Future Directions of Chronic Total Occlusion Management: Identifying the Right Patient for Intervention With a Focus on Biomarkers

ABSTRACT The management of a chronic total occlusion (CTO) of a coronary artery has been a conundrum in interventional cardiology, as revascularization has not been proven to provide a mortality benefit. However, there are subgroups of patients with a CTO that have high levels of ischemia on myocardial perfusion imaging and high circulating levels of high sensitivity troponin‐I (hsTn‐I) and N terminal pro‐brain natriuretic peptide (NT pro‐BNP) that are at a particularly high‐risk for adverse cardiovascular events. These high‐risk subgroups of patients with a CTO may have not been well represented in prior clinical trials, and may gain a mortality benefit from revascularization of the CTO. Conversely, patients with low levels of ischemia and these biomarkers are at lower risk and may not gain a mortality benefit from revascularization of their CTO. It is important for future randomized controlled trials to investigate the efficacy of CTO PCI in patients with elevated biomarkers and high ischemic burden on myocardial perfusion imaging to determine if patients at high‐risk gain a mortality benefit from revascularization.