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Evaluation of Coronary Flow Reserve After Myocardial Ischemia Reperfusion in Rats
Published on: June 28, 2019
Real-world effectiveness of early revascularization in stable coronary artery disease with moderate or severe
Ferdinand Jr Gerodias1,2, Robert M Iwanochko1,2, Peter C Austin3
1Robert J. Burns Nuclear Cardiology Laboratory and the Joint Department of Medical Imaging of University Health Network, University of Toronto, Toronto, Canada.
Insights
Early revascularization for stable coronary artery disease patients with moderate to severe ischemia significantly reduces long-term cardiovascular death and hospitalizations. This finding supports timely intervention after myocardial perfusion imaging.
Area of Science:
- Cardiology
- Interventional Cardiology
- Nuclear Cardiology
Background:
- Comparative effectiveness studies are crucial for generalizing clinical trial findings to real-world patient populations.
- The ISCHEMIA trial's generalizability to diverse patient groups requires further investigation.
- Myocardial perfusion imaging (MPI) plays a key role in assessing ischemia severity in stable coronary artery disease (CAD).
Purpose of the Study:
- To evaluate the long-term effectiveness of early revascularization in patients with stable CAD.
- To compare outcomes of early revascularization versus conservative management in moderate to severe ischemia detected by MPI.
- To assess the impact of revascularization timing on cardiovascular mortality and morbidity.
Main Methods:
- A retrospective study included patients with moderate or severe ischemia (summed difference score ≥7) on MPI.
- Early revascularization (PCI or CABG within 90 days) was compared to non-early revascularization.
- Exclusion criteria included left main disease, severe CKD, LV dysfunction, recent ACS, or HF hospitalization. Inverse-probability treatment weighting was used.
Main Results:
- 1530 patients were followed for a median of 9.9 years.
- Early revascularization was associated with a significantly lower risk of cardiovascular death (HR 0.54; p=0.022).
- A significant reduction in the composite endpoint of cardiovascular hospitalization or death was observed with early revascularization (HR 0.67; p=0.013).
Conclusions:
- Early revascularization in stable CAD patients with moderate to severe ischemia on MPI leads to better long-term outcomes.
- Patients undergoing early revascularization experienced reduced cardiovascular mortality and hospitalizations.
- These findings support the benefit of timely revascularization strategies in selected CAD patients.
Background:
Comparative effectiveness studies may provide insights into generalizability of the ISCHEMIA trial to real-world patients. We evaluated the long-term effectiveness of revascularization within 90 days after detecting moderate or severe ischemia on myocardial perfusion imaging (MPI) in stable coronary artery disease.
Methods:
All consecutive patients with moderate or severe ischemia (summed difference score ≥7) on single photon emission computed tomography MPI at a tertiary academic medical center were included (January 2003 to March 2020). Early revascularization (defined as percutaneous coronary intervention or coronary artery bypass grafting within 90 days) after MPI, was compared to those patients treated without early revascularization, excluding those with left main disease, severe chronic kidney disease, severe left ventricular dysfunction, recent acute coronary syndrome or heart failure hospitalization. Primary outcomes were cardiovascular death or the composite of cardiovascular hospitalization or cardiovascular death, and were tracked throughout the provincial healthcare system.
Results:
1530 patients (mean age: 65 years; 70 % male) were followed for a median of 9.9 years. After inverse-probability treatment weighting, early revascularization was associated with lower risks of cardiovascular death (3.76 % vs 8.93 %; HR 0.54, 95 % CI: 0.31-0.91, p = 0.022) and a reduction in the composite endpoint (33.73 % vs 43.94 %; HR 0.67, 95 % CI: 0.49-0.92, p = 0.013) compared to those treated without early revascularization.
Conclusions:
Patients with stable coronary artery disease treated with early revascularization after MPI showing moderate or severe ischemia experienced lower risks of cardiovascular death and composite of cardiovascular hospitalization or cardiovascular death compared to those treated without early revascularization.
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