Percutaneous Revascularization for Ischemic Left Ventricular Dysfunction

Molecular Imaging of Heart Failure: An Update and Future Trends

Molecular imaging can detect and quantify pathophysiological processes underlying heart failure, complementing evaluation of cardiac structure and function with other imaging modalities. Targeted tracers have enabled assessment of various cellular and subcellular mechanisms of heart failure aiming for improved phenotyping, risk stratification, and personalized therapy. This review outlines the current status of molecular imaging in heart failure, accompanied with discussion on novel developments. The focus is on radionuclide methods with data from clinical studies. Imaging of myocardial metabolism can identify left ventricle dysfunction caused by myocardial ischemia that may be reversible after revascularization in the presence of viable myocardium. In vivo imaging of active inflammation and amyloid deposition have an established role in the detection of cardiac sarcoidosis and transthyretin amyloidosis. Innervation imaging has well documented prognostic value in predicting heart failure progression and arrhythmias. Tracers specific for inflammation, angiogenesis and myocardial fibrotic activity are in earlier stages of development, but have demonstrated potential value in early characterization of the response to myocardial injury and prediction of cardiac function over time. Early detection of disease activity is a key for transition from medical treatment of clinically overt heart failure towards a personalized approach aimed at supporting repair and preventing progressive cardiac dysfunction.

Efficacy of revascularization in CTO patients based on hibernating myocardium therapy

BACKGROUND

The effectiveness of percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) is still uncertain, especially for patients with ischemic left ventricular dysfunction. This study aimed to assess hibernating myocardium (HM), as determined by single-photon emission computed tomography (SPECT) and 18F-FDG positron emission tomography (PET), and to compare the benefits of PCI and optimal medical therapy (OMT).

METHODS

A retrospective study collected data from 332 patients with CTO and ischemic left ventricular dysfunction. The study compared patients who underwent PCI or OMT via propensity score matching (PSM) analysis which was performed with a 1:2 matching protocol using the nearest neighbour matching algorithm. The primary endpoint of the study was the occurrence of major adverse cardiac events (MACE), defined as a composite of cardiac death, readmission for worsening heart failure (WHF), revascularization and myocardial infarction (MI).

RESULTS

After PSM, there were a total of 246 individuals in the PCI and OMT groups. Following Cox regression, hibernating myocardium/total perfusion defect (HM/TPD) was identified as an independent risk factor (hazard ratio (HR): 1.03, 95% confidence interval (CI): 1.008-1.052, p = .007). The cut-off value of HM/TPD was 38%. The results of the subgroup analysis suggest that for patients with HM/TPD >38%, the OMT group had a greater risk of MACE (p = .035). A sensitivity analysis restricting patients with single-vessel CTO lesions, HM/TPD remained an independent predictor (HR 1.025, 95% CI 1.008-1.043, p = .005).

CONCLUSION

HM/TPD is an independent predictor of MACE, and for patients with HM/TPD > 38%, CTO-PCI had a lower risk of MACE compared with OMT. However, further validation is still needed through large-scale studies.

Left main revascularization guidelines: navigating the data

PURPOSE OF REVIEW

This article explores recent developments in left main revascularization, with a focus on appraising the latest American and European guidelines.

RECENT FINDINGS

Recent pooled data analysis from four major randomized controlled trials (RCTs) for left main coronary artery stenosis indicate an advantage for CABG over PCI in regard to freedom from major adverse cardiovascular events, despite no significant difference in mortality observed at 5 years. Additional data support the use of CABG for patients with left ventricular dysfunction, complex left main lesions, diffuse coronary disease, and diabetes.

SUMMARY

The data underpinning the guidelines on each revascularization modality (PCI versus CABG) must consider factors such as lesion complexity, diabetes, and left ventricular dysfunction. Additionally, the findings of the four major RCTs upon which the guidelines are based must be ascertained in light of the latest advancements in these revascularization techniques.

Percutaneous coronary revascularization versus medical therapy in chronic coronary syndromes: An updated meta-analysis of randomized controlled trials

INTRODUCTION

Coronary artery disease (CAD) is a main cause of morbidity and mortality. The effectiveness of coronary revascularization in chronic coronary syndromes (CCS) is still debated. Our recent study showed the superiority of coronary revascularization over optimal medical therapy (OMT) in reducing cardiovascular (CV) mortality and myocardial infarction (MI). The recent publication of the ORBITA-2 trial suggested superiority of percutaneous coronary revascularization (PCI) in reducing angina and improving quality of life. Therefore, we aimed to provide an updated meta-analysis evaluating the impact of PCI on both clinical outcomes and angina in CCS.

METHODS

Relevant studies were screened in PubMed/Medline until 08/01/2024. Randomized controlled trials (RCTs) comparing PCI to OMT in CCS were selected. The primary outcome was CV death. Secondary outcomes were MI, all-cause mortality, stroke, major bleeding and angina severity.

RESULTS

Nineteen RCTs involving 8616 patients were included. Median follow-up duration was 3.3 years. Revascularization significantly reduced CV death (4.2% vs. 5.5%; OR = .77; 95% CI .62-.96, p = .02). Subgroup analyses favoured revascularization in patients without chronic total occlusions (CTOs) (p = .052) and those aged <65 years (p = .02). Finally, a follow-up duration beyond 3 years showed increased benefit of coronary revascularization (p = .04). Secondary outcomes analyses showed no significant differences, except for a lower angina severity in the revascularization group according to the Seattle Angina Questionnaire (SAQ) (p = .04) and to the Canadian Cardiovascular Society (CCS) classification (p = .005).

CONCLUSIONS

PCI compared to OMT significantly reduces CV mortality and angina severity, improving quality of life in CCS patients. This benefit was larger without CTOs, in patients aged <65 years and with follow-up duration beyond 3 years.

Optimizing Management of Stable Angina: A Patient-Centered Approach Integrating Revascularization, Medical Therapy, and Lifestyle Interventions

Angina pectoris may arise from obstructive coronary artery disease (CAD) or in the absence of significant CAD (ischemia with nonobstructed coronary arteries [INOCA]). Therapeutic strategies for patients with angina and obstructive CAD focus on reducing cardiovascular events and relieving symptoms, whereas in INOCA the focus shifts toward managing functional alterations of the coronary circulation. In obstructive CAD, coronary revascularization might improve angina status, although a significant percentage of patients present angina persistence or recurrence, suggesting the presence of functional mechanisms along with epicardial CAD. In patients with INOCA, performing a precise endotype diagnosis is crucial to allow a tailored therapy targeted toward the specific pathogenic mechanism. In this expert opinion paper, we review the evidence for the management of angina, highlighting the complementary role of coronary revascularization, optimal medical therapy, and lifestyle interventions and underscoring the importance of a personalized approach that targets the underlying pathobiology.

