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Can Functional Testing for Ischemia and Viability Guide Revascularization?
Lisa M Mielniczuk1, Gabor G Toth2, Joe X Xie3
1Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Canada.
Insights
Cardiac imaging guides treatment for heart disease by assessing severity and risk. Ongoing trials will refine its role in improving patient outcomes through better management decisions.
Area of Science:
- Cardiology
- Medical Imaging
- Clinical Trials
Background:
- Cardiac imaging is crucial for diagnosing and managing heart disease.
- Optimal patient management relies on assessing symptom burden, risk, and disease severity.
- Flow measurements and ischemia/viability imaging inform revascularization and intervention decisions.
Purpose of the Study:
- To review the current role of cardiac imaging in managing ischemic heart disease and heart failure.
- To highlight the impact of imaging on clinical decision-making and patient outcomes.
- To discuss evidence from ongoing randomized trials that will shape future practice.
Main Methods:
- Review of recent clinical trials and their findings on cardiac imaging.
- Analysis of the strengths and limitations of various imaging modalities.
- Discussion of the indirect effect of imaging on patient outcomes through management decisions.
Main Results:
- Flow measurements effectively guide revascularization decisions.
- Ischemia and viability imaging serve as important risk markers for interventions.
- Evaluating imaging's impact on outcomes is challenging due to its influence on management choices.
Conclusions:
- Cardiac imaging plays a vital role in guiding therapeutic decisions for patients with ischemic heart disease.
- Ongoing randomized trials like FAME 3, ISCHEMIA, and IMAGE-HF will provide high-level evidence.
- Future practice changes informed by these studies are expected to improve patient outcomes.
Abstract:
Cardiac imaging procedures are a cornerstone of the diagnosis and management of patients with cardiac disease. The optimal management of the patient with stable ischemic heart disease or ischemic heart failure often rests on the totality of symptom burden, patient risk, and disease severity, whether assessed anatomically or functionally. Recent trials have demonstrated the power of flow measurements to direct revascularization as well as the strengths and limitations of ischemia and viability/hibernation imaging as markers of risk to direct interventions. They have also highlighted the challenges in evaluating imaging or functional testing to direct therapies, because imaging does not directly affect outcome itself, rather it affects the management decisions that may result in a positive outcome. Ongoing studies with randomized designs, such as FAME 3 (Fractional Flow Reserve versus Angiography for Multivessel Evaluation), ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches), and AIMI-HF (Alternative Imaging Modalities in Ischemic Heart Failure) (IMAGE-HF [Imaging Modalities to Assist with Guiding Therapy in The Evaluation of Patients with Heart Failure]), will provide the highest level of evidence to support practice changes that may further clarify the role of cardiac imaging in the evaluation of these patients and result in improved patient outcomes.
