Benefit of Early Revascularization Based on Inducible Ischemia and Left Ventricular Ejection Fraction.

Abstract

BACKGROUND:

The utility of performing early myocardial revascularization among patients presenting with inducible myocardial ischemia and low left ventricular ejection fraction (LVEF) is currently unknown.

OBJECTIVES:

In this study, we sought to assess the relationship between stress-induced myocardial ischemia, revascularization, and all-cause mortality (ACM) among patients with normal vs low LVEF.

METHODS:

We evaluated 43,443 patients undergoing stress-rest single-photon emission computed tomography myocardial perfusion imaging from 1998 to 2017. Median follow-up was 11.4 years. Myocardial ischemia was assessed for its interaction between early revascularization and mortality. A propensity score was used to adjust for nonrandomization to revascularization, followed by multivariable Cox modeling adjusted for the propensity score and clinical variables to predict ACM.

RESULTS:

The frequency of myocardial ischemia varied markedly according to LVEF and angina, ranging from 6.7% among patients with LVEF ≥55% and no typical angina to 64.0% among patients with LVEF <45% and typical angina (P < 0.001). Among 39,883 patients with LVEF ≥45%, early revascularization was associated with increased mortality risk among patients without ischemia and lower mortality risk among patients with severe (≥15%) ischemia (HR: 0.70; 95% CI: 0.52-0.95). Among 3,560 patients with LVEF <45%, revascularization was not associated with mortality benefit among patients with no or mild ischemia, and was associated with decreased mortality among patients with moderate (10%-14%) (HR: 0.67; 95% CI: 0.49-0.91) and severe (≥15%) (HR: 0.55; 95% CI: 0.38-0.80) ischemia.

CONCLUSIONS:

Within this cohort, early myocardial revascularization was associated with a significant reduction in mortality among both patients with normal LVEF and severe inducible myocardial ischemia and patients with low LVEF and moderate or severe inducible myocardial ischemia.

• Authors: Alan Rozanski, Robert J H Miller, Heidi Gransar, Donghee Han, Piotr Slomka, Damini Dey, Sean W Hayes, John D Friedman, Louise Thomson, Daniel S Berman
• Journal: Journal of the American College of Cardiology (J Am Coll Cardiol) Vol. 80 Issue 3 Pg. 202-215 (07 19 2022) ISSN: 1558-3597 [Electronic] United States
• PMID: 35835493 (Publication Type: Journal Article, Research Support, Non-U.S. Gov't, Research Support, N.I.H., Extramural)
• Copyright: Copyright © 2022. Published by Elsevier Inc.

Topics

• Angina Pectoris
• Coronary Artery Disease
• Humans
• Ischemia
• Myocardial Ischemia (surgery)
• Myocardial Perfusion Imaging (methods)
• Myocardial Revascularization
• Stroke Volume
• Tomography, Emission-Computed, Single-Photon
• Ventricular Function, Left