Predictive utility of residual SYNTAX score for clinical outcomes after successful primary percutaneous coronary intervention

BACKGROUND

In patients presenting with ST-segment elevation myocardial infarction (STEMI), the prevalence of having concomitant severe non-culprit lesion(s) is ≥40%. While timely primary PCI (pPCI) for the culprit lesion is the standard practice, management of the non-culprit lesions remains unsettled.

RESULTS

This prospective multi-center observational study recruited 492 acute STEMI patients who underwent successful pPCI for the culprit lesion. Culprit-only versus complementary non-culprit lesion(s) PCI (either immediate or staged during the same hospital stay) was according to the operator's discretion. Clinical, echocardiographic, and angiographic data were collected and tabulated. The residual SYNTAX score (rSS) was completed by the time of discharge considering the residual lesions after all in-hospital revascularization procedures. Through a minimum follow-up of 12 months, older age, presentation with heart failure Killip class ≥ II, lower estimated glomerular filtration rate (eGFR) on admission, lower left ventricular ejection fraction (LVEF), and higher rSS by discharge were significantly associated with recurrent MACE. In multivariate regression analysis, Killip class ≥ II, LVEF, and rSS were found to be independent predictors for recurrent MACE. In the Receiver Operating Characteristics curve, an rSS of >8 had a sensitivity of 70.1%, and specificity of 75.3% to predict 1-year MACE.

CONCLUSIONS

Residual syntax score proved to be an independent predictor for recurrent MACE through the subsequent year post STEMI. Patients with rSS >8 seem to be at the highest risk for adverse events and are likely to be the most deserving for completing revascularization to reduce the disease burden.

The impact of stress testing to guide PCI in patients with chronic coronary disease

BACKGROUND

Guidelines and international appropriate use criteria increasingly endorse non-invasive stress testing to evaluate patients with suspected chronic coronary disease (CCD). We sought to review the real-world utilisation of non-invasive stress testing and investigate whether their use prior to PCI associates with outcomes in patients with CCD.

METHODS

Consecutive patients from a multicentre registry who underwent PCI for CCD between 2006 and 2018 were included. Clinical characteristics and outcomes were stratified according to whether stress testing was performed prior to PCI (stress vs no-stress groups). The primary outcome was 3-year all-cause mortality.

RESULTS

Among the 8251 patients included, 4970 (60.2 %) underwent pre-PCI stress testing and this proportion increased over time (p-for-trend<0.001). The stress group had a lower prevalence of prior revascularization, myocardial infarction, or heart failure, and a lower incidence of triple vessel disease, in stent re-stenosis, and ACC/AHA class B2/C lesions (all p < 0.001). When comparing post-procedural outcomes, the stress group had lower rates of arrhythmia (1.5 % vs 2.6 %, p = 0.001), new heart failure (0.2 % vs 0.8 %, p = 0.001), renal impairment, and a shorter length of stay (1.6 vs 2.1 days, p < 0.001). Mortality at 3-years was lower in those undergoing PCI following stress testing (5.8 % vs 8.8 %, p < 0.001). After adjusting for key clinical variables, stress guided revascularization was associated with a significantly lower risk of 3-year mortality (adjusted Hazard Ratio 0.77, 95 % CI 0.64-0.92).

CONCLUSIONS

In patients with CCD, PCI guided by non-invasive stress testing is increasingly utilized and associated with improved survival. Further studies are necessary to investigate whether this results from differences in patient characteristics, optimized patient selection, or refined choice of target vessel.

Cardiac shockwave therapy in addition to coronary bypass surgery improves myocardial function in ischaemic heart failure: the CAST-HF trial

BACKGROUND AND AIMS

In chronic ischaemic heart failure, revascularisation strategies control symptoms but are less effective in improving left ventricular ejection fraction (LVEF). The aim of this trial is to investigate the safety of cardiac shockwave therapy (SWT) as a novel treatment option and its efficacy in increasing cardiac function by inducing angiogenesis and regeneration in hibernating myocardium.

METHODS

In this single-blind, parallel-group, sham-controlled trial (cardiac shockwave therapy for ischemic heart failure, CAST-HF; NCT03859466) patients with LVEF ≤40% requiring surgical revascularisation were enrolled. Patients were randomly assigned to undergo direct cardiac SWT or sham treatment in addition to coronary bypass surgery. The primary efficacy endpoint was the improvement in LVEF measured by cardiac magnetic resonance imaging from baseline to 360 days.

RESULTS

Overall, 63 patients were randomized, out of which 30 patients of the SWT group and 28 patients of the Sham group attained 1-year follow-up of the primary endpoint. Greater improvement in LVEF was observed in the SWT group (Δ from baseline to 360 days: SWT 11.3%, SD 8.8; Sham 6.3%, SD 7.4, P = .0146). Secondary endpoints included the 6-minute walking test, where patients randomized in the SWT group showed a greater Δ from baseline to 360 days (127.5 m, SD 110.6) than patients in the Sham group (43.6 m, SD 172.1) (P = .028) and Minnesota Living with Heart Failure Questionnaire score on day 360, which was 11.0 points (SD 19.1) for the SWT group and 17.3 points (SD 15.1) for the Sham group (P = .15). Two patients in the treatment group died for non-device-related reasons.

CONCLUSIONS

In conclusion, the CAST-HF trial indicates that direct cardiac SWT, in addition to coronary bypass surgery improves LVEF and physical capacity in patients with ischaemic heart failure.

Incremental prognostic value of cardiovascular magnetic resonance imaging in patients with severe LV dysfunction undergoing coronary artery bypass grafting

BACKGROUND

Coronary artery disease (CAD) remains a significant global health issue, particularly when complicated by left ventricular ejection fraction (LVEF) < 35%. Although coronary artery bypass grafting (CABG) is recommended for such cases, the unclear prognosis necessitates further investigation.

METHOD

This retrospective study aimed to determine whether cardiovascular magnetic resonance (CMR) imaging provides additional prognostic value in guiding effective clinical management. The study included patients with CAD and LVEF < 35% who underwent CABG surgery after enhanced CMR between March 2016 and March 2023. CMR was performed using a 3.0T scanner with steady-state free precession and phase-sensitive inversion recovery sequences. Prognostic analysis of clinical and CMR data was conducted, with the endpoint defined as cardiovascular death, revascularization, hospitalization for heart failure, or stroke. Statistical analysis included Student's t-test, chi-squared test, univariate and multivariate Cox regression analysis, receiver operating characteristic analysis, Harrell C statistical analysis, integrated discrimination improvement (IDI), and net reclassification improvement (NRI) analysis.

RESULT

The study included 152 patients (mean age 58.6 ± 9.7 years; 138 men). During a mean follow-up of 2.0 years, 8 patients experienced cardiovascular death, while 1 case had revascularization, 13 had hospitalization for heart failure, and 11 had a stroke. Left atrial diameter index (LADi) (hazard ratio [HR], 1.08 [95% confidence interval (CI): 1.02-1.15]; P = 0.04) and late gadolinium enhancement (LGE) mass (HR, 1.03 [95% CI: 1.01-1.06]; P < 0.001) were associated with the endpoint, even after adjusting for multiple clinical variables. Adding LADi and LGE mass improved risk prediction for adverse events, as indicated by the C-index (0.738, p < 0.01), IDI (0.36), and NRI (0.13).

