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NOTION-3 Trial Investigates How to Manage CAD in Patients Undergoing Valve Implantation
European Society of Cardiology (ESC) News
Key take-aways
- In the NOTION-3 trial, performing percutaneous coronary intervention (PCI) in patients undergoing transcatheter aortic valve implantation (TAVI) significantly reduced death, myocardial infarction or urgent revascularisation compared with TAVI alone.
- There was an increase in bleeding events, mainly minor bleeding, with PCI plus TAVI vs. TAVI alone.
- Performing PCI should be the standard of care, but the final decision to perform PCI in addition to TAVI should always be made based on the individual patient’s characteristics and risk.
London, United Kingdom: Performing percutaneous coronary intervention (PCI) significantly improved outcomes in patients with stable coronary artery disease (CAD) and severe aortic stenosis selected for transcatheter aortic valve implantation (TAVI), according to late-breaking research presented in a Hot Line session at ESC Congress 2024.1 The NOTION-3 trial is simultaneously published in the New England Journal of Medicine.
“TAVI is being increasingly used to treat patients with severe aortic valve stenosis. Many of these patients also have CAD but whether patients should undergo PCI to treat CAD in addition to TAVI is uncertain due to their older age and risk of complications. We designed the NOTION-3 trial to investigate the efficacy and safety of PCI in addition to TAVI compared with conservative management using TAVI alone and found that PCI plus TAVI is in fact beneficial,” explained Principal Investigator, Dr. Jacob Thomsen Loenborg from the Copenhagen University Hospital, Copenhagen, Denmark.
The NOTION-3 trial was an open-label, investigator-initiated trial. Eligible participants had been selected for TAVI due to severe aortic valve stenosis and had at least one physiologically significant PCI-eligible coronary artery stenosis (fractional flow reserve [FFR] ≤0.80 or diameter stenosis >90% in a coronary artery ≥2.5 mm in diameter). Patients were randomised in a 1:1 ratio to either complete revascularisation with PCI in addition to TAVI or conservative management with TAVI alone. The primary endpoint was the composite of all-cause mortality, myocardial infarction (MI) or urgent revascularisation until the last included patient was followed for 1 year after TAVI.
In total, 455 patients were randomised from 12 centres in Denmark, Finland, Latvia and Sweden. The mean age was around 81 years and 33% were female. The mean Society of Thoracic Surgeons risk score was 3%. Almost 60% of patients had angina symptoms (Canadian Cardiovascular Society grade ≥1). PCI was performed before TAVI in 74% of patients, concomitantly with TAVI in 17% and shortly after in 9%.
The incidence of the primary composite endpoint was significantly lower in the PCI group compared with the conservative group (26% vs. 36%, respectively; hazard ratio [HR] 0.71; 95% confidence interval [CI] 0.51–0.99; p=0.041) after a median follow-up of 2 years.
Significantly lower rates were observed with PCI compared with conservative treatment for MI (8% vs. 14%; HR 0.54; 95% CI 0.30–0.97; p=0.037) and for urgent revascularisation (2% vs. 11%; HR 0.20; 95% CI 0.08–0.51; p<0.001). Similar rates were observed in the PCI group and the conservative group for all-cause mortality (23% and 27%, respectively; HR 0.85; 95% CI 0.59–1.23; p=0.40).
The rate of bleeding events – minor, major, life-threatening or disabling – was 28% in the PCI group and 20% in the conservative group (HR 1.51; 95% CI 1.03–2.22).
“NOTION-3 has answered an important clinical question, demonstrating that TAVI patients with CAD can derive considerable benefits from PCI, driven by reductions in MI and urgent revascularisation. We suggest that performing PCI should be the recommended treatment for patients undergoing TAVI that have CAD, but the final decision should be made based on the patient’s age, comorbidities, life expectancy and their bleeding risk,” concluded Dr. Loenborg.
Funding: Supported by unrestricted, investigator-initiated grants from Boston Scientific and the Danish Heart Foundation.
Disclosures: Jacob Thomsen Loenborg reports receiving speaker fees from Boston Scientific and Abbott.
References and notes
1‘NOTION-3 - Percutaneous coronary intervention in patients undergoing transcatheter aortic valve implantation’ will be discussed during Hot Line 5 on Saturday 31 August 2024 in room London.
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