Guideline-Directed Medical Therapy After Revascularization and Outcomes in Ischaemic Cardiomyopathy

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.