Impact of Ischemia-Guided Revascularization With Myocardial Perfusion Imaging
What is the impact of ischemia-guided revascularization (IGR) on outcome of patients undergoing percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) for multivessel coronary artery disease?
The authors compared the impact of IGR, in which revascularization was performed in the matched coronary artery with the perfusion abnormality on myocardial perfusion image (MPI), with patients who underwent non-IGR in a registry of 5,340 patients with multivessel coronary disease who were treated with PCI (n = 2,587) or CABG (n = 2,753). Propensity adjustment was used to account for the nonrandom use of different strategies.
MPI was performed in 42% of patients, and IG revascularization was performed in 17.3%, including 12.4% in PCI and 21.8% in CABG patients. The incidence of major adverse cardiac and cerebrovascular events (MACCE) including death, myocardial infarction, stroke, or repeat revascularization was significantly lower in the IGR than in the non-IGR group (16.2% vs. 20.7%; hazard ratio [HR], 0.73; 95% confidence interval [CI], 0.60-0.88; p = 0.001). This was primarily driven by a difference in the rate of repeat revascularization (9.9% vs. 22.8%; HR, 0.66; 95% CI, 0.49-0.90; p = 0.009). The reduction in major adverse events with IGR was seen in patients undergoing PCI (17.4% vs. 22.8%; HR, 0.59; 95% CI, 0.43-0.81; p = 0.001), but not in those treated with CABG (16.0% vs. 18.5%; HR, 0.87; 95% CI, 0.67-1.14; p = 0.31).
The authors concluded that IGR is associated with a reduction in MACCE in patients undergoing PCI or CABG for multivessel disease.
This study provides further corroboration to the concept of functional revascularization that has been validated by the FAME trial (Tonino, et al. N Engl J Med 2009;360:213-24). Based on these studies, it would be reasonable to expect demonstration of ischemia before considering revascularization in most patients with multivessel coronary disease.
Keywords: Myocardial Perfusion Imaging, Coronary Artery Disease, Percutaneous Coronary Intervention
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