Understanding the role of coronary artery revascularization in patients with left ventricular dysfunction and
Vincenzo Acerbo1,2, Arturo Cesaro3,4, Gianmaria Scherillo1,2
1Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", 80131, Naples, Italy.
Insights
Coronary artery disease (CAD) significantly causes heart failure with reduced ejection fraction (HFrEF). This review examines coronary revascularization strategies for CAD-HFrEF patients, highlighting ongoing debates and the need for better patient selection.
Area of Science:
- Cardiology
- Cardiovascular Surgery
- Interventional Cardiology
Background:
- Coronary artery disease (CAD) is the leading cause of heart failure with reduced ejection fraction (HFrEF).
- Despite medical therapy advances, mortality in CAD-HFrEF patients remains high.
- The role of revascularization strategies (surgical or percutaneous) in CAD-HFrEF is debated.
Purpose of the Study:
- To review current evidence on coronary revascularization in CAD with left ventricular dysfunction.
- To explore uncertainties arising from major trials like STICH and REVIVED.
- To suggest improved patient selection and management strategies for this high-risk group.
Main Methods:
- Review of existing clinical trial data, focusing on STICH and REVIVED trials.
- Analysis of evidence regarding myocardial viability and hibernation theories.
- Synthesis of current guidelines and expert opinions.
Main Results:
- Major trials (STICH, REVIVED) did not definitively establish the benefits of revascularization in all CAD-HFrEF patients.
- Findings challenge traditional concepts of myocardial viability and hibernation.
- Uncertainty persists regarding the optimal patient phenotype for revascularization.
Conclusions:
- Current evidence does not provide a clear answer on the ideal candidates for coronary revascularization in HFrEF.
- Revascularization strategies require refined patient selection criteria.
- Further research is needed to optimize management for CAD-HFrEF patients.
Abstract:
Coronary artery disease (CAD) is the most common cause of heart failure with reduced ejection fraction (HFrEF). Advances and innovations in medical therapy have been shown to play a crucial role in improving the prognosis of patients with CAD and HFrEF; however, mortality rate in these patients remains high, and the role of surgical and/or percutaneous revascularization strategy is still debated. The Surgical Treatment for Ischemic Heart Failure (STICH) trial and the Revascularization for Ischemic Ventricular Dysfunction (REVIVED) trial have attempted to provide an answer to this issue. Nevertheless, the results of these two trials have generated further uncertainties. Their findings do not provide a definitive answer about the ideal clinical phenotype for surgical or percutaneous coronary revascularization and dispute the historical dogma on myocardial viability and the theory of myocardial hibernation, raising new questions about the proper selection of patients who are candidates for coronary revascularization. The aim of this review is to provide an overview on the actual available evidence of coronary artery revascularization in patients with CAD and left ventricular dysfunction and to suggest new insights on the proper selection and management strategies in this high-risk clinical setting.
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