CONCLUSION

Left atrial diameter index (LADi) and scar burden are valuable prognostic indicators in patients with LVEF < 35% undergoing CABG. They offer enhanced risk stratification beyond traditional clinical factors, highlighting their importance in guiding clinical management.

Utility of coronary revascularization in patients with ischemic left ventricular dysfunction

BACKGROUND

Revascularization in patients with left ventricular (LV) dysfunction has been a subject of ongoing uncertainty and conflicting results. This is further complicated by factors including viability, severity of LV dysfunction, and method of revascularization using percutaneous coronary intervention (PCI) versus coronary-artery bypass grafting (CABG).

OBJECTIVES

The purpose of this meta-analysis is to evaluate the association of coronary revascularization with outcomes in patients with ischemic LV dysfunction.

METHODS

A literature search was conducted for studies reporting on cardiovascular outcomes after revascularization compared to optimal medical therapy (OMT) in patients with ischemic LV dysfunction.

RESULTS

A total of 23 studies with 10,110 participants met inclusion criteria. Revascularization was significantly associated with lower all-cause mortality and CV mortality compared to OMT. The association was statistically significant regardless of severity of LV dysfunction or method of revascularization. Subgroup analysis demonstrated that revascularization was significantly associated with lower all-cause and CV mortality compared to OMT for patients with viable myocardium and mixed cohorts with variable viability, but not patients without viable myocardium. Revascularization was not associated with a significant difference in risk of heart failure (HF) hospitalization or acute myocardial infarction (AMI) compared to OMT.

CONCLUSIONS

Revascularization in patients with ischemic LV dysfunction is associated with lower risk of all-cause and CV mortality independent of severity of LV dysfunction or method of revascularization. Revascularization is not associated with lower risk of mortality in patients without evidence of viable myocardium and is not associated with lower risk of AMI or HF hospitalization.

Complete percutaneous coronary revascularization: An elegant solution to left ventricular dysfunction caused by severe coronary artery disease

With increased complexity in both medical comorbidities and coronary anatomy, the proportion of surgically turndown patients and high-risk PCI will continue to rise. Impella-assisted complex PCI can be performed with high technical success and can improve quality of life, angina score, and potentially left ventricular ejection fraction.

Coronary bypass surgery for multivessel disease after percutaneous coronary intervention in acute coronary syndromes: why, for whom, how early?

Multivessel coronary artery disease is present in ∼50% of patients with acute coronary syndrome and, compared with single-vessel disease, entails a higher risk of new ischaemic events and a worse prognosis. Randomized controlled trials have shown the superiority of 'complete revascularization' over culprit lesion-only treatment. Trials, however, only included patients treated with percutaneous coronary intervention (PCI), and evidence regarding complete revascularization with coronary artery bypass graft (CABG) surgery after culprit lesion-only PCI ('hybrid revascularization') is lacking. The CABG after PCI is an open, non-negligible therapeutic option, for patients with non-culprit left main and/or left anterior descending coronary artery disease where evidence in chronic coronary syndrome patients points in several cases to a preference of CABG over PCI. This valuable but poorly studied 'PCI first-CABG later' option presents, however, relevant challenges, mostly in the need of interrupting post-stenting dual antiplatelet therapy (DAPT) for surgery to prevent excess bleeding. Depending on patients' clinical characteristics and coronary anatomical features, either deferring surgery after a safe interruption of DAPT or bridging DAPT interruption with intravenous short-acting antithrombotic agents appears to be a suitable option. Off-pump minimally invasive surgical revascularization, associated with less operative bleeding than open-chest surgery, may be an adjunctive strategy when revascularization cannot be safely deferred and DAPT is not interrupted. Here, the rationale, patient selection, optimal timing, and adjunctive strategies are reviewed for an ideal approach to hybrid revascularization in post-acute coronary syndrome patients to support physicians' choices in a case-by-case patient-tailored approach.

Impact of right ventricular failure on the outcomes of acute inferior wall myocardial infarction

Aim: Right ventricular failure (RVF) complicates 30-50% of cases with inferior wall myocardial infarctions (IWMI). Large-scale studies exploring the recent trends in morbidity and mortality of IWMI with RVF in the context of improved reperfusion strategies are currently lacking. Materials & methods: The International Classification of Diseases, Tenth Revision, Clinical Modification codes were used to query the National Inpatient Sample of 2018-2019 to yield IWMI admissions and stratified based on presence of RVF. The primary outcome was in-hospital mortality. Results: Out of the 182,485 weighed hospital admissions for IWMI, 1005 patients (0.6%) also had RVF. Patients with both IWMI and RVF had significantly higher mortality than patients with IWMI and no RVF (p < 0.001). Conclusion: RVF in patients with IWMI is an independent predictor of poor outcomes.

Impact of Anatomical and Viability-Guided Completeness of Revascularization on Clinical Outcomes in Ischemic Cardiomyopathy

BACKGROUND

Complete revascularization of coronary artery disease has been linked to improved outcomes in patients with preserved left ventricular (LV) function.

OBJECTIVES

This study sought to identify the impact of complete revascularization in patients with severe LV dysfunction.

METHODS

Patients enrolled in the REVIVED-BCIS2 (Revascularization for Ischemic Ventricular Dysfunction) trial were eligible if baseline/procedural angiograms and viability studies were available for analysis by independent core laboratories. Anatomical and viability-guided completeness of revascularization were measured by the coronary and myocardial revascularization indices (RIcoro and RImyo), respectively, where RIcoro = (change in British Cardiovascular Intervention Society Jeopardy score [BCIS-JS]) / (baseline BCIS-JS) and RImyo= (number of revascularized viable segments) / (number of viable segments supplied by diseased vessels). The percutaneous coronary intervention (PCI) group was classified as having complete or incomplete revascularization by median RIcoro and RImyo. The primary outcome was death or hospitalization for heart failure.

RESULTS

Of 700 randomized patients, 670 were included. The baseline BCIS-JS and SYNTAX (Synergy Between PCI With Taxus and Cardiac Surgery) scores were 8 (Q1-Q3: 6-10) and 22 (Q1-Q3: 15-29), respectively. In those patients assigned to PCI, median RIcoro and RImyo values were 67% and 85%, respectively. Compared with the group assigned to optimal medical therapy alone, there was no difference in the likelihood of the primary outcome in those patients receiving complete anatomical or viability-guided revascularization (HR: 0.90; 95% CI: 0.62-1.32; and HR: 0.95; 95% CI: 0.66-1.35, respectively). A sensitivity analysis by residual SYNTAX score showed no association with outcome.

