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Early Revascularization Based on Inducible Ischemia and LVEF
Quick Takes
- This single-center, large retrospective analysis assessed the relationship between revascularization, myocardial ischemia, mortality, and LV function among patients undergoing myocardial perfusion stress/rest imaging.
- Revascularization was associated with a decline in mortality among patients with severe ischemia and LVEF ≥45%.
- Revascularization was associated with a decline in mortality among patients with moderate to severe ischemia and LVEF <45%.
Study Questions:
What is the relationship between stress-induced myocardial ischemia, revascularization, and all-cause mortality (ACM) among patients with normal versus low left ventricular ejection fraction (LVEF)?
Methods:
Data from 43,443 patients undergoing stress-rest single-photon emission computed tomography myocardial perfusion imaging from 1998–2017 were analyzed. Median follow-up was 11.4 years. Myocardial ischemia was assessed for its interaction between early revascularization and mortality. A propensity score was used to adjust for nonrandomization to revascularization, followed by multivariable Cox modeling adjusted for the propensity score and clinical variables to predict ACM.
Results:
The frequency of myocardial ischemia varied markedly according to LVEF and angina, ranging from 6.7% among patients with LVEF ≥55% and no typical angina to 64.0% among patients with LVEF <45% and typical angina (p < 0.001). Among 39,883 patients with LVEF ≥45%, early revascularization was associated with increased mortality risk among patients without ischemia and lower mortality risk among patients with severe (≥15%) ischemia (hazard ratio [HR], 0.70; 95% confidence interval [CI], 0.52-0.95). Among 3,560 patients with LVEF <45%, revascularization was not associated with mortality benefit among patients with no or mild ischemia, and was associated with decreased mortality among patients with moderate (10%-14%) (HR, 0.67; 95% CI, 0.49-0.91) and severe (≥15%) (HR, 0.55; 95% CI, 0.38-0.80) ischemia.
Conclusions:
Within this cohort, early myocardial revascularization was associated with a significant reduction in mortality among both patients with normal LVEF and severe inducible myocardial ischemia and patients with low LVEF and moderate or severe inducible myocardial ischemia.
Perspective:
This single-center, large retrospective analysis assessed the relationship between revascularization, myocardial ischemia, mortality, and LV function among patients undergoing myocardial perfusion stress/rest imaging. There are several notable findings: 1) There is increasing frequency of ischemia with decreasing LVEF. 2) There is increasing mortality with increased ischemia among medically treated patients. 3) Revascularization was associated with a decline in mortality among patients with severe ischemia and LVEF ≥45%, and moderate to severe ischemia and LVEF <45%. Findings of this study supporting the benefits of revascularization (vs. medical therapy) among patients with moderate to severe ischemia are in contradiction with the results of the ISCHEMIA trial and fuels continued debate about optimal management among patients with demonstrable ischemia on stress testing.
Clinical Topics: Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Atherosclerotic Disease (CAD/PAD), Cardiac Surgery and Heart Failure, Acute Heart Failure, Interventions and Coronary Artery Disease, Interventions and Imaging, Computed Tomography, Nuclear Imaging
Keywords: Coronary Artery Disease, Diagnostic Imaging, Heart Failure, Ischemia, Myocardial Ischemia, Myocardial Perfusion Imaging, Myocardial Revascularization, Perfusion, Stroke Volume, Tomography, Emission-Computed, Tomography, Emission-Computed, Single-Photon, Ventricular Function, Left
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