]; P=0.80) or in all-cause mortality, myocardial infarction, cardiovascular death, stroke, or urgent revascularization. PCI was, however, associated with a lower risk of any revascularization (adjusted hazard ratio, 0.46 [95% CI, 0.30–0.72]; adjusted P=0.002) and a higher risk of bleeding (instrumental variable–adjusted odds ratio, 1.59 [95% CI, 1.23–2.04]; adjusted P=0.002). CONCLUSIONS: – In this nationwide cohort, PCI before TAVR did not improve survival or reduce urgent revascularization but did reduce nonurgent revascularization at the cost of increased bleeding. Decisions should be individualized, balancing ischemic and bleeding risks and considering anticipated coronary access after TAVR.

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organization
publishing date
type
Contribution to journal
publication status
epub
subject
keywords
coronary artery disease, myocardial infarction, percutaneous coronary intervention, Sweden, transcatheter aortic valve replacement
in
Circulation: Cardiovascular Interventions
publisher
American Heart Association
external identifiers
  • pmid:41717702
  • scopus:105035736956
ISSN
1941-7640
DOI
10.1161/CIRCINTERVENTIONS.125.016337
language
English
LU publication?
yes
id
a8b4f18d-9ebd-4833-931d-c0dbcccb9279
date added to LUP
2026-06-24 14:36:15
date last changed
2026-09-04 02:35:49
@article{a8b4f18d-9ebd-4833-931d-c0dbcccb9279,
  abstract     = {{<p>BACKGROUND: – The optimal management of coronary artery disease in patients undergoing transcatheter aortic valve replacement (TAVR) remains unclear, and evidence supporting routine percutaneous coronary intervention (PCI) beforehand is limited. This study aimed to evaluate whether PCI before TAVR provides clinical benefit compared with conservative management in patients with significant coronary artery disease, using nationwide Swedish registry data. METHODS: – This observational study included 2578 Swedish patients with significant coronary artery disease (≥50% angiographic stenosis or physiologically significant lesions) who underwent TAVR between 2008 and 2023. 1182 underwent PCI before TAVR, and 1396 were managed conservatively. The primary outcome was a composite of all-cause mortality, myocardial infarction, and urgent revascularization. Secondary outcomes included the individual components, cardiovascular mortality, any revascularization, stroke, and bleeding. The primary analysis used an instrumental variable approach based on each region’s quarterly PCI treatment preference to account for confounding. RESULTS: – PCI was not associated with a significant difference in the primary composite outcome (instrumental variable–adjusted hazard ratio, 0.98 [95% CI, 0.85–1.14]; P=0.80) or in all-cause mortality, myocardial infarction, cardiovascular death, stroke, or urgent revascularization. PCI was, however, associated with a lower risk of any revascularization (adjusted hazard ratio, 0.46 [95% CI, 0.30–0.72]; adjusted P=0.002) and a higher risk of bleeding (instrumental variable–adjusted odds ratio, 1.59 [95% CI, 1.23–2.04]; adjusted P=0.002). CONCLUSIONS: – In this nationwide cohort, PCI before TAVR did not improve survival or reduce urgent revascularization but did reduce nonurgent revascularization at the cost of increased bleeding. Decisions should be individualized, balancing ischemic and bleeding risks and considering anticipated coronary access after TAVR.</p>}},
  author       = {{Louca, Antros and Petursson, Petur and Sundström, Joakim and Hagström, Henrik and Rück, Andreas and James, Stefan and Koul, Sasha and Skoglund, Kristofer and Mohammed, Mohammed and Jeppsson, Anders and Ioanes, Dan and Völz, Sebastian and Myredal, Anna and Angerås, Oskar and Rawshani, Araz and Råmunddal, Truls}},
  issn         = {{1941-7640}},
  keywords     = {{coronary artery disease; myocardial infarction; percutaneous coronary intervention; Sweden; transcatheter aortic valve replacement}},
  language     = {{eng}},
  publisher    = {{American Heart Association}},
  series       = {{Circulation: Cardiovascular Interventions}},
  title        = {{PCI Versus Conservative Management Before TAVR in Patients With Significant Coronary Artery Disease : A Nationwide Instrumental Variable Analysis}},
  url          = {{http://dx.doi.org/10.1161/CIRCINTERVENTIONS.125.016337}},
  doi          = {{10.1161/CIRCINTERVENTIONS.125.016337}},
  year         = {{2026}},
}