CONCLUSIONS

In patients with severe LV dysfunction, neither complete anatomical nor viability-guided revascularization was associated with improved event-free survival compared with incomplete revascularization or treatment with medical therapy alone. (Revascularization for Ischemic Ventricular Dysfunction) [REVIVED-BCIS2]; NCT01920048).

Prognostic role of coronary angiography and revascularization in patients firstly admitted for heart failure in Italy

BACKGROUND

Coronary artery disease (CAD) is a common underlying cause of de novo heart failure (HF) and is associated with poor outcome despite advances in medical therapy. There are no data clearly supporting coronary angiogram (CVG) and revascularization in this setting.

METHODS

We analysed a nationwide, comprehensive, and universal administrative database of consecutive patients for the first time admitted in hospital for HF, without a history of CAD, who survived 30 days after index admission from 2015 to 2019 in Italy. Enrolled patients were classified into subjects who did not undergo CVG; those who underwent CVG without coronary revascularization; those who underwent percutaneous coronary intervention (PCI); and those who underwent coronary artery bypass grafting (CABG).

RESULTS

During the study period, 342,090 patients were hospitalized for the first time due to HF and survived 30 days after admission, in Italy. Among them, 30,806 (9.0%) patients underwent CVG without undergoing coronary revascularization, 5855 (1.7%) underwent PCI and 1594 (0.5%) underwent CABG. After adjusting for age, gender and comorbidity, the hazard ratio (HR) for 1-year all-cause mortality in patients undergoing CVG vs no CVG were 0.56 (p < 0.0001), 0.66 (p < 0.0001) and 0.83 (p = 0.020) for CVG, PCI and CABG patients, respectively. When considering the re-hospitalization for HF as the outcome, using death as a competing risk, after multiple corrections, CVG (HR = 0.80; p < 0.0001) and CABG (HR = 0.73; p < 0.0002) were protective versus No CVG, but not PCI (HR = 1.02; p = 0.642).

CONCLUSIONS

This study provides evidence that CVG and coronary revascularization may be beneficial for patients with de novo HF.

Coronary Artery Disease Is A Stronger Predictor of All-Cause Mortality Than Left Ventricular Ejection Fraction Among Patients With Newly Diagnosed Heart Failure: Insights From the WDHR

BACKGROUND

In patients with newly diagnosed heart failure (HF) and left ventricular ejection fraction (LVEF) <50%, little is known whether LVEF per se or presence of coronary artery disease (CAD) provides independent prognostic information on all-cause mortality.

METHODS AND RESULTS

Using the WDHR (Western Denmark Heart Registry), we identified 3620 patients with newly diagnosed HF and LVEF 10% to 49% referred for first-time coronary angiography as part of general workup of HF. Patients were stratified by LVEF (10%-35% versus 36%-49%) and presence of CAD. We estimated 10-year all-cause mortality risk and calculated hazard ratios adjusted for relevant comorbidities and risk factors (aHRs). CAD was present in 1592 (44%) patients. Lower LVEF was associated with a relative 15% increased 10-year mortality: 37% for LVEF 36% to 49% versus 42% for LVEF 10% to 35% (aHR, 1.15 [95% CI, 0.99-1.34]). This result did not change when stratified into those with CAD (52% versus 56%; aHR, 1.11 [95% CI, 0.91-1.35]) and those without CAD (27% versus 33%; aHR, 1.24 [95% CI, 0.97-1.57]). In comparison, presence and extent of CAD were associated with a relative 43% increased 10-year mortality (CAD versus no CAD, 55.0% versus 31.5%; aHR, 1.43 [95% CI, 1.25-1.64]). Compared with a matched general population, excess mortality risk was higher for patients with HF and CAD (54.7% versus 26.3%; aHR, 2.10 [95% CI, 1.85-2.39]) versus those with HF and no CAD (31.4% versus 17.2%; aHR, 1.76 [95% CI, 1.52-2.02]).

CONCLUSIONS

Among newly diagnosed patients with HF and LVEF <50%, presence and extent of CAD are associated with substantial higher all-cause mortality risk than lower LVEF.

Intentional coronary revascularization versus conservative therapy in patients after peripheral artery revascularization due to critical limb ischemia: the INCORPORATE trial

OBJECTIVES

INCORPORATE trial was designed to evaluate whether default coronary-angiography (CA) and ischemia-targeted revascularization is superior compared to a conservative approach for patients with treated critical limb ischemia (CLI). Registered at clinicaltrials.gov (NCT03712644) on October 19, 2018.

BACKGROUND

Severe peripheral artery disease is associated with increased cardiovascular risk and poor outcomes.

METHODS

INCORPORATE was an open-label, prospective 1:1 randomized multicentric trial that recruited patients who had undergone successful CLI treatment. Patients were randomized to either a conservative or invasive approach regarding potential coronary artery disease (CAD). The conservative group received optimal medical therapy alone, while the invasive group had routine CA and fractional flow reserve-guided revascularization. The primary endpoint was myocardial infarction (MI) and 12-month mortality.

RESULTS

Due to COVID-19 pandemic burdens, recruitment was halted prematurely. One hundred eighty-five patients were enrolled. Baseline cardiac symptoms were scarce with 92% being asymptomatic. Eighty-nine patients were randomized to the invasive approach of whom 73 underwent CA. Thirty-four percent had functional single-vessel disease, 26% had functional multi-vessel disease, and 90% achieved complete revascularization. Conservative and invasive groups had similar incidences of death and MI at 1 year (11% vs 10%; hazard ratio 1.21 [0.49-2.98]). Major adverse cardiac and cerebrovascular events (MACCE) trended for hazard in the Conservative group (20 vs 10%; hazard ratio 1.94 [0.90-4.19]). In the per-protocol analysis, the primary endpoint remained insignificantly different (11% vs 7%; hazard ratio 2.01 [0.72-5.57]), but the conservative approach had a higher MACCE risk (20% vs 7%; hazard ratio 2.88 [1.24-6.68]).

CONCLUSION

This trial found no significant difference in the primary endpoint but observed a trend of higher MACCE in the conservative arm.

The Current State of Coronary Revascularization: Coronary Artery Bypass Graft Surgery Versus Percutaneous Coronary Interventions

PURPOSE OF REVIEW

The optimal revascularization strategy for coronary artery disease depends on various factors, such as disease complexity, patient characteristics, and preferences. Including a heart team in complex cases is crucial to ensure optimal outcomes. Decision-making between percutaneous coronary intervention and coronary artery bypass grafting must consider each patient's clinical profile and coronary anatomy. While current practice guidelines offer some insight into the optimal revascularization approach for the various phenotypes of coronary artery disease, the evidence to support either strategy continues to evolve and grow. Given the large amount of contemporary data on revascularization, this review aims to comprehensively summarize the literature on coronary artery bypass grafting and percutaneous coronary intervention in patients across the spectrum of coronary artery disease phenotypes.

