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What is the role for revascularisation in patients being considered for ICD therapy?
J R Paisey1, J M Morgan, N P Curzen
1Wessex Cardiac Unit, Southampton University Hospitals NHS Trust, Southampton, United Kingdom.
Insights
Coronary anatomy assessment in patients considered for implantable cardioverter-defibrillator (ICD) therapy is complex. Current practices lack clear guidance on revascularization when ischemia or viability is uncertain, necessitating further research.
Area of Science:
- Cardiology
- Electrophysiology
- Interventional Cardiology
Background:
- Patients evaluated for implantable cardioverter-defibrillator (ICD) therapy often have left ventricular impairment.
- Assessing coronary artery anatomy is common practice to infer ischemia or viability in these patients.
- Coronary anatomy frequently presents a dilemma regarding the need for revascularization.
Purpose of the Study:
- To review the current literature regarding revascularization decisions in ICD candidates with uncertain ischemia or viability.
- To highlight the dilemma faced by electrophysiologists and interventionists in managing these complex cases.
- To identify the need for further data to guide clinical practice.
Main Methods:
- Literature review of studies concerning coronary anatomy, ischemia, viability, and revascularization in ICD candidates.
- Analysis of clinical scenarios where coronary anatomy may not accurately predict ischemia or viability.
- Examination of current practices and decision-making processes.
Main Results:
- The literature review did not definitively resolve the dilemma of revascularization in all cases.
- Coronary anatomy is not always a reliable surrogate for the presence of ischemia or viability.
- A significant proportion of patients lack clear indications for revascularization based solely on coronary anatomy.
Conclusions:
- Further observational data are crucial to guide cardiologists on revascularization benefits in ICD candidates.
- Clinical decisions should not solely rely on coronary anatomy when ischemia or viability is uncertain.
- Improved evidence is needed to optimize patient selection for revascularization procedures like percutaneous coronary intervention (PCI).
Abstract:
Patients being considered for ICD therapy are a heterogeneous group.For the vast majority, who have significant left ventricular impairment, it has become common practice to assess their coronary artery anatomy as a surrogate for ischaemia and/or viability. Such patients are therefore frequently under the care of both electrophysiologists and interventionists. The coronary anatomy often raises the dilemma about whether such patients should undergo revascularisation. If the patients present with angina or in the context of an acute myocardial infarct then this decision is clear cut. By contrast, however, a significant proportion of them have no history to suggest ongoing ischaemia or of recent MI. In conventional practice, therefore, there would be no decisive mandate to offer them revascularisation, especially PCI, in the absence of further objective evidence of ischaemia or viability. A review of the literature in our paper does not resolve this dilemma.Further observational data are required to help guide cardiologists as to which of these patients will benefit from revascularisation, since in many cases the coronary anatomy is no surrogate for the presence of ischaemia or viability.
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