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

doi:10.1016/j.jacc.2022.04.052

Journal of the American College of Cardiology

Volume 80, Issue 3, 19 July 2022, Pages 202-215

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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.

Central Illustration

Key Words

cardiac stress testing

coronary artery disease

myocardial ischemia

myocardial perfusion imaging

myocardial revascularization

Abbreviations and Acronyms

ACM

all-cause mortality

CAD

coronary artery disease

CSMC

Cedars Sinai Medical Center

left ventricular

LVEF

left ventricular ejection fraction

MPI

myocardial perfusion imaging

SPECT

single-photon emission computed tomography

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: Listen to this manuscript's audio summary by Editor-in-Chief Dr Valentin Fuster on www.jacc.org/journal/jacc.

: Mouaz Al-Mallah, MD, MSc, served as Guest Associate Editor for this paper. Christie Ballantyne, MD, served as Guest Editor-in-Chief for this paper.

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