Quantification of coronary flow reserve in patients with ischaemic and non-ischaemic cardiomyopathy and its association with clinical outcomes
Maulik D. MajmudarVenkatesh L. MurthyRavi V. ShahSwathy KolliNegareh MousaviCourtney FosterJon HainerRon BlanksteinSharmila DorbalaArkadiusz SitekLynne W. StevensonMandeep R. MehraMarcelo F. Di Carli
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Abstract:
Patients with left ventricular systolic dysfunction frequently show abnormal coronary vascular function, even in the absence of overt coronary artery disease. Moreover, the severity of vascular dysfunction might be related to the aetiology of cardiomyopathy. We sought to determine the incremental value of assessing coronary vascular dysfunction among patients with ischaemic (ICM) and non-ischaemic (NICM) cardiomyopathy at risk for adverse cardiovascular outcomes. Coronary flow reserve (CFR, stress/rest myocardial blood flow) was quantified in 510 consecutive patients with rest left ventricular ejection fraction (LVEF) ≤45% referred for rest/stress myocardial perfusion PET imaging. The primary end point was a composite of major adverse cardiovascular events (MACE) including cardiac death, heart failure hospitalization, late revascularization, and aborted sudden cardiac death. Median follow-up was 8.2 months. Cox proportional hazards model was used to adjust for clinical variables. The annualized MACE rate was 26.3%. Patients in the lowest two tertiles of CFR (CFR ≤ 1.65) experienced higher MACE rates than those in the highest tertile (32.6 vs. 15.5% per year, respectively, P = 0.004), irrespective of aetiology of cardiomyopathy. Impaired coronary vascular function, as assessed by reduced CFR by PET imaging, is common in patients with both ischaemic and non-ischaemic cardiomyopathy and is associated with MACE.Keywords:
Mace
Coronary flow reserve
Ischemic Cardiomyopathy
Ischemic Cardiomyopathy
Myocardial Revascularization
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Background Myocardial revascularization has been advocated to improve myocardial function and prognosis in ischemic cardiomyopathy (ICM). We discuss the evidence for revascularization in patients with ICM and the role of ischemia and viability detection in guiding treatment. Methods and Results We searched for randomized controlled trials evaluating the prognostic impact of revascularization in ICM and the value of viability imaging for patient management. Out of 1397 publications, 4 randomized controlled trials were included, enrolling 2480 patients. Three trials (HEART [Heart Failure Revascularisation Trial], STICH [Surgical Treatment for Ischemic Heart Failure], and REVIVED [REVascularization for Ischemic VEntricular Dysfunction]‐BCIS2) randomized patients to revascularization or optimal medical therapy. HEART was stopped prematurely without showing any significant difference between treatment strategies. STICH showed a 16% lower mortality with bypass surgery compared with optimal medical therapy at a median follow‐up of 9.8 years. However, neither the presence/extent of left ventricle viability nor ischemia interacted with treatment outcomes. REVIVED‐BCIS2 showed no difference in the primary end point between percutaneous revascularization or optimal medical therapy. PARR‐2 (Positron Emission Tomography and Recovery Following Revascularization) randomized patients to imaging‐guided revascularization versus standard care, with neutral results overall. Information regarding the consistency of patient management with viability testing results was available in ≈65% of patients (n=1623). No difference in survival was revealed according to adherence or no adherence to viability imaging. Conclusions In ICM, the largest randomized controlled trial, STICH, suggests that surgical revascularization improves patients' prognosis at long‐term follow‐up, whereas evidence supports no benefit of percutaneous coronary intervention. Data from randomized controlled trials do not support myocardial ischemia or viability testing for treatment guidance. We propose an algorithm for the workup of patients with ICM considering clinical presentation, imaging results, and surgical risk.
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Background— Patients with ischemic cardiomyopathy and viable myocardium may improve in function and prognosis following revascularization. Delayed revascularization may result in less favorable outcome, and therefore the impact of timing of revascularization on long-term outcome was evaluated. Methods and Results— Patients (n=85) with ischemic cardiomyopathy and substantial viability (≥25% of the left ventricle) on dobutamine stress echocardiography underwent surgical revascularization. Based on the waiting time for revascularization, patients were divided into 2 groups: early (≤1 month) and late (>1 month) revascularization. Left ventricular ejection fraction (LVEF) was assessed before and 9 to 12 months after revascularization; follow-up data were acquired up to 2 years after revascularization. Hence, 40 patients underwent early (20±12 days) and 45 late (85±47 days) revascularization. Baseline characteristics of the two groups were comparable. Preoperative deaths were 0 in the early and 2 in the late group. Patients with early revascularization remained shorter time in the intensive care unit (2.4±1.5 days versus 5.9±2.1 days for the late group, P <0.05). Low output syndrome was observed more frequently in the late group (8% versus 22%, P =0.06). On long-term follow-up, mortality (5% versus 20%, P <0.05) and re-hospitalization for heart failure (10% versus 24%, NS) were higher in the late group. LVEF improved from 28±9% to 40±12% ( P <0.05) in the early group and remained unchanged in the late group (27±10% versus 25±7%, NS). Conclusion— Patients with ischemic cardiomyopathy and viable myocardium benefit from early revascularization (with improvement in LVEF and favorable prognosis), whereas delayed revascularization of these patients is associated with worse outcome.
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Myocardial Revascularization
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Patients with heart failure symptoms due to ischemic cardiomyopathy face a poor prognosis without adequate treatment. In these patients with viable ischemic myocardium, revascularization surgery is not a new but an established treatment concept. the CASS study, published in 1983, was already able to document the superiority of coronary artery revascularization in patients with poor left ventricular function. It is of utmost importance to predict regional functional recovery in order to assess viability and, thus, the indication for revascularization. Late gadoliniium enhancement cardiovascular magnetic resonance is the new gold standard. By applying this technique, it can be demonstrated that the transmural extent of a scar predicts segmental functional recovery. Numerous studies describe the predictors of survival of surgical revascularization, the indication and impact of medical antiarrhythmic treatment or choice of graft. In addition to conventional surgery, off-pump procedures, minimal extracorporeal circulation and hybrid revascularization have a special role in the treatment of patients with ischemic cardiomyopathy. Surgical techniques and medical therapies continue to improve. The future revascularization in these patients will focus on improving results and making coronary artery bypass grafting for elective revascularization less invasive and safer. Technical evolution, including the use of robotics and anastomotic connectors, intraoperative imaging and protein enzyme therapies, have to be defined concerning their special impact in these patients.
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