RECENT FINDINGS

Contemporary evidence suggests that for patients with triple vessel disease, coronary artery bypass grafting is preferred over percutaneous coronary intervention due to better long-term outcomes, including lower rates of death, myocardial infarction, and target vessel revascularization. Similarly, for patients with left main coronary artery disease, both percutaneous coronary intervention and coronary artery bypass grafting can be considered, as they have shown similar efficacy in terms of major adverse cardiac events, but there may be a slightly higher risk of death with percutaneous coronary intervention. For proximal left anterior descending artery disease, both percutaneous coronary intervention and coronary artery bypass grafting are viable options, but coronary artery bypass grafting has shown lower rates of repeat revascularization and better relief from angina. The Synergy Between PCI with Taxus and Cardiac Surgery score can help in decision-making by predicting the risk of adverse events and guiding the choice between percutaneous coronary intervention and coronary artery bypass grafting. European and American guidelines both agree with including a heart team that can develop and lay out individualized, optimal treatment options with respect for patient preferences. The debate between coronary artery bypass grafting versus percutaneous coronary intervention in multiple different scenarios will continue to develop as technology and techniques improve for both procedures. Risk factors, pre, peri, and post-procedural complications involved in both revascularization strategies will continue to be mitigated to optimize outcomes for those patients for which coronary artery bypass grafting or percutaneous coronary intervention provide ultimate benefit. Methods to avoid unnecessary revascularization continue to develop as well as percutaneous technology that may allow patients to avoid surgical intervention when possible. With such changes, revascularization guidelines for specific patient populations may change in the coming years, which can serve as a limitation of this time-dated review.

Change in left ventricular function and outcomes following high-risk percutaneous coronary intervention with Impella-guided hemodynamic support

Introduction

High-risk percutaneous coronary interventions (HRPCI) are a potential treatment option for patients with reduced left ventricular ejection fraction (LVEF) and coronary artery disease. The extent to which such intervention is coupled with improvement in LVEF and associated with favorable outcomes is unknown.

Methods

We aimed to characterize the incidence and correlates of LVEF improvement after Impella-guided HRPCI, and compare clinical outcomes in patients with versus without LVEF improvement. Data on consecutive patients undergoing Impella-guided HRPCI from a single center registry were analyzed. LVEF-improvement was defined as an absolute increase of LVEF of ≥10% measured at ≥30-days after intervention. The primary outcome was a composite of all-cause death, myocardial infarction or target vessel revascularization within 1-year.

Results

Out of 161 consecutive patients undergoing Impella-guided HRPCI from June 2008 to December 2017, 43% (n = 70) demonstrated LVEF-improvement (baseline LVEF of 25.09 ± 6.19 to 33.30 ± 11.98 post intervention). Patients without LVEF-improvement had higher frequency of previous MI (61.5% vs. 37.1%, p = 0.0021), Q-waves on ECG (17.6% vs. 5.7%, p = 0.024) and higher SYNTAX scores (30.8 ± 17.6 vs. 25.2 ± 12.2; p = 0.043). After correction of these confounders by multivariable analysis, no significant differences were found regarding the composite endpoint in patients with versus without LVEF-improvement (34.9% vs. 38.3%; p = 0.48).

Discussion

In this single-center retrospective analysis, we report the following findings. First, LVEF improvement of at least 10% was documented in over 40% of patients undergoing Impella supported high-risk PCI. Second, a history of MI, Q-waves on admission ECG, and higher baseline SYNTAX scores were independent correlates of no LVEF improvement. Third, one year rates of adverse CV events were substantial and did not vary by the presence or absence of LVEF improvement Prospective studies with longer follow-up are needed to elucidate the impact of LVEF improvement on clinical outcomes.

After RIPCORD 2, FAME 3, FLOWER-MI and FUTURE: Has the Pressure Wire had its Day?

Recent years have seen the publication of several high-profile, negative trials about pressure wires. This has coincided with a consistent increase in the ratio of angioplasty for acute coronary syndromes versus percutaneous coronary intervention in stable coronary artery disease, a greater use of intracoronary imaging during percutaneous coronary intervention and the continued evolution of computational fluid dynamics-derived estimations of fractional flow reserve from both CT and invasive coronary angiography. Consequently, many interventional cardiologists now wonder if the pressure wire will soon become obsolete. This head-to-head article provides a critical appraisal of recent trial data, discusses a potential evolution in how pressure wires are used and debates the motion that the device (and by extension, invasive assessment of coronary physiology) has now had its day.

Clinical impact of multimodality assessment of myocardial viability

Coronary artery disease (CAD) is a prevalent cause of left ventricular dysfunction. Nevertheless, effective elective revascularization, particularly surgical revascularization, can enhance long-term outcomes and, in selected cases, global left ventricular contractility. The assessment of myocardial viability and scars is still relevant in guiding treatment decisions and selecting patients who are likely to benefit most from blood flow restoration. Although the most recent randomized studies challenge the notion of "hibernating myocardium" and the clinical usefulness of assessing myocardial viability, the advancement of imaging techniques still renders this assessment valuable in specific situations. According to the guidelines of the European Society of Cardiology, non-invasive stress imaging may be employed to define myocardial ischemia and viability in patients with CAD and heart failure before revascularization. Currently, several non-invasive imaging techniques are available to evaluate the presence and extent of viable myocardium. The selection of the most suitable technique should be based on the patient, clinical context, and resource availability. This narrative review evaluates the characteristics of available imaging modalities for assessing myocardial viability to determine the most appropriate therapeutic strategy.

Myocardial work in patients with heart failure and ischemic cardiomyopathy according to the mode of coronary revascularization

BACKGROUND

The association of percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) on myocardial function, as reflected in myocardial work (MyW) parameters, in patients with ischemic cardiomyopathy and heart failure (HF) is unknown.

METHODS

We analyzed data from 68 patients who were hospitalized with chronic HF due to ischemic cardiomyopathy and stratified them according to the mode of revascularization. All patients underwent a 2D speckle tracking echocardiography exam performed by the same expert sonographer and had complete MyW data including global work index (GWI), global constructive work (GCW), global wasted work (GWW), and global work efficiency (GWE).

RESULTS

The mean age of patients was 70 ± 10 years and 86.8% were men. The mean left ventricular ejection fraction (LVEF) in overall cohort was 31.6 ± 9.5%. Both subgroups did not significantly differ in terms of baseline LVEF, comorbidities, and pharmacotherapy. Compared with those who received PCI, patients revascularized with CABG had significantly greater GWI (821 vs. 555 mmHg%, p = 0.002), GCW (1101 vs. 794 mmHg%, p = 0.001), GWE (78 vs. 72.6%, p = 0.025), and global longitudinal strain (-8.7 vs. -6.7%, p = 0.004). Both patient subgroups did not significantly differ with respect to GWW (273 vs. 245 mmHg%, p = 0.410 for CABG and PCI, respectively) and survival during the median follow-up of 18 months (log-rank p = 0.813).

