Elsevier

American Heart Journal

Volume 235, May 2021, Pages 149-157
American Heart Journal

Clinical Investigation
Percutaneous coronary intervention in patients with stable coronary artery disease and left ventricular systolic dysfunction: insights from the VA CART program

https://doi.org/10.1016/j.ahj.2021.02.002Get rights and content

Background

Revascularization of ischemic cardiomyopathy by coronary artery bypass grafting has been shown to improve survival among patients with left ventricular ejection fraction (LVEF) ≤35%, but the role of percutaneous coronary intervention (PCI) in this context is incompletely described. This study sought to evaluate the effect of PCI on mortality and hospitalization among patients with stable coronary artery disease and reduced left ventricular ejection fraction.

Methods

We performed a retrospective analysis comparing PCI with medical therapy among patients with ischemic cardiomyopathy in the Veterans Affairs Health Administration. Patients with angiographic evidence of 1 or more epicardial stenoses amenable to PCI and LVEF ≤35% were included in the analysis. Outcome data were determined by VA and non-VA data sources on mortality and hospital admission.

Results

From 2008 through 2015, a study sample of 4,628 patients was identified, of which 1,322 patients underwent ad hoc PCI. Patients were followed to a maximum of 3 years. Propensity score weighted landmark analysis was used to evaluate the primary and secondary outcomes. The primary outcome of all-cause mortality was significantly lower in the PCI cohort compared with medical therapy (21.6% vs 30.0%, P <.001). The secondary outcome of all-cause rehospitalization or death was also lower in the PCI cohort (76.5% vs 83.8%, P <.001).

Conclusions

In this retrospective analysis of patients with ischemic cardiomyopathy with coronary artery disease amenable to PCI and LVEF ≤35%, revascularization by PCI was associated with decreased all-cause mortality and decreased all-cause death or rehospitalization.

Section snippets

Data sources

This study utilized data from the VA Clinical Assessment, Reporting, and Tracking (CART) Program. Part of CART's quality and safety program involves a clinical software application to collect standardized data on all invasive cardiac procedures in the VA. The CART software was designed using standardized data definitions from the National Cardiovascular Data Registry and the dataset has been previously validated.11,12 Furthermore, its integration with the VA Computerized Patient Record System

Results

From January 1, 2008 through December 31, 2015, there were 16,751 coronary angiograms recorded in the CART system documenting at least 1 significant stenosis and a corresponding LVEF ≤35%. After excluding those with ACS, prior PCI, prior CABG, subsequent CABG within 30 days of index coronary angiography, or significant comorbidities, there were 4,664 patients identified for study eligibility. A final study sample of 4,628 was defined after exclusion of medical center sites that had patients

Discussion

Recent clinical trial data have shown survival benefit among patients with significant coronary stenosis and LVEF ≤35% who underwent revascularization by CABG.4 However, the role of PCI in this context remains uncertain as no clinical trial to date has successfully evaluated its efficacy and safety specifically on patients with severe left ventricular systolic dysfunction. In this retrospective study of patients with stable ischemic heart disease and documented LVEF ≤35%, revascularization by

Conclusions

In conclusion, in patients with stable ischemic heart disease and documented LVEF ≤35%, revascularization by PCI was associated with a significant improvement in survival compared with optimal medical therapy. Future prospective studies and randomized clinical trials are necessary to define the potential role of PCI in ischemic cardiomyopathy with severe left ventricular systolic dysfunction.

Funding sources

No extramural funding was used to support this work.

Disclosures

Dr. Adam D. DeVore receives research support from the American Heart Association, Amgen, AstraZeneca, Bayer, IntraCellular Therapies, Luitpold Pharmaceuticals, Merck, the NHLBI, Novartis, and PCORI. He also provides consulting services for Amgen, AstraZeneca, Bayer, InnaMed, LivaNova, Mardil Medical, Novartis, Procyrion, scPharmaceuticals, and Zoll.

Dr. J. Antonio Gutierrez provides consulting services for Amgen and Janssen Pharmaceuticals.

Dr. Rajesh V. Swaminathan receives research support from

Acknowledgments

The authors acknowledge the contributions of Anna Baron, PhD (Colorado School of Public Health, Colorado University Anschutz Medical Campus) and Gray Grunwald, PhD, MA (Colorado School of Public Health, Colorado University Anschutz Medical Campus) in statistical analysis development and manuscript revision.

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