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Myocardial viability testing and impact of revascularization on prognosis in patients with coronary artery disease
Kevin C Allman1, Leslee J Shaw, Rory Hachamovitch
1Concord Hospital, Concord NSW, Australia. kevina@nucmd.crg.cs.nsw.gov.au
Insights
Revascularization significantly improves survival in patients with coronary artery disease and viable myocardium. Myocardial viability testing is crucial for guiding treatment decisions in severe coronary artery disease.
Area of Science:
- Cardiology
- Medical Imaging
- Interventional Cardiology
Background:
- Observational studies suggest revascularization improves survival in patients with coronary artery disease (CAD) and left ventricular (LV) dysfunction if myocardial viability is detected.
- Myocardial viability testing aids in identifying patients who may benefit from revascularization.
Purpose of the Study:
- To pool data from published studies to examine late survival rates.
- To compare revascularization versus medical therapy in patients with severe CAD and LV dysfunction.
- To assess the impact of myocardial viability on survival outcomes.
Main Methods:
- Meta-analysis of 24 published viability studies.
- Inclusion of studies using thallium perfusion imaging, F-18 fluorodeoxyglucose imaging, or dobutamine echocardiography.
- Random effects model used for pooling annual death rates and meta-regression for risk-adjusted analysis.
Main Results:
- Revascularization was associated with a 79.6% reduction in annual mortality in patients with viable myocardium (3.2% vs. 16%).
- Patients without viability showed no significant difference in mortality between revascularization and medical therapy (6.2% vs. 7.7%).
- A direct relationship was observed between LV dysfunction severity and the magnitude of survival benefit from revascularization in viable patients.
Conclusions:
- Myocardial viability detected by noninvasive testing is strongly associated with improved survival after revascularization in chronic CAD patients with LV dysfunction.
- Absence of myocardial viability indicates no significant difference in outcomes regardless of treatment strategy.
- Myocardial viability testing is essential for patient selection for revascularization in severe CAD.
Objectives:
This study pools data from published series examining late survival with revascularization versus medical therapy after myocardial viability testing in patients with severe coronary artery disease (CAD) and left ventricular (LV) dysfunction.
Background:
Previous observational studies have suggested survival benefit in such patients if they are revascularized when myocardial viability is detected on imaging tests.
Methods:
A MEDLINE database search returned 24 viability studies reporting patient survival using thallium perfusion imaging, F-18 fluorodeoxyglucose metabolic imaging or dobutamine echocardiography. Annual death rates were extracted, pooled and analyzed with a random effects model. The risk-adjusted relationship between severity of LV dysfunction, presence of viability and survival benefit associated with revascularization was assessed by meta-regression.
Results:
There were 3,088 patients (2,228 men), ejection fraction 32 +/- 8%, followed for 25 +/- 10 months. In patients with viability, revascularization was associated with 79.6% reduction in annual mortality (16% vs. 3.2%, chi-square = 147, p < 0.0001) compared with medical treatment. Patients without viability had intermediate mortality, trending to higher rates with revascularization versus medical therapy (7.7% vs. 6.2%, p = NS). Patients with viability showed a direct relationship between severity of LV dysfunction and magnitude of benefit with revascularization (p < 0.001). There was no measurable performance difference for predicting revascularization benefit between the three testing techniques.
Conclusions:
This meta-analysis demonstrates a strong association between myocardial viability on noninvasive testing and improved survival after revascularization in patients with chronic CAD and LV dysfunction. Absence of viability was associated with no significant difference in outcomes, irrespective of treatment strategy.
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