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Revascularization in ischaemic heart failure with preserved ejection fraction: a nationwide cohort study
Salil V Deo1,2, Yogesh N V Reddy3, Rosita Zakeri4
1Louis Stokes Veteran Affairs Medical Center, Cleveland, OH, USA.
Insights
Coronary artery bypass grafting (CABG) in patients with heart failure with preserved ejection fraction (HFpEF) shows comparable long-term survival to controls. However, these patients face higher risks of heart failure hospitalizations and myocardial infarction post-CABG.
Area of Science:
- Cardiology
- Cardiac Surgery
- Heart Failure Research
Background:
- Coronary artery disease (CAD) and heart failure with preserved ejection fraction (HFpEF) are prevalent conditions.
- Limited evidence exists to guide revascularization strategies in patients with both CAD and HFpEF.
Purpose of the Study:
- To investigate the long-term outcomes of coronary artery bypass grafting (CABG) in patients with significant CAD and heart failure (HF) across the spectrum of ejection fraction.
- To compare outcomes of CABG in patients with HFpEF, HF with mid-range ejection fraction (HFmrEF), and HF with reduced ejection fraction (HFrEF) against patients without preoperative HF.
Main Methods:
- Analysis of a large national cohort of 10,396 patients from the US Veteran Affairs (VA) Medical Centers.
- Stratification of HF patients into HFpEF, HFmrEF, and HFrEF groups.
- Comparison of long-term survival and recurrent HF hospitalization rates post-CABG.
Main Results:
- Long-term survival for HFpEF patients post-CABG was similar to controls (HR 0.85, 95% CI 0.68-1.06), despite increased short-term hazard.
- Survival progressively declined in HFmrEF and HFrEF groups compared to controls.
- HFpEF patients had lower rates of HF hospitalization (43.9 ± 6.9/100 patient-years) than HFmrEF (65.9 ± 3.8/100 patient-years) and HFrEF (93.4 ± 4.8/100 patient-years).
- HFpEF patients experienced the highest rates of future myocardial infarction.
Conclusions:
- CABG is a safe option for HFpEF patients with CAD, offering comparable long-term survival to those without HF.
- Patients with HFpEF undergoing CABG face increased risks of future myocardial infarction and HF hospitalizations.
- These findings suggest a continuum of mortality risk in ischemic heart failure when stratified by baseline ejection fraction prior to revascularization.
Aims:
Despite the common occurrence of coronary artery disease (CAD) and heart failure (HF) with preserved ejection fraction (HFpEF), there is limited evidence to guide revascularization.
Methods And Results:
We investigated the long-term outcomes of coronary artery bypass grafting (CABG) in patients with HF and significant CAD across the spectrum of ejection fraction, using a large national cohort of patients from the Veteran Affairs (VA) Medical Centers in the US. Patients with HF were stratified into groups, HFpEF, HF with mid-range ejection fraction (HFmrEF), and HF with reduced ejection fraction (HFrEF) and compared to patients with no preoperative HF. We analysed 10 396 patients. Despite an increased hazard in the first year following revascularization, the long-term survival (median follow-up 6.6 years; interquartile range 3.7-10.1) of HFpEF post-CABG was similar to controls (hazard ratio 0.85, 95% confidence interval 0.68-1.06), but survival progressively declined with HFmrEF and HFrEF. Similar trends were seen with recurrent HF hospitalization with lower risk with baseline HFpEF (43.9 ± 6.9/100 patient-years) compared to HFmrEF (65.9 ± 3.8/100 patient-years) and HFrEF (93.4 ± 4.8/100 patient-years). Although HFpEF patients had lower mortality and HF hospitalization post-CABG compared to patients with a lower ejection fraction, they experienced the highest rates of future myocardial infarction.
Conclusion:
Although HFpEF patients with CAD have greater short-term risk post-CABG, their long-term survival is comparable to controls. However, they are at increased risk for HF hospitalizations and myocardial infarction. These data support the safety of CABG in HFpEF patients and suggest continuum of mortality risk for ischaemic HF when stratified by baseline ejection fraction before revascularization.
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