Physiologic risk assessment in stable ischemic heart disease: still superior to the anatomic angiographic approach

In patients with ischemic heart disease (IHD), a functional risk assessment based on non-invasive tests may conflict with a health care policy oriented toward cost containment and direct reperfusion delivery. In this respect, a survey of the European Society of Cardiology has shown that noninvasive tests are underutilized, with wide variability between different countries, so that several patients without significant IHD directly undergo invasive coronary angiography. On the other hand, coronary lesions detected by coronary angiography often are revascularized even without the evidence that myocardial blood supply or mechanical function is altered. This ''anatomically oriented'' invasive approach may negatively impact patient management, with consequent suboptimal medical treatment, inappropriate revascularizations, additional risks, and increased health costs. To investigate the prognostic power of gated SPECT in current practice, we recently studied a cohort of 676 consecutive patients admitted for known or suspected IHD.3 Each patient underwent a complete diagnostic work-up that included clinical evaluation, laboratory tests, 12-lead electrocardiogram, two-dimensional echocardiography, stress/rest gated SPECT, and coronary angiography. During follow-up (median, 37 months), 24 patients died from cardiac causes and 19 had a nonfatal myocardial infarction (MI). Several variables were independent predictors of event-free survival (cardiac death and non-fatal MI) in the different phases of diagnostic work-up. When the above predictors were tested together, summed rest score (SRS), summed difference score (SDS), serumcreatinine, and LDL/HDL cholesterol were the only final independent predictors of event-free survival (Table 1). The results of this study lead us to make some considerations on risk stratification in stable IHD.