PCI Versus Conservative Management Before TAVR in Patients With Significant Coronary Artery Disease: A Nationwide Instrumental Variable Analysis

BACKGROUND: The optimal management of coronary artery disease in patients undergoing transcatheter aortic valve replacement (TAVR) remains unclear, and evidence supporting routine percutaneous coronary intervention (PCI) beforehand is limited. This study aimed to evaluate whether PCI before TAVR provides clinical benefit compared with conservative management in patients with significant coronary artery disease, using nationwide Swedish registry data. METHODS: This observational study included 2578 Swedish patients with significant coronary artery disease (≥50% angiographic stenosis or physiologically significant lesions) who underwent TAVR between 2008 and 2023. 1182 underwent PCI before TAVR, and 1396 were managed conservatively. The primary outcome was a composite of all-cause mortality, myocardial infarction, and urgent revascularization. Secondary outcomes included the individual components, cardiovascular mortality, any revascularization, stroke, and bleeding. The primary analysis used an instrumental variable approach based on each region’s quarterly PCI treatment preference to account for confounding. RESULTS: PCI was not associated with a significant difference in the primary composite outcome (instrumental variable–adjusted hazard ratio, 0.98 [95% CI, 0.85–1.14]; P =0.80) or in all-cause mortality, myocardial infarction, cardiovascular death, stroke, or urgent revascularization. PCI was, however, associated with a lower risk of any revascularization (adjusted hazard ratio, 0.46 [95% CI, 0.30–0.72]; adjusted P =0.002) and a higher risk of bleeding (instrumental variable–adjusted odds ratio, 1.59 [95% CI, 1.23–2.04]; adjusted P =0.002). CONCLUSIONS: In this nationwide cohort, PCI before TAVR did not improve survival or reduce urgent revascularization but did reduce nonurgent revascularization at the cost of increased bleeding. Decisions should be individualized, balancing ischemic and bleeding risks and considering anticipated coronary access after TAVR.