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Published on: April 25, 2014
Inducible myocardial ischemia and outcomes in patients with coronary artery disease and left ventricular dysfunction
Julio A Panza1, Thomas A Holly, Federico M Asch
1Division of Cardiology, MedStar Washington Hospital Center, Washington, DC 20010, USA. julio.a.panza@medstar.net
Insights
Stress-induced ischemia in patients with coronary artery disease (CAD) and left ventricular (LV) dysfunction does not predict worse outcomes or identify those who benefit most from bypass surgery over medical therapy.
Area of Science:
- Cardiology
- Cardiac Surgery
- Diagnostic Imaging
Background:
- The prognostic significance of stress-induced ischemia in patients with coronary artery disease (CAD) and reduced left ventricular (LV) ejection fraction (EF) remains unclear.
- Understanding this is crucial for guiding treatment decisions in this high-risk population.
Purpose of the Study:
- To determine if stress-induced ischemia has prognostic value in patients with CAD and LV dysfunction.
- To identify if ischemia predicts greater benefit from coronary artery bypass grafting (CABG) versus medical therapy.
Main Methods:
- Analysis of STICH trial participants (CAD, EF ≤35%) who underwent radionuclide (RN) or dobutamine stress echocardiogram (DSE).
- Ischemia defined by RN summed difference score (≥4) or DSE (≥2 ischemic segments).
- Clinical outcomes assessed by intention-to-treat over a median 56-month follow-up.
Main Results:
- 64% of 399 patients (mean EF 26%) showed inducible ischemia during stress testing.
- No significant differences in all-cause mortality, cardiovascular mortality, or hospitalization between ischemic and non-ischemic groups.
- No interaction found between ischemia and treatment allocation (CABG vs. medical therapy) for any clinical endpoint.
Conclusions:
- Inducible myocardial ischemia during stress testing does not identify patients with worse prognosis in CAD with severe LV dysfunction.
- Ischemia does not predict enhanced benefit from CABG compared to optimal medical therapy in this patient cohort.
Objectives:
The study objectives were to test the hypotheses that ischemia during stress testing has prognostic value and identifies those patients with coronary artery disease (CAD) with left ventricular (LV) dysfunction who derive the greatest benefit from coronary artery bypass grafting (CABG) compared with medical therapy.
Background:
The clinical significance of stress-induced ischemia in patients with CAD and moderately to severely reduced LV ejection fraction (EF) is largely unknown.
Methods:
The STICH (Surgical Treatment for IsChemic Heart Failure) trial randomized patients with CAD and EF ≤35% to CABG or medical therapy. In the current study, we assessed the outcomes of those STICH patients who underwent a radionuclide (RN) stress test or a dobutamine stress echocardiogram (DSE). A test was considered positive for ischemia by RN testing if the summed difference score (difference in tracer activity between stress and rest) was ≥4 or if ≥2 of 16 segments were ischemic during DSE. Clinical endpoints were assessed by intention to treat during a median follow-up of 56 months.
Results:
Of the 399 study patients (51 women, mean EF 26 ± 8%), 197 were randomized to CABG and 202 were randomized to medical therapy. Myocardial ischemia was induced during stress testing in 256 patients (64% of the study population). Patients with and without ischemia were similar in age, multivessel CAD, previous myocardial infarction, LV EF, LV volumes, and treatment allocation (all p = NS). There was no difference between patients with and without ischemia in all-cause mortality (hazard ratio: 1.08; 95% confidence interval: 0.77 to 1.50; p = 0.66), cardiovascular mortality, or all-cause mortality plus cardiovascular hospitalization. There was no interaction between ischemia and treatment for any clinical endpoint.
Conclusions:
In CAD with severe LV dysfunction, inducible myocardial ischemia does not identify patients with worse prognosis or those with greater benefit from CABG over optimal medical therapy. (Comparison of Surgical and Medical Treatment for Congestive Heart Failure and Coronary Artery Disease [STICH]; NCT00023595).
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