CONCLUSION

Patients with HF and ischemic cardiomyopathy revascularized with CABG had greater myocardial work performance when compared with those revascularized with PCI. This might suggest a higher degree of functional myocardial revascularization associated with the CABG procedure.

Assessment of Myocardial Viability in Ischemic Cardiomyopathy With Reduced Left Ventricular Function Undergoing Coronary Artery Bypass Grafting

BACKGROUND

We aim to provide a comprehensive review of the current state of knowledge of myocardial viability assessment in patients undergoing coronary artery bypass grafting (CABG), with a focus on the clinical markers of viability for each imaging modality. We also compare mortality between patients with viable myocardium and those without viability who undergo CABG.

METHODS

A systematic database search with meta-analysis was conducted of comparative original articles (both observations and randomized controlled studies) of patients undergoing CABG with either viable or nonviable myocardium, in EMBASE, MEDLINE, Cochrane database, and Google Scholar, from inception to 2022. Imaging modalities included were dobutamine stress echocardiography (DSE), cardiac magnetic resonance (CMR), single-photon emission computed tomography (SPECT), and positron emission tomography (PET).

RESULTS

A total of 17 studies incorporating a total of 2317 patients were included. Across all imaging modalities, the relative risk of death post-CABG was reduced in patients with versus without viability (random-effects model: odds ratio: 0.42; 95% confidence interval: 0.29-0.61; p < 0.001). Imaging for myocardial viability has significant clinical implications as it can affect the accuracy of the diagnosis, guide treatment decisions, and predict patient outcomes. Generally, based on local availability and expertise, either SPECT or DSE should be considered as the first step in evaluating viability, while PET or CMR would provide further evaluation of transmurality, perfusion metabolism, and extent of scar tissue.

CONCLUSION

The assessment of myocardial viability is an essential component of preoperative evaluation in patients with ischemic heart disease undergoing surgical revascularization. Careful patient selection and individualized assessment of viability remain paramount.

Clinical impact of coronary revascularization over medical treatment in chronic coronary syndromes: A systematic review and meta-analysis

OBJECTIVE

To provide a quantitative comparison between myocardial revascularization (REVASC) and optimal medical treatment (OMT) alone in patients with chronic coronary syndrome (CCS).

METHODS

Pertinent studies were searched for in PubMed/Medline until 12/03/2023. Randomized controlled trials that compare REVASC to OMT reporting clinical outcomes were selected according to PRISMA guidelines. The primary outcome was cardiovascular death. Two investigators independently assessed the study quality and extracted data.

RESULTS

Twenty-eight randomized controlled studies (RCTs) including 20692 patients were included in this meta-analysis. The rate of cardiovascular mortality was significantly lower among patients treated with myocardial revascularization [risk ratio (RR) 0.79, 95% CI 0.69-0.90]. Age (p = 0.03), multivessel disease (p < 0.001), and follow-up duration (p = 0.001) were significant moderators of CV mortality. Subgroup analyses showed a larger benefit in patients treated with drug-eluting stents and those without chronic total occlusion. Among secondary outcomes, myocardial infarction was less frequent in the REVASC group (RR = 0.74; p < 0.001), while no significant difference was found for all-cause mortality (p = 0.09) nor stroke (p = 0.26).

CONCLUSIONS

The present analysis showed lower rates of CV mortality and myocardial infarction in CCS patients treated with myocardial revascularization compared to OMT. This benefit was larger with increasing follow-up duration. Personalized treatment based on patient characteristics and lesion complexity may optimize clinical outcomes in patients with CCS.

Mechanisms of myocardial reverse remodelling and its clinical significance: A scientific statement of the ESC Working Group on Myocardial Function

Cardiovascular disease (CVD) is the leading cause of morbimortality in Europe and worldwide. CVD imposes a heterogeneous spectrum of cardiac remodelling, depending on the insult nature, that is, pressure or volume overload, ischaemia, arrhythmias, infection, pathogenic gene variant, or cardiotoxicity. Moreover, the progression of CVD-induced remodelling is influenced by sex, age, genetic background and comorbidities, impacting patients' outcomes and prognosis. Cardiac reverse remodelling (RR) is defined as any normative improvement in cardiac geometry and function, driven by therapeutic interventions and rarely occurring spontaneously. While RR is the outcome desired for most CVD treatments, they often only slow/halt its progression or modify risk factors, calling for novel and more timely RR approaches. Interventions triggering RR depend on the myocardial insult and include drugs (renin-angiotensin-aldosterone system inhibitors, beta-blockers, diuretics and sodium-glucose cotransporter 2 inhibitors), devices (cardiac resynchronization therapy, ventricular assist devices), surgeries (valve replacement, coronary artery bypass graft), or physiological responses (deconditioning, postpartum). Subsequently, cardiac RR is inferred from the degree of normalization of left ventricular mass, ejection fraction and end-diastolic/end-systolic volumes, whose extent often correlates with patients' prognosis. However, strategies aimed at achieving sustained cardiac improvement, predictive models assessing the extent of RR, or even clinical endpoints that allow for distinguishing complete from incomplete RR or adverse remodelling objectively, remain limited and controversial. This scientific statement aims to define RR, clarify its underlying (patho)physiologic mechanisms and address (non)pharmacological options and promising strategies to promote RR, focusing on the left heart. We highlight the predictors of the extent of RR and review the prognostic significance/impact of incomplete RR/adverse remodelling. Lastly, we present an overview of RR animal models and potential future strategies under pre-clinical evaluation.

High-resolution free-breathing automated quantitative myocardial perfusion by cardiovascular magnetic resonance for the detection of functionally significant coronary artery disease

AIMS

Current assessment of myocardial ischaemia from stress perfusion cardiovascular magnetic resonance (SP-CMR) largely relies on visual interpretation. This study investigated the use of high-resolution free-breathing SP-CMR with automated quantitative mapping in the diagnosis of coronary artery disease (CAD). Diagnostic performance was evaluated against invasive coronary angiography (ICA) with fractional flow reserve (FFR) measurement.

METHODS AND RESULTS

Seven hundred and three patients were recruited for SP-CMR using the research sequence at 3 Tesla. Of those receiving ICA within 6 months, 80 patients had either FFR measurement or identification of a chronic total occlusion (CTO) with inducible perfusion defects seen on SP-CMR. Myocardial blood flow (MBF) maps were automatically generated in-line on the scanner following image acquisition at hyperaemic stress and rest, allowing myocardial perfusion reserve (MPR) calculation. Seventy-five coronary vessels assessed by FFR and 28 vessels with CTO were evaluated at both segmental and coronary territory level. Coronary territory stress MBF and MPR were reduced in FFR-positive (≤0.80) regions [median stress MBF: 1.74 (0.90-2.17) mL/min/g; MPR: 1.67 (1.10-1.89)] compared with FFR-negative regions [stress MBF: 2.50 (2.15-2.95) mL/min/g; MPR 2.35 (2.06-2.54) P < 0.001 for both]. Stress MBF ≤ 1.94 mL/min/g and MPR ≤ 1.97 accurately detected FFR-positive CAD on a per-vessel basis (area under the curve: 0.85 and 0.96, respectively; P < 0.001 for both).

