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Guideline-directed medical therapy after revascularization and outcomes in ischaemic cardiomyopathy
Carlos Moliner-Abós1,2,3,4, Maria Calvo-Barceló5, Eduard Solé-Gonzalez6
1Cardiology Department, Hospital de la Santa Creu i Sant Pau, CIBERCV, Universitat Autònoma de Barcelona, Barcelona, Spain.
Insights
Guideline-directed medical therapy (GDMT) implementation in heart failure with reduced ejection fraction (HFrEF) patients showed lower unadjusted mortality. Combining GDMT with coronary artery bypass grafting (CABG) yielded the best long-term survival outcomes.
Area of Science:
- Cardiology
- Heart Failure Research
- Medical Therapy Optimization
Background:
- Guideline-directed medical therapy (GDMT) is crucial for heart failure (HF) with reduced ejection fraction (HFrEF) and coronary artery disease (CAD).
- Real-world adherence to GDMT (GDMTi) is often suboptimal.
- This study examines GDMTi's impact on mortality in ischemic HFrEF patients post-revascularization.
Purpose of the Study:
- To evaluate the long-term effects of GDMT implementation on mortality in patients with de novo ischemic heart failure.
- To assess the impact of GDMTi in conjunction with different revascularization strategies.
- To analyze trends in GDMTi over time within this patient cohort.
Main Methods:
- A landmark analysis of 275 one-year survivors from 409 patients with HFrEF (LVEF ≤40%) and CAD who underwent revascularization.
- GDMTi defined as initiation of all recommended drug classes by 12 months post-admission.
- Primary endpoints included all-cause and cardiovascular mortality; secondary endpoints examined outcomes by revascularization strategy.
Main Results:
- Over a median follow-up of 41.6 months, unadjusted all-cause mortality was 18% for GDMTi vs. 42% for non-GDMTi patients.
- Adjusted analyses did not show a significant reduction in all-cause (HR 0.63) or cardiovascular mortality (HR 0.62) with GDMTi alone.
- GDMTi combined with coronary artery bypass grafting (CABG) significantly reduced all-cause (HR 0.42) and cardiovascular mortality (HR 0.40).
Conclusions:
- GDMTi demonstrated a trend towards lower mortality, but significance was not reached after adjustment.
- The combination of GDMTi and CABG provided the most favorable long-term survival outcomes.
- Progressive improvement in GDMTi rates was observed throughout the study period.
Aims:
Guideline-directed medical therapy (GDMT) remains the cornerstone for treating patients with heart failure (HF) and reduced ejection fraction (HFrEF) and coronary artery disease (CAD). However, real-world implementation of GDMT (GDMTi) is suboptimal. This subanalysis of the RevascHeart study evaluates the impact of GDMTi on long-term mortality in patients with de novo ischaemic heart failure (HF) undergoing revascularization.
Methods:
Among 409 patients with HFrEF (left ventricular ejection fraction ≤40%) and CAD, 275 one-year survivors who underwent revascularisation shortly after index HF admission were included in this landmark analysis (LA). GDMTi at 12 months was defined as initiation of each recommended drug class, regardless of dose. Primary endpoints were all-cause and cardiovascular mortality by GDMTi. Secondary endpoints included outcomes by revascularisation strategy and temporal trends in GDMTi.
Results:
Over a median follow-up of 41.6 months, all-cause mortality occurred in 29 GDMTi patients (18%) versus 47 non-GDMTi (42%) and cardiovascular mortality in 10% versus 24%, respectively. After adjustment, GDMTi was not significantly associated with lower all-cause [hazard ratio (HR) 0.63, 95% confidence interval (CI) 0.39-1.02; P = 0.06] or cardiovascular mortality (HR 0.62, 95% CI 0.33-1.18; P = 0.14). GDMTi/coronary artery bypass grafting (CABG) was associated with lower all-cause (HR 0.42, 95% CI 0.20-0.87; P = 0.02) and cardiovascular mortality (HR 0.40, 95% CI 0.16-0.99; P = 0.05). GDMTi use increased progressively over the study period.
Conclusions:
GDMTi was associated with lower unadjusted mortality, though not significant after adjustment. GDMTi combined with CABG showed the best outcomes. The use of GDMTi improved over time.
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