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Role of viability imaging in the post-STICH era
Benoy Nalin Shah1, Roxy Senior
1aDepartment of Cardiology, Royal Brompton Hospital bCardiovascular Biomedical Research Unit, Royal Brompton Hospital cNational Heart and Lung Institute, Imperial College, London, UK.
Insights
Recent trials show revascularization offers no survival benefit over optimal medical therapy (OMT) for ischemic cardiomyopathy (ICM). Viability testing also did not improve outcomes, leaving management uncertain.
Area of Science:
- Cardiology
- Clinical Trials
- Heart Failure Management
Background:
- Ischemic cardiomyopathy (ICM) management is debated.
- Optimal medical therapy (OMT) is standard care.
- Revascularization's role in ICM requires clarification.
Purpose of the Study:
- Summarize recent trial evidence on ICM management.
- Evaluate revascularization versus OMT.
- Assess viability testing's utility.
Main Methods:
- Review of recent prospective randomized controlled trials (RCTs).
- Analysis of STICH, PPAR-2, and HF-RECOVER trials.
- Examination of STICH viability substudy data.
Main Results:
- No trial demonstrated revascularization superiority over OMT for ICM survival.
- Viability testing did not enhance outcomes in the STICH trial.
- Recent RCTs present limitations impacting management decisions.
Conclusions:
- Optimal management for ICM patients remains unclear.
- Revascularization is still used with evidence of myocardial viability.
- Further research is essential for definitive ICM treatment guidelines.
Purpose Of Review:
Recent results from prospective randomized controlled trials examining the management of patients with ischemic cardiomyopathy (ICM) have questioned both the added value of revascularization over contemporary optimal medical therapy (OMT) and the use of viability testing as a gate-keeper to revascularization. The purpose of this review is to summarize recent trial evidence before discussing future perspectives in the field.
Recent Findings:
The Surgical Treatment of Ischemic Heart Failure (STICH) trial, PPAR-2 trial and Heart Failure Revascularisation Trial have all reported their results within the past 5 years. None of these trials found revascularization superior to OMT in improving survival of ICM patients. Additionally, the STICH trial's viability substudy suggested that pretreatment viability testing was not beneficial.
Summary:
ICM patients remain a clinical conundrum. The numerous limitations of the recent RCTs have led to uncertainty about optimal management. Revascularization continues to be offered to patients with evidence of myocardial viability. Further studies are required to answer the outstanding questions in the management of patients with ICM.