CONCLUSION

A novel scanner-integrated high-resolution free-breathing SP-CMR sequence with automated in-line perfusion mapping is presented which accurately detects functionally significant CAD.

Guiding early revascularization using [15O]H2O positron emission tomography myocardial perfusion imaging: impact of atrial fibrillation

AIMS

Myocardial perfusion imaging (MPI) using [15O]H2O positron emission tomography (PET) is used to guide the selection of patients with angina for invasive angiography and possible revascularization. Our study evaluated (i) whether atrial fibrillation (AF) reduces global hyperaemic myocardial blood flow (MBF) and (ii) whether [15O]H2O PET MPI effectively guides revascularization procedures for patients with ongoing AF.

METHODS AND RESULTS

We prospectively recruited 346 patients with angina and persistent or paroxysmal AF referred for baseline/hyperaemic [15O]H2O PET MPI. The primary outcome was revascularization within 3 months of MPI. In the analyses, patients were divided into four groups based on whether they had ongoing AF or sinus rhythm (SR) and whether they had previously documented coronary artery disease (CAD) or not. Thus, four groups were compared: SR-noCAD, AF-noCAD, SR-CAD, and AF-CAD. Hyperaemic MBF was affected by both ongoing AF and prior CAD [MBF (mL/min/g): 2.82 (SR-noCAD) vs. 2.12 (AF-noCAD) vs. 2.22 (SR-CAD) vs. 1.80 (AF-CAD), two-way analysis of variance P < 0.0001]. In multiple linear regression, ongoing AF was independently associated with reduced hyperaemic MBF. Every 0.1 mL/min/g decrease in hyperaemic MBF was associated with a 23% increase in odds of early revascularization. Receiver operating characteristic (ROC) analysis of vessel-specific hyperaemic MBF to predict early revascularization yielded the following areas under the ROC curve: SR-noCAD: 0.95 (P < 0.0001); AF-noCAD: 0.79 (P < 0.0001); SR-CAD: 0.78 (P < 0.0001); and AF-CAD: 0.88 (P < 0.0001).

CONCLUSION

Ongoing AF is associated with 19-25% reduced global hyperaemic MBF as measured by [15O]H2O MPI PET. Regardless, vessel-specific hyperaemic MBF still predicts early revascularization in patients with AF.

82-rubidium positron emission tomography determined myocardial flow reserve and outcomes following cardiac revascularisation - A multicentre registry study

BACKGROUND

Finding patients with chronic coronary syndromes (CCS) whom revascularization could benefit, is complicated. Myocardial flow reserve (MFR), a measurement of myocardial perfusion, has proven prognostic value on survival and risk of major adverse cardiac events (MACE). We investigated if MFR identifies who may benefit from revascularization.

METHODS

Among 7462 patients from Danish hospitals examined with 82Rb PET between January 2018 and August 2020, patients with ≥5% reversible perfusion defects were followed for MACE and all-cause mortality. Associations between revascularisation (within 90 days) and outcomes according to MFR (< and ≥ 2) was assessed by Cox regression adjusted by inverse probability weighting for demographics, cardiovascular risk factors, comorbidities, and 82Rb PET variables.

RESULTS

Of 1806 patients with ≥5% reversible perfusion defect, 893 (49%) had MFR < 2 and 491 underwent revascularisation (36.6% in MFR < 2 versus 17.9% MFR ≥ 2, p < 0.001). During a median follow-up of 37.0 [31.0-45.8 IQR] months, 251 experienced a MACE and 173 died. Revascularisation was associated with lower adjusted risk of all-cause mortality (hazard ratio [HR], 0.51 [95% CI, 0.30-0.88], p = 0.015) and MACE (HR, 0.54 [0.33-0.87], p = 0.012) in patients with MFR < 2 but not MFR ≥ 2 for all-cause mortality (HR 1.33 [0.52-3.40], p = 0.542) and MACE (HR 1.50 [0.79-2.84], p = 0.211). MFR significantly modified the association between revascularisation and MACE, but not all-cause mortality (interaction p-value 0.021 and 0.094, respectively).

CONCLUSIONS

Revascularization was associated with improved prognosis among patients with impaired MFR. No association was seen in patients with normal MFR. In patients with regional ischemia, MFR may identify patients with a prognostic benefit from revascularization.

Machine learning predictions of the adverse events of different treatments in patients with ischemic left ventricular systolic dysfunction

This study aimed to develop several new machine learning models based on hibernating myocardium to predict the major adverse cardiac events(MACE) of ischemic left ventricular systolic dysfunction(LVSD) patients receiving either percutaneous coronary intervention(PCI) or optimal medical therapy(OMT). This study included 329 LVSD patients, who were randomly assigned to the training or validation cohort. Least absolute shrinkage and selection operator(LASSO) regression was used to identify variables associated with MACE. Subsequently, various machine learning models were established. Model performance was compared using receiver operating characteristic(ROC) curves, the Brier score(BS), and the concordance index(C-index). A total of 329 LVSD patients were retrospectively enrolled between January 2016 and December 2021. Utilizing LASSO regression analysis, five factors were selected. Based on these factors, RSF, GBM, XGBoost, Cox, and DeepSurv models were constructed. In the development and validation cohorts, the C-indices were 0.888 vs. 0.955 (RSF). The RSF model (0.991 vs. 0.982 vs. 0.980) had the highest area under the ROC curve (AUC) compared with the other models. The BS (0.077 vs. 0.095vs. 0.077) of RSF model were less than 0.25 at 12, 18, and 24 months. This study developed a novel predictive model based on RSF to predict MACE in LVSD patients who underwent either PCI or OMT.

Percutaneous Coronary Intervention Versus Optimal Medical Therapy for Severe Ischemic Left Ventricular Systolic Dysfunction

Coronary artery disease is the most common cause of heart failure, which is the leading cause of cardiovascular-related death worldwide. There are insufficient data to make strong recommendations for percutaneous coronary intervention (PCI) in patients with severe ischemic left ventricular systolic dysfunction (LVSD). In that context, we performed a meta-analysis to compare the outcomes of PCI with those of optimal medical therapy alone in patients with severe ischemic LVSD. A systematic search was conducted in PubMed, EMBASE, and ClinicalTrials.gov from inception to December 2023. Our outcome of interest was all-cause mortality in patients undergoing PCI vs medical therapy. We used random effects models to aggregate data and to calculate pooled incidence and relative risk with 95% CIs. Four studies including 2 randomized controlled trials with 2080 patients (PCI, 1082; optimal medical therapy, 998) were included. All-cause mortality did not differ significantly between the groups: 168 patients (15.5%) in the PCI group vs 200 patients (20.0%) in the optimal medical therapy group (relative risk, 0.88; 95% CI, 0.75-1.09; P=.25). In conclusion, the available evidence indicates that PCI does not improve all-cause mortality in patients with severe LVSD without lifestyle-limiting anginal symptoms. Further data are needed to identify subgroups of patients better served by each modality.

