REVIVED-BCIS2: Cardiologists’ reactions around the Globe

Collated by Dr. Oliver Jones, edited by Dr. Ahmed El-Medany

The bombshell results of REVIVED-BCIS landed this week at ESC 2022. BCS Heartbeat has reactions from key figures from the across the globe…Cardiac electrophysiologist, Dr Afal Sohaib, reported an “audible gasp” as the slide was revealed in the auditorium. He highlighted the inclusion of three-vessel and left main stem disease, and shared his impression of a “generational divide” in expectations prior to the announcement.

Cardiologist Dr Purvi Parwani described the same moment as a “mic drop,” whilst also bringing her audience’s attention to the exclusion of acute myocardial infarction and acute heart failure.

Cardiologist Dr Sanjay Kaul shared his view that “this was the best chance for PCI to win (they really cued it up for PCI), and it still came up short.” He also highlighted the finding that completeness of revascularisation was not an effect modifier. He summarised his take: “Unequivocal evidence of benefit for PCI is confined to primary PCI. Evidence for NSTEMI is conditional, dependent on timing of PCI, risk of patient, & choice of endpoint. No Evidence for SIHD +/- LV systolic dysfunction.”

In response, interventional cardiologist Dr Alfredo E Rodriguez pointed out that PCI has “numerically less CV death than OMT.”

Cardiologist and host of This Week in Cardiology podcast, John Mandrola, MD, described the trial as “remarkable” given the lack of benefit despite “the perfect setup for PCI” – do not update your priors!

Imaging cardiologist and President of the British Heart Valve Society, Dr Benoy Shah, shared his detailed insights in a “deep dive”, pointing out that enrolled patients were not highly symptomatic, and were included based on imaging findings (some of which are pending publication), acknowledging the lack of ischaemia testing (without accepting the need for it). He also reminded readers that the extent of utilisation of intracoronary imaging and pressure studies was not yet clear, nor were details around the indications for unplanned revascularisation (which exceeded 10% in the control arm). Finally, he pointed out that comparisons with STICH were not a level playing field given advancements in medical therapies, but also expressed dismay that even with today’s optimal therapy, almost one-third of patients with ischaemic cardiomyopathy died within 3.4 years.

Interventional cardiologist Professor Davide Capodanno, of the University of Catania, also argued that the results challenged the decades-old concept of myocardial hibernation and questioned whether we should still believe this can be reversed by revascularisation.

In response to this, Professor Victor Dayan, cardiac surgeon at the University Cardiovascular Center, National Institute of Cardiac Surgery, Montevideo, pointed out that LVEF improvement in STICH did suggest viable myocardium can respond to revascularisation. He also suggested guidelines should be updated to remove recommendations for PCI to achieve complete revascularisation in one or -two-vessel disease.

Interventional and obstetric cardiologist, Dr Sarah Fairley, described feeling “delighted,” despite the null results, hoping that it would “stop the nonsensical practice of cherrypickoplasty in heart failure patients when we should be focusing on all the superb GDMT agents we have.”

Professor Nick Curzen, interventional cardiologist and President of the British Cardiovascular Intervention Society, called for balance, pointing out that “30% of OMT group in COURAGE and 25% in ISCHEMIA had to undergo revascularisation (mainly PCI) for intractable angina.”

Ritu Thamman, MD, assistant professor of cardiology at the University of Pittsburgh, echoed this sentiment, outlining a role for revascularisation in symptomatic patients.

Interventional cardiologist and noted triallist, Greg W. Stone, MD, shared his opinion that patients with the most severe disease were likely referred for bypass surgery, and therefore missed randomisation.

Interventional cardiologist Shariqu Shamim, MD, summed up his opinion simply: “Time to accept PCI has limited roles outside of ACS.”

Interventional cardiologist Dr Ayman Magd replied “totally disagree,” pointing out the crossover to revascularisation in previous PCI trials, and arguing that “STITCH just proved that ‘viability’ as we define it today is inadequate to guide therapy for most patients.”

Heart Failure cardiologist Dr Zorba Blazquez Bermejo also questioned the paradigm of viability, albeit from a different perspective, with some thoughtful replies below.

Professor David L. Brown, MD, of Renaissance School of Medicine, Stony Brook University, known for his outspoken stance on the evidence-base for PCI, described watching “fantasies crumble,” calling REVIVED-BCIS “the last nail in the coffin”, and “a dose of reality.” Professor Brown also shared an unattributed image of a forest plot showing null results across seven large trial papers.

UK-based academic cardiology registrar Dr Joshua Wilcox presented a helpful thread summarising the patient characteristics and trial protocol, describing the cohort as “definitely not low risk patients.”

Interventional cardiologist Dr Mirvat Alasnag, of The King Fah Armed Forces Hospital in Jeddah, described being “flabbergasted” at learning that “people are offering PCI for ambulatory patients on the basis of low EF alone.”

Interventional cardiologist Enrique Gutierrez asked if the real answer to criticisms of the trial design was that “the treatment does not work.”

Professor Ajay Kirtane, MD, of Columbia University Irving Medical Center, introducing his New England Journal of Medicine editorial, advised readers to wait for further details, including core lab analyses of coronary lesions, before “throwing out the utility of revascularisation.” He also shared his take-home message: the fundamental importance of guideline-directed medical therapy.

Despite the fierce debate, nearly all readers seemed united in congratulating the triallists on their achievement and contribution to the field.