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Revascularization of chronic total coronary occlusions
Christophe Bauters a, b, c, MD; Gilles Lemesle a, c, MD.
a Centre Hospitalier R?gional et Universitaire de Lille, Lille,
b Inserm U1167, Institut Pasteur de Lille, Universit? de Lille 2, Lille,
c Facult? de M?decine de Lille, Lille, France
To the Editor,
We read with great interest the article by Ladwiniec et al. (1...
We read with great interest the article by Ladwiniec et al. (1) on
the prognostic impact of percutaneous interventions (PCI) for chronic
total coronary occlusions (CTO). Indeed, there are obvious limitations in
the previously published literature that essentially demonstrated a better
prognosis after successful CTO PCI than after failed CTO PCI. A propensity
-matched approach comparing CTO PCI versus medically treated CTO as
performed in the present report, does not have the strength of a
randomized trial, but nevertheless has the potential to provide meaningful
information for physicians.
In the modern era of secondary prevention, the prognosis of patients with
stable coronary artery disease (CAD) has been shown to be favorable (2).
Although this may make difficult to demonstrate a survival benefit by a
new intervention, this is however a global figure and subgroups of
patients, such as those with CTO, may do worse than others; therefore,
focusing studies on these high-risk stable CAD patients certainly makes
The study by Ladwiniec et al. (1) reports interesting trends suggesting
that revascularization of a CTO might be beneficial. However, one
important point that would need to be clarified is the level of secondary
prevention in this study, and whether this level was the same in all
groups of patients. There are consistent data in the literature showing
that patients with a recent revascularization have higher prescription of
secondary prevention drugs (statins, antiplatelets, angiotensin-converting
enzyme inhibitors, ?-blockers) than patients without revascularization
(3). In addition, information on the use of dual antiplatelet therapy
(DAPT) would also be important. Due to the frequent use of drug-eluting
stents (DES), and long stented segments, it is conceivable that an
extended duration of DAPT was used in a significant proportion of the
patients with CTO PCI. Extended DAPT has recently been shown to reduce
thrombotic events after DES implantation (4); this impact is not only
related to a decrease in very late stent thrombosis but also to a
reduction in non-stent-thrombosis-related myocardial infarction. An
imbalance toward more intense secondary prevention in the CTO PCI group
could potentially explain the trends for the improved outcome. If the
information is available, providing data on the combination of secondary
prevention drugs at discharge and also during the course of the study
would therefore be very useful.
 Ladwiniec A, Allgar V, Thackray S, Alamgir F, Hoye A. Medical
therapy, percutaneous coronary intervention and prognosis in patients with
chronic total occlusions. Heart 2015;101:1907-14.
 Bauters C, Deneve M, Tricot O, Meurice T, Lamblin N. Prognosis of
patients with stable coronary artery disease (from the CORONOR study). Am
J Cardiol 2014;113:1142-5.
 Meurice T, Tricot O, Lemesle G et al. Prevalence and correlates of non
-optimal secondary medical prevention in patients with stable coronary
artery disease. Arch Cardiovasc Dis 2015;108:340-6.
 Mauri L, Kereiakes DJ, Yeh RW et al. Twelve or 30 months of dual
antiplatelet therapy after drug-eluting stents. N Engl J Med 2014;371:2155