Revascularization based on coronary computed tomography angiography and novel antiplatelet therapy in coronary artery disease

Invasive coronary angiography (ICA) is the cornerstone of cardiology and has revolutionized the diagnosis and treatment of coronary artery disease (CAD). Its history can be traced back to the early 20th century, with evolution through a series of experimental advances, technological breakthroughs, and clinical applications (1). Although ICA remains the gold standard for visualising the coronary anatomy, coronary computed tomography angiography (CCTA) has evolved into a non-invasive imaging modality that plays a pivotal role in the management of CAD in contemporary clinical practice (2). Current clinical guidelines, including those from the European Society of Cardiology (ESC) and the American College of Cardiology (ACC), have recommended CCTA as the first-line diagnostic test in patients with an intermediate pre-test probability of obstructive CAD (3,4). Its high sensitivity and negative predictive value make it a powerful tool for excluding significant coronary artery stenoses, reducing the need for ICA in many patients. In those without significant epicardial obstruction, its role is either to rule out atherosclerosis or to detect subclinical plaque, that can be monitored for progression/regression following preventative therapy and provide risk stratification (2). Furthermore, FFR-CT has become increasingly integrated into the management of CAD, enhancing patient care and optimizing revascularization strategies by providing anatomical and functional assessment in one modality (5). Coronary revascularisation, whether percutaneous or surgical, aims not simply to address coronary artery obstruction but to improve clinical outcomes. Previous randomized controlled trials (RCTs) have shown that the anatomical SYNTAX score plays an essential role in risk stratification and is associated with clinical outcomes; notably the treatment effects observed in RCTs often achieved the basis of treatment guidelines, but despite the wide range of treatment effects between patients the focus has been on the average treatment effect. The optimal revascularization strategy should be individualized, considering both the severity of CAD and factors affecting the patient's prognosis. Additionally, as the first-line test for investigating CAD is moving from ICA to CCTA, it is essential to investigate the feasibility and long-term prognosis of revascularization strategies based on CCTA. Optimal medical therapy is essential to improve clinical outcomes regardless of the modality of revascularization. In recent years, the approach to short dual antiplatelet therapy (DAPT) after coronary artery stent deployment has evolved significantly. The latest ESC guidelines recommend tailoring the duration of DAPT based on patient risk profiles, balancing the risk of bleeding against thrombotic events (6). This shift is an essential step in optimizing post-stenting treatment and improving long-term clinical outcomes while preventing ischemic events, and reducing bleeding events.

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University of Galway

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Attribution-NonCommercial-NoDerivatives 4.0 International

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University of Galway Theses (PhD Theses)