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Published on: February 16, 2016
Impact of Anatomical and Viability-Guided Completeness of Revascularization on Clinical Outcomes in Ischemic
Saad M Ezad1, Margaret McEntegart2, Matthew Dodd3
1British Heart Foundation Centre of Research Excellence at the School of Cardiovascular and Metabolic Medicine & Sciences, King's College London, London, United Kingdom.
Insights
Complete revascularization did not improve event-free survival in patients with severe left ventricular dysfunction. This finding applies to both anatomical and viability-guided approaches compared to medical therapy alone.
Area of Science:
- Cardiology
- Interventional Cardiology
- Heart Failure Research
Background:
- Complete revascularization in coronary artery disease is associated with better outcomes in patients with preserved left ventricular (LV) function.
- The benefit of complete revascularization in patients with severe LV dysfunction remains unclear.
Purpose of the Study:
- To evaluate the impact of complete revascularization on outcomes in patients with severe left ventricular dysfunction.
- To compare anatomical and viability-guided revascularization strategies against optimal medical therapy.
Main Methods:
- The REVIVED-BCIS2 trial randomized patients with severe LV dysfunction to percutaneous coronary intervention (PCI) or optimal medical therapy.
- Completeness of revascularization was assessed using coronary (RIcoro) and myocardial (RImyo) revascularization indices.
- The primary outcome was the composite of death or hospitalization for heart failure.
Main Results:
- In patients undergoing PCI, median RIcoro was 67% and median RImyo was 85%.
- Complete anatomical or viability-guided revascularization showed no significant difference in the primary outcome compared to optimal medical therapy alone (HR: 0.90; 0.95).
- Sensitivity analysis using residual SYNTAX score did not reveal an association with outcomes.
Conclusions:
- Complete anatomical or viability-guided revascularization does not improve event-free survival in patients with severe LV dysfunction.
- Percutaneous coronary intervention (PCI) with complete revascularization did not offer advantages over optimal medical therapy in this patient cohort.
Background:
Complete revascularization of coronary artery disease has been linked to improved outcomes in patients with preserved left ventricular (LV) function.
Objectives:
This study sought to identify the impact of complete revascularization in patients with severe LV dysfunction.
Methods:
Patients enrolled in the REVIVED-BCIS2 (Revascularization for Ischemic Ventricular Dysfunction) trial were eligible if baseline/procedural angiograms and viability studies were available for analysis by independent core laboratories. Anatomical and viability-guided completeness of revascularization were measured by the coronary and myocardial revascularization indices (RIcoro and RImyo), respectively, where RIcoro = (change in British Cardiovascular Intervention Society Jeopardy score [BCIS-JS]) / (baseline BCIS-JS) and RImyo= (number of revascularized viable segments) / (number of viable segments supplied by diseased vessels). The percutaneous coronary intervention (PCI) group was classified as having complete or incomplete revascularization by median RIcoro and RImyo. The primary outcome was death or hospitalization for heart failure.
Results:
Of 700 randomized patients, 670 were included. The baseline BCIS-JS and SYNTAX (Synergy Between PCI With Taxus and Cardiac Surgery) scores were 8 (Q1-Q3: 6-10) and 22 (Q1-Q3: 15-29), respectively. In those patients assigned to PCI, median RIcoro and RImyo values were 67% and 85%, respectively. Compared with the group assigned to optimal medical therapy alone, there was no difference in the likelihood of the primary outcome in those patients receiving complete anatomical or viability-guided revascularization (HR: 0.90; 95% CI: 0.62-1.32; and HR: 0.95; 95% CI: 0.66-1.35, respectively). A sensitivity analysis by residual SYNTAX score showed no association with outcome.
Conclusions:
In patients with severe LV dysfunction, neither complete anatomical nor viability-guided revascularization was associated with improved event-free survival compared with incomplete revascularization or treatment with medical therapy alone. (Revascularization for Ischemic Ventricular Dysfunction) [REVIVED-BCIS2]; NCT01920048).
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