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Published on: June 28, 2019
Benefit of Early Revascularization Based on Inducible Ischemia and Left Ventricular Ejection Fraction
Alan Rozanski1, Robert J H Miller2, Heidi Gransar3
1Department of Cardiology, Mount Sinai Morningside Hospital and Mount Sinai Heart, New York, New York, USA.
Insights
Early revascularization reduces mortality in patients with inducible myocardial ischemia. This benefit is significant for those with normal or low left ventricular ejection fraction (LVEF) and moderate to severe ischemia.
Area of Science:
- Cardiology
- Nuclear Cardiology
- Cardiovascular Imaging
Background:
- The effectiveness of early myocardial revascularization in patients with inducible myocardial ischemia and low left ventricular ejection fraction (LVEF) remains unclear.
- Assessing the impact of revascularization on mortality in relation to LVEF is crucial for clinical decision-making.
Purpose of the Study:
- To evaluate the association between stress-induced myocardial ischemia, revascularization, and all-cause mortality (ACM).
- To compare outcomes in patients with normal versus low LVEF undergoing myocardial revascularization.
Main Methods:
- Analysis of 43,443 patients undergoing stress-rest single-photon emission computed tomography myocardial perfusion imaging (1998-2017).
- Median follow-up of 11.4 years.
- Propensity score adjustment and multivariable Cox modeling to predict ACM, accounting for revascularization nonrandomization.
Main Results:
- Myocardial ischemia prevalence varied significantly with LVEF and angina symptoms.
- In patients with LVEF ≥45%, early revascularization reduced mortality in severe ischemia (HR: 0.70) but increased risk in non-ischemic patients.
- In patients with LVEF <45%, revascularization decreased mortality in moderate (HR: 0.67) and severe (HR: 0.55) ischemia, with no benefit in mild ischemia.
Conclusions:
- Early myocardial revascularization significantly reduces mortality in patients with normal LVEF and severe inducible ischemia.
- Revascularization also lowers mortality in patients with low LVEF and moderate to severe inducible ischemia.
Background:
The utility of performing early myocardial revascularization among patients presenting with inducible myocardial ischemia and low left ventricular ejection fraction (LVEF) is currently unknown.
Objectives:
In this study, we sought to assess the relationship between stress-induced myocardial ischemia, revascularization, and all-cause mortality (ACM) among patients with normal vs low LVEF.
Methods:
We evaluated 43,443 patients undergoing stress-rest single-photon emission computed tomography myocardial perfusion imaging from 1998 to 2017. Median follow-up was 11.4 years. Myocardial ischemia was assessed for its interaction between early revascularization and mortality. A propensity score was used to adjust for nonrandomization to revascularization, followed by multivariable Cox modeling adjusted for the propensity score and clinical variables to predict ACM.
Results:
The frequency of myocardial ischemia varied markedly according to LVEF and angina, ranging from 6.7% among patients with LVEF ≥55% and no typical angina to 64.0% among patients with LVEF <45% and typical angina (P < 0.001). Among 39,883 patients with LVEF ≥45%, early revascularization was associated with increased mortality risk among patients without ischemia and lower mortality risk among patients with severe (≥15%) ischemia (HR: 0.70; 95% CI: 0.52-0.95). Among 3,560 patients with LVEF <45%, revascularization was not associated with mortality benefit among patients with no or mild ischemia, and was associated with decreased mortality among patients with moderate (10%-14%) (HR: 0.67; 95% CI: 0.49-0.91) and severe (≥15%) (HR: 0.55; 95% CI: 0.38-0.80) ischemia.
Conclusions:
Within this cohort, early myocardial revascularization was associated with a significant reduction in mortality among both patients with normal LVEF and severe inducible myocardial ischemia and patients with low LVEF and moderate or severe inducible myocardial ischemia.
