Prognostication in 3-vessel coronary artery disease based on left ventricular ejection fraction during exercise : influence of coronary artery bypass grafting
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Published on: January 15, 2017
P G Supino1, J S Borer, E M Herrold
1Division of Cardiovascular Pathophysiology, The Joan and Sanford I. Weill Medical College of Cornell University, The New York Presbyterian Hospital-Weill Cornell Medical Center, New York, NY 10021, USA.
Insights
Left ventricular ejection fraction (LVEF) response to exercise predicts outcomes in 3-vessel coronary artery disease (CAD). Severe ischemia (DeltaLVEF ≤ -8%) identifies patients who benefit from early coronary artery bypass grafting (CABG).
Area of Science:
- Cardiology
- Cardiac Surgery
- Nuclear Cardiology
Background:
- Left ventricular ejection fraction (LVEF) offers prognostic value in coronary artery disease (CAD).
- The benefit of coronary artery bypass grafting (CABG) may depend on exercise-induced ischemia severity in patients with CAD.
Purpose of the Study:
- To assess the prognostic significance of preoperative ischemia severity for CABG outcomes in patients with extensive CAD.
- To determine if exercise-induced ischemia predicts the benefits of CABG.
Main Methods:
- 167 stable patients with 3-vessel CAD underwent radionuclide cineangiography (rest and exercise).
- Outcomes were correlated with baseline clinical data, coronary arteriography, and radionuclide testing.
- Multivariate Cox model analysis was used to identify predictors of cardiac events and CABG benefit.
Main Results:
- Change in LVEF from rest to exercise (DeltaLVEF) was the strongest independent predictor of major cardiac events (P=0.003) and predicted CABG benefit (P=0.04).
- Patients with DeltaLVEF ≤ -8% showed significant survival and event reduction with early CABG (<1 month).
- Benefits of CABG were not observed in patients with DeltaLVEF > -8% or those with delayed surgery.
Conclusions:
- Exercise-induced ischemia severity, assessed by LVEF response, effectively prognosticates outcomes in 3-vessel CAD.
- This assessment defines the likelihood of life-prolonging and event-reducing benefits from CABG.
Background:
Previous data indicate that left ventricular ejection fraction (LVEF) provides prognostic information among patients with coronary artery disease (CAD), but the value of such testing specifically for defining benefits of coronary artery bypass grafting (CABG) may relate to severity of exercise-inducible ischemia measured noninvasively before surgery.
Methods And Results:
To determine the independent prognostic importance of preoperative ischemia severity for predicting outcomes of CABG among patients with extensive CAD, we monitored 167 stable patients with angiographically documented 3-vessel CAD (average follow-up of 9 years in event-free patients) who previously had undergone rest and exercise radionuclide cineangiography. Their course was correlated with data obtained during initial radionuclide testing, coronary arteriography, and clinical evaluation at study entry. Fifty-two patients received medical treatment only, and 115 underwent CABG (44 early [
Conclusions:
Assessment of ischemia severity based on LVEF response to exercise enables effective prognostication among patients with 3-vessel CAD and defines the likelihood of life-prolonging and event-reducing benefits from CABG.
