Impact of repeat myocardial revascularization on outcome in patients with silent ischemia after previous
Nael Aldweib1, Kazuaki Negishi, Rory Hachamovitch
1Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA.
Insights
Repeat revascularization offers no survival advantage for asymptomatic patients with prior revascularization and inducible ischemia. An ischemia-based treatment strategy did not change mortality rates in this patient group.
Area of Science:
- Cardiology
- Nuclear Cardiology
- Outcomes Research
Background:
- Coronary artery disease (CAD) is a progressive condition requiring ongoing management.
- Stress myocardial perfusion scintigraphy (MPS) is crucial for detecting ischemia in patients with prior revascularization.
Purpose of the Study:
- To compare survival outcomes between repeat revascularization and medical therapy (MT) in asymptomatic patients with previous revascularization and ischemia.
- To evaluate the impact of an ischemia-based treatment strategy on mortality in this population.
Main Methods:
- A cohort of 769 asymptomatic patients with previous revascularization and ischemia (identified via MPS) was analyzed.
- Propensity score analysis and Cox proportional hazards models were used to compare mortality between repeat revascularization and MT groups.
- Follow-up was conducted for a median of 5.7 years for all-cause death.
Main Results:
- Repeat revascularization was performed in 15% of patients shortly after MPS.
- Mortality rates were similar between the MT (18.3%) and revascularization (19.1%) groups (p=0.84).
- Only age and hypercholesterolemia, not revascularization, were independently associated with mortality after adjusting for covariates and propensity scores.
Conclusions:
- Asymptomatic patients with prior revascularization and inducible ischemia do not benefit from repeat revascularization in terms of survival.
- An ischemia-driven treatment approach did not significantly alter mortality in this post-revascularization cohort.
Objectives:
This study sought to compare the survival of asymptomatic patients with previous revascularization and ischemia, who subsequently underwent repeat revascularization or medical therapy (MT).
Background:
Coronary artery disease is progressive and recurring; thus, stress myocardial perfusion scintigraphy (MPS) is widely used to identify ischemia in patients with previous revascularization.
Methods:
Of 6,750 patients with previous revascularization undergoing MPS between January 1, 2005, and December 31, 2007, we identified 769 patients (age 67.7 ± 9.5 years; 85% men) who had ischemia and were asymptomatic. A propensity score was developed to express the associations of revascularization. Patients were followed up over a median of 5.7 years (interquartile range: 4.7 to 6.4 years) for all-cause death. A Cox proportional hazards model was used to identify the association of revascularization with all-cause death, with and without adjustment for the propensity score. The model was repeated in propensity-matched groups undergoing MT versus revascularization.
Results:
Among 769 patients, 115 (15%) underwent revascularization a median of 13 days (interquartile range: 6 to 31 days) after MPS. There were 142 deaths; mortality with MT and revascularization were 18.3% and 19.1% (p = 0.84). In a Cox proportional hazards model (chi-square test = 89.4) adjusting for baseline characteristics, type of previous revascularization, MPS data, and propensity scores, only age and hypercholesterolemia but not revascularization were associated with mortality. This result was confirmed in a propensity-matched group.
Conclusions:
Asymptomatic patients with previous revascularization and inducible ischemia on MPS realize no survival benefit from repeat revascularization. In this group of post-revascularization patients, an ischemia-based treatment strategy did not alter mortality.
Related Concept Videos
01:27Angina II: Classification
01:30Acute Coronary Syndrome III: Diagnostic Studies
01:27Coronary Artery Disease V: Interprofessional Care
01:17Ischemic Heart Disease: Overview
Atherosclerosis, the primary malefactor, orchestrates this dangerous condition. It manifests as the accumulation of fatty deposits, akin to insidious plaques, within arterial walls. As time elapses, these plaques metamorphose, hardening and narrowing...