Selecting patients with ischemic cardiomyopathy for medical treatment, revascularization, or heart transplantation

Three major treatment options are available to patients with ischemic cardiomyopathy: medical therapy, coronary revascularization, or heart transplantation. Although survival rates have been enhanced with vasodilator therapy in such patients, the ultimate outcome is still poor. Coronary revascularization, although beneficial in some patients, may lead to disappointing outcomes in others. Cardiovascular specialists have searched for better criteria to predict which patients are most likely to benefit from revascularization compared with medical therapy, which is often followed by heart transplantation. An accurate noninvasive assessment of myocardial viability that can distinguish irreversible myocardial cellular injury from myocardial hibernation may be useful for clinical decision making. It permits selection of patients with ischemic cardiomyopathy who will most benefit from revascularization strategies with respect to postoperative improvement in regional and global left ventricular function and survival. In general, the greater the extent of viability in patients with left ventricular dysfunction and coronary artery disease, the better the prognosis with revascularization strategies. Radionuclide methods have emerged that can evaluate myocardial viability accurately. As hospitals face more pressure from managed-care organizations to reduce health-care costs, more practice guidelines are necessary to identify which patients are to benefit from which strategies and to identify when they are unlikely to benefit from costly interventions such as coronary bypass. Conversely, the cost-effectiveness of nuclear cardiology may be substantial if certain patients referred for transplantation are identified to have a good outcome with revascularization, even in the absence of anginal symptoms. Thus nuclear cardiology might provide valuable information that not only improves outcomes but also reduces overall costs of managing patients with ischemic cardiomyopathy.