Key result
Early revascularization linked to ~45% lower mortality in severe ischemia with reduced LVEF.
Why the study?
The utility of early myocardial revascularization among patients with inducible myocardial ischemia and low LVEF is currently unknown.
Does early myocardial revascularization reduce all-cause mortality in patients with varying severities of inducible ischemia and normal versus low LVEF?
Cohort (n=43,443)
Does early myocardial revascularization reduce all-cause mortality in patients with varying severities of inducible ischemia and normal versus low LVEF?
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“Importantly, the presence of severe ischemia does not necessarily mean that coronary revascularization should be applied. New data from a large clinical trial suggests that when medical therapy is optimized, it may be as effective as coronary revascularization in such patients. Regardless, the presence of severe ischemia indicates high clinical risk, which then requires aggressive management to reduce clinical risk.”
“Findings of this study supporting the benefits of revascularization (vs. medical therapy) among patients with moderate to severe ischemia are in contradiction with the results of the ISCHEMIA trial and fuels continued debate about optimal management among patients with demonstrable ischemia on stress testing.”
“These results confirm the benefits of stress testing for clinical management. What you want from any test when considering coronary revascularization procedures is that the test will identify a large percentage of patients who are at low clinical risk and do so correctly, while identifying only a small percentage of patients who are at high clinical risk and do so correctly. That is what we found with nuclear stress testing in this study.”
Early myocardial revascularization offers a significant survival benefit for patients with severe inducible ischemia and normal LVEF, as well as for patients with moderate-to-severe ischemia and low LVEF.
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.
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Rozanski et al. (2022) conducted a cohort in Inducible myocardial ischemia (n=43,443). Early revascularization vs. No early revascularization was evaluated on All-cause mortality (HR 0.55, 95% CI 0.38-0.80). Early revascularization was associated with lower mortality in patients with severe ischemia and either LVEF ≥45% (HR 0.70; 95% CI 0.52-0.95) or LVEF <45% (HR 0.55; 95% CI 0.38-0.80).
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