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Outcome of revascularisation in stable coronary artery disease without ischaemia: a Danish registry-based follow-up
Jane Angel Simonsen1, Hans Mickley2, Allan Johansen1
1Department of Nuclear Medicine, Odense University Hospital, Odense, Denmark.
Insights
Coronary revascularisation in stable coronary artery disease (CAD) patients without myocardial ischaemia showed a higher risk of death and cardiac events. Medical treatment is recommended for these patients, as revascularisation did not demonstrate improved outcomes.
Area of Science:
- Cardiology
- Interventional Cardiology
- Nuclear Cardiology
Background:
- Stable coronary artery disease (CAD) management often involves assessing myocardial ischaemia to guide revascularisation decisions.
- Revascularisation is generally recommended for patients with significant ischaemia to reduce mortality.
- However, the benefit of revascularisation in patients without demonstrable ischaemia is less clear.
Purpose of the Study:
- To compare the outcomes of coronary revascularisation versus medical treatment in patients with stable CAD but without significant myocardial ischaemia.
- To evaluate the association between revascularisation and mortality or major adverse cardiac events in this specific patient subgroup.
Main Methods:
- A registry-based study followed 1327 patients with normal myocardial perfusion scintigraphy (MPS) and 278 with fixed perfusion defects.
- Patients were categorized into medical treatment (Med) or revascularisation (Revasc) groups.
- Outcomes assessed included all-cause death (ACD) and cardiac death/myocardial infarction (CD/MI) over a median follow-up of 6.1 years.
Main Results:
- In patients with normal MPS, revascularisation was associated with significantly higher rates of ACD (6.2%/year vs 1.9%/year) and CD/MI (6.9%/year vs 0.6%/year) compared to medical treatment.
- These findings persisted after adjustment for clinical predictors and in matched patient comparisons.
- In patients with fixed defects, revascularisation showed no significant difference in ACD or CD/MI rates compared to medical treatment.
Conclusions:
- Coronary revascularisation in stable CAD patients without myocardial ischaemia is associated with increased mortality and cardiac events.
- The study found no evidence to support revascularisation in patients with stable CAD and normal myocardial perfusion scintigraphy.
- For patients with fixed perfusion defects, outcomes between revascularisation and medical treatment were similar, suggesting equipoise.
Objectives:
In stable coronary artery disease (CAD), coronary revascularisation may reduce mortality of patients with a certain amount of left ventricular myocardial ischaemia. However, revascularisation does not always follow the guidance suggested by ischaemia testing. We compared outcomes in patients without ischaemia who had either revascularisation or medical treatment.
Design And Population:
Based on registries, 1327 consecutive patients with normal myocardial perfusion scintigraphy (MPS) and 278 with fixed perfusion defects were followed for a median of 6.1 years. Most patients received medical therapy alone (Med), but 26 (2%) with a normal MPS and 15 (5%) with fixed perfusion defects underwent revascularisation (Revasc).
Outcome Measures:
Incidence rates of all-cause death (ACD) and rates of cardiac death/myocardial infarction (CD/MI).
Results:
With a normal MPS, the ACD rate was 6.2%/year in the Revasc group versus 1.9%/year in the Med group (p=0.01); the CD/MI rates were 6.9%/year and 0.6%/year, respectively (p<0.00001). Results persisted after adjustment for predictors of revascularisation, in particular angina score, and in comparisons of matched Revasc and Med patients. With fixed defects, the ACD rate was 9.1%/year in the Revasc group and 6.7%/year in the Med group (p=0.44); the CD/MI rate was 5.0%/year versus 4.2%/year, respectively (p=0.69). If adjusted for angiographic variables or analysed in matched subsets, differences remained insignificant.
Conclusions:
With normal MPS, revascularisation conferred a higher risk, even after adjustment for predictors of revascularisation. With fixed defects, the Revascversus Med difference was close to equipoise. Hence, in patients with stable CAD without ischaemia, we could not find evidence to justify exceptional revascularisation.
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