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Impact of revascularization guided by functional testing in ischaemic cardiomyopathy
Eduard Ródenas-Alesina1, Guillermo Romero-Farina2,3,4, Pablo Jordán1
1Cardiology Department, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain.
Insights
Ischaemia burden impacts outcomes for patients with ischaemic cardiomyopathy (ICM). Early coronary revascularization (ECR) benefits patients with >10% ischaemia, suggesting an ischaemia-guided approach.
Area of Science:
- Cardiology
- Nuclear Cardiology
- Interventional Cardiology
Background:
- Ischaemia is a significant risk factor for adverse outcomes in ischaemic cardiomyopathy (ICM).
- The role of ischaemia burden in guiding early coronary revascularization (ECR) decisions for ICM patients is not well-established.
- Limited data exists on the interaction between ischaemia and ECR outcomes in ICM.
Purpose of the Study:
- To determine if the extent of myocardial ischaemia modifies the outcomes of early coronary revascularization (ECR) in patients with ischaemic cardiomyopathy (ICM).
- To investigate the relationship between ischaemia burden and major adverse cardiovascular events (MACE) following ECR in ICM.
Main Methods:
- A cohort of 747 patients with ICM (left ventricular ejection fraction <40%) underwent stress-rest gated single-photon emission computed tomography.
- Patients were followed for ECR and major cardiovascular events (MACE).
- A propensity score-matched cohort (1:1) was created to evaluate the interaction between ischaemia and ECR, with P for interaction at 10% ischaemia = 0.021.
Main Results:
- In the matched cohort (109 ECR vs. 109 non-ECR), after a median follow-up of 4.1 years, 102 patients experienced MACE.
- The effect of ECR on MACE was dependent on the percent of ischaemia (P=0.021).
- A trend towards decreased MACE was observed in patients with >10% ischaemia (HR=0.59), while a non-significant increase in MACE was seen in those with <10% ischaemia (HR=1.67).
Conclusions:
- In contemporary ICM patients, the benefits of ECR may be linked to the degree of myocardial ischaemia.
- This study supports the use of stress testing in ICM patients.
- An ischaemia-guided strategy for ECR appears beneficial in managing ICM.
Aims:
The burden of ischaemia is a risk factor for adverse outcomes in ischaemic cardiomyopathy (ICM) but is not systematically tested when deciding on revascularization. Limited data exists in patients with ICM regarding the interaction between ischaemia and early coronary revascularization (ECR). This study sought to determine if the burden of ischaemia modifies the outcomes of ECR in ICM.
Methods And Results:
Consecutive patients with ICM (left ventricular ejection fraction < 40%) with a stress-rest gated single-photon emission computed tomography (N = 747) were followed-up for ECR and major cardiovascular events (MACEs, cardiovascular death, myocardial infarction, or heart failure hospitalization). A 1:1 matched population was selected using a propensity score for ECR. The interaction between ischaemia and ECR was evaluated in the matched cohort. In the initial cohort, 131 patients underwent ECR. Of them, 109 were matched to non-ECR patients. After a median follow up of 4.1 years, 102 (46.8%) patients experienced a MACE. The effect of revascularization on MACE was dependent of the percent of ischaemia (P for the interaction at 10% ischaemia = 0.021), so that a trend towards a decreased risk of MACE was seen in patients with >10% of ischaemia [hazard ratio (HR) = 0.59 (0.30-1.18)], whereas a non-significant increase of MACE was observed in those with <10% ischaemia (HR = 1.67 [0.94-2.96]).
Conclusions:
In a contemporary cohort of patients with ICM, the beneficial effects of ECR may be mediated by the percent of ischaemia. This study supports stress testing in ICM and an ischaemia-guided approach for ECR.
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