Elsevier

American Heart Journal

Volume 256, February 2023, Pages 95-103
American Heart Journal

Clinical Investigations
Cardiovascular events in patients with coronary artery disease with and without myocardial ischemia: Long-term follow-up

https://doi.org/10.1016/j.ahj.2022.11.011Get rights and content

Background

After the results of the ISCHEMIA Trial, the role of myocardial ischemia in the prognosis of coronary artery disease (CAD) was under debate. We sought to comparatively evaluate the long-term prognosis of patients with multivessel CAD with or without documented myocardial ischemia.

Methods

This is a single-center, retrospective, observational cohort study that included patients with CAD obtained from the research protocols database of “The Medicine, Angioplasty or Surgery Study,” the MASS Study Group. Patients were stratified according to the presence or absence of myocardial ischemia. Cardiovascular events (overall mortality and myocardial infarction) were tracked from the registry entry up to a median follow-up of 8.7 years. Myocardial ischemia was assessed at baseline by a functional test with or without imaging.

Results

From 1995 to 2018, 2015 patients with multivessel CAD were included. Of these, 1001 presented with conclusive tests at registry entry, 790 (79%) presenting with ischemia and 211 (21%) without ischemia. The median follow-up was 8.7 years (IQR 4.04 to 10.07). The primary outcome occurred in 228 (28.9%) patients with ischemia and in 64 (30.3%) patients without ischemia (plog-rank=0.60). No significant interaction was observed with the presence of myocardial ischemia and treatment strategies in the occurrence of the combined primary outcome (pinteration=0.14).

Conclusions

In this sample, myocardial ischemia was not associated with a worse prognosis compared with no ischemia in patients with multivessel CAD. These results refer to debates about the role of myocardial ischemia in the occurrence of cardiovascular events.

Section snippets

Study design

This was a single-center, retrospective, observational cohort study that included patients with CAD extracted from the research protocols database of “The Medicine, Angioplasty or Surgery Study,” the “MASS Study Group,” from the Heart Institute of University of São Paulo- (InCor-HCFMUSP)

Patient selection

Patients included in the present study are part of the MASS Research Group. This database was created to include patients with myocardial ischemia and CAD confirmed by angiographic studies. Thus, patients with

Definition

Diagnosis of CAD was confirmed by angiographic examination with presentation of luminal stenosis >70% in the main coronary arteries or their major branches. Myocardial ischemia was identified by the presence of angina pectoris and confirmed by functional testing with or without imaging. Left ventricular function estimated by LV ejection fraction ≥50% was considered preserved.

Objective evidence of myocardial ischemia was defined as a new resting ST-segment and T-wave alteration or the emergence

Baseline clinical characteristics

In the period between 1995 and 2018, 1915 patients with chronic CAD in follow-up were available in the MASS registry database. Of this sample, 1188 had undergone an ischemic test at entry into the registry, and of these, 1001 had an ischemic test with conclusive results. Of these, 790 patients had positive tests for ischemia and 211 had negative tests for ischemia. The median follow-up for this population was 8.7 years (IQR: 4.04-10.07), with no loss to follow-up (Figure 1).

The baseline

Discussion

In this sample, the presence of myocardial ischemia was not related to an increase in cardiovascular outcomes, death, or AMI in the long-term follow-up. The ischemic burden was also not related to the increase in cardiovascular outcomes. Moreover, myocardial ischemia was not an independent predictor for combined events or death in this sample. The interpretation of this result must be made considering the population studied. In this sample, we observed more than 70% with 3-vessel disease,

Conclusions

In our sample, the presence of myocardial ischemia was not associated with a higher event rate in patients with multivessel CAD, regardless of the initial treatment used.

Author Contributions

FPCC: carried out conception and design, acquisition of data, analysis and interpretation of data, was involved in drafting the manuscript and revising it critically for important intellectual content, has given final approval of the version to be published.

WH: carried out conception and design, acquisition of data, analysis and interpretation of data, was involved in drafting the manuscript and revising it critically for important intellectual content, has given final approval of the version

Funding

Financial support for the present study was provided in part by a research grant from Zerbini Foundation.

Disclosures

None reported.

Acknowledgments

Support for the present study was provided in part by the Zerbini Foundation, São Paulo, Brazil, and Ann Conti Morcos of MorcosMedia provided medical writing support during the preparation of this paper. The authors are solely responsible for the design and conduct of this study, all study analyses, the drafting and editing of the paper, and its final contents.

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