The clinical utility of routine coronary computed tomography angiography (CCTA) following percutaneous coronary intervention (PCI) for unprotected left main (LM) disease remains an area of uncertainty.¹ The PULSE trial sought to determine if a CCTA-guided follow-up strategy improves clinical outcomes compared to standard care driven by symptoms or ischaemia.²

PULSE (Angiographic Control vs Ischemia-Driven Management of Patients Treated With PCI on Left Main With Drug-Eluting Stents) was a prospective, multicentre, open-label randomised trial. The study enrolled 606 patients who had been treated with second-generation drug-eluting stents for unprotected LM disease between October 2019 and September 2024.

Participants were randomised on a 1:1 basis to either an experimental arm, involving a CCTA scan at 6 months post-procedure, or a control arm receiving standard care. The primary endpoint was a composite of all-cause death, spontaneous myocardial infarction (MI), unstable angina, or definite or probable stent thrombosis at 18 months. Secondary endpoints included target-lesion revascularisation (TLR) and the individual components of the primary endpoint.²

In the experimental arm, 272 of 303 patients (89.8%) completed the CCTA scan at a median of 200 days. The study found no significant difference in the primary endpoint between the two groups. The primary endpoint occurred in 36 patients (11.9%) in the CCTA group compared with 38 patients (12.5%) in the standard care group (HR: 0.97; 95% CI: 0.76–1.23; p=0.80).

However, analysis of the secondary endpoints revealed notable differences. The CCTA-guided group had a significantly lower risk of spontaneous MI (0.9% vs 4.9%; HR: 0.26; 95% CI: 0.07–0.91; p=0.004). This benefit was accompanied by a significantly increased rate of imaging-triggered TLR (4.9% vs 0.3%; HR: 7.7; 95% CI: 1.70–33.7; p=0.001). Rates of clinically driven TLR were similar between the arms (5.3% vs 7.2%; HR: 0.74; 95% CI: 0.38–1.41; p=0.32).²

The PULSE trial demonstrates that a strategy of routine CCTA follow-up after LM PCI does not reduce the composite primary endpoint of major adverse cardiac events at 18 months. While the approach was associated with a reduction in spontaneous MIs, this came at the expense of a notable increase in revascularisations prompted by imaging findings rather than clinical presentation.

The investigators concluded that while routine CCTA did not meet its primary endpoint, the findings suggest a need for further investigation. They state that, “Future trials to clarify its value in complex anatomic subsets appear to be warranted.”²

References

1. Vrints C, Andreotti F, Koskinas KC, et al. 2024 ESC guidelines for the management of chronic coronary syndromes. Eur Heart J. 2024;45(36):3415–3537. https://doi.org/10.1093/eurheartj/ehae177

2. D’Ascenzo F, Cerrato E, De Filippo O, et al. Computed tomography angiography or standard care after left main PCI?. JACC. 2025;86(19):1724–1734. https://doi.org/10.1016/j.jacc.2025.07.060

Disclaimer: The information presented in this article is for educational purposes only. Any quotes included reflect the opinions of the individual quoted, and do not necessarily reflect the views of the publisher. The publisher does not guarantee the accuracy or completeness of the content and accepts no responsibility for any errors, or any consequences arising from its use.