PCI versus CABG in coronary artery disease

The evidence basis for percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in coronary artery disease (CAD) has become more firmly established over the last decade in view of new evidence from several large, randomized trials and propensity-matched registries. In comparison to PCI, CABG offers substantial survival benefits and significant reductions in myocardial infarction and need for repeat revascularization in multivessel disease in patients with intermediate and high severity disease, whereas for left main disease these benefits are largely observed in patients with the highest-severity disease. In general, the benefits of CABG are further enhanced in patients with diabetes and/or impaired ventricular function. In stable or urgent clinical situations most decisions for intervention should be agreed by a multidisciplinary group ('Heart Team'), incorporating the severity of CAD and the patient's overall clinical suitability and personal wishes for any proposed procedure.

Managing chronic coronary syndrome: how do we achieve optimal patient outcomes?

INTRODUCTION

Chronic coronary syndrome (CCS) remains the leading cause of death worldwide with high admission/re-admission rates. Medical databases were searched on CCS & its management.

AREAS COVERED

This review discusses phenotypes per stress-echocardiography, noninvasive/invasive testing (coronary computed-tomography angiography-CCTA; coronary artery calcium - CAC score; echocardiography assessing wall-motion, LV function, valvular disease; biomarkers), multidisciplinary management (risk factors/anti-inflammatory/anti-ischemic/antithrombotic therapies and revascularization), newer treatments (colchicine/ivabradine/ranolazine/melatonin), cardiac rehabilitation/exercise improving physical activity and quality-of-life, use of the implantable-defibrillator, and treatment with extracorporeal shockwave-revascularization for refractory symptoms.

EXPERT OPINION

CCS is age-dependent, leading cause of death worldwide with high hospitalization rates. Stress-echocardiography defines phenotypes and guides prophylaxis and management. CAC is a surrogate for atherosclerosis burden, best for patients of intermediate/borderline risk. Higher CAC-scores indicate more severe coronary abnormalities. CCTA is preferred for noninvasive detection of CAC and atherosclerosis burden, determining stenosis' functional significance, and guiding management. Combining CAC score with CCTA improves diagnostic yield and assists prognosis. Echocardiography assesses LV wall-motion and function and valvular disease. Biomarkers guide diagnosis/prognosis. CCS management is multidisciplinary: risk-factor management, anti-inflammatory/anti-ischemic/antithrombotic therapies, and revascularization. Newer therapies comprise colchicine, ivabradine, ranolazine, melatonin, glucagon-like peptide-1-receptor antagonists. Cardiac rehabilitation/exercise improves physical activity and quality-of-life. An ICD protects from sudden death. Extracorporeal shockwave-revascularization treats refractory symptoms.

Acute Coronary Syndrome Revascularization Strategies With Multivessel Coronary Artery Disease

In acute coronary syndromes (ACS), revascularization is the standard of care. However, trials comparing contemporary coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) are limited. Optimal revascularization in patients with multivessel coronary artery disease (MV-CAD) presenting with ACS is unclear. This is a multicentered, retrospective observational study from a large hospital system in the United States. We abstracted data in patients with MV-CAD and ACS from 2018 to 2022 who underwent revascularization with PCI, CABG, or medical management (MM). We evaluated multivariate statistics comparing categorical variables and outcomes, including all-cause mortality and myocardial infarction (MI) at 1 year. All logistic and Cox proportional-hazard models were balanced using inverse probability treatment weights accounting for age and gender. There were 295 patients with CABG (median age 66 years [interquartile range 59.7 to 73.1]; 73% male), 1,559 patients with PCI (median age 68.3 years [interquartile range 60 to 76.6]; 69.1% male], and 307 patients with MM (median age 70 years [60.9 to 77.1] 74% male]. Patients revascularized with PCI had greater all-cause mortality at 1 year (14.1% vs 5.1%; hazard ratio 2.4, confidence interval [1.5 to 3.8], p <0.001) and similar mortality to MM (13.4%). CABG also showed a reduced 1-year MI rate compared with PCI (1.7% vs 3.9%; hazard ratio 0.36, confidence interval 0.21 to 0.61, p ≤0.001), with a similar 1-year rate of MI to MM (3.9%). In conclusion, CABG is associated with lower mortality than are PCI and MM, and repeat ACS events at 1 year in patients with ACS and MV-CAD.

Association Between Coronary Assessment in Heart Failure and Clinical Outcomes Within a Safety-Net Setting Using a Target Trial Emulation Observational Design

BACKGROUND

Ischemic cardiomyopathy is the leading cause of heart failure (HF). Most patients do not undergo coronary assessment after HF diagnosis. There are no randomized clinical trials of coronary assessment after HF diagnosis.

METHODS

Using an electronic health record cohort of all individuals with HF within the San Francisco Health Network from 2001 to 2019, we identified factors associated with coronary assessment. Then, we studied the association of coronary assessment within 30 days of HF diagnosis with all-cause mortality and a composite of mortality and emergent angiography using a target trial emulation observational comparative-effectiveness approach. Target trial emulation is an approach to causal inference based on creating a hypothetical randomized clinical trial protocol and using observational data to emulate the protocol. We used propensity scores for covariate adjustment. We used national death records to improve the ascertainment of mortality and included falsification end points for the cause of death.

RESULTS

Among 14 829 individuals with HF (median, 62 years old; 5855 [40%] women), 3987 (26.9%) ever completed coronary assessment, with 2467/13 301 (18.5%) with unknown coronary artery disease status at HF diagnosis assessed. Women, older individuals, and people without stable housing were less likely to complete coronary assessment. Among 5972 eligible persons of whom 627 underwent early elective coronary assessment, coronary assessment was associated with lower mortality (hazard ratio, 0.84 [95% CI, 0.72-0.97]; P=0.025), reduced risk of the composite outcome (hazard ratio, 0.86 [95% CI, 0.73-1.00]), higher rates of revascularization (odds ratio, 7.6 [95% CI, 5.4-10.6]), and higher use of medical therapy (odds ratio, 2.5 [95% CI, 1.7-3.6]), but not the falsification end points.

CONCLUSIONS

In a safety-net population, disparities in coronary assessment after HF diagnosis are not fully explained by coronary artery disease risk factors. Early coronary assessment is associated with improved HF outcomes possibly related to higher rates of revascularization and guideline-directed medical therapy but with low certainty that this finding is not attributable to unmeasured confounding.

Imaging of Cardiac Fibrosis: An Update, From the AJR Special Series on Imaging of Fibrosis

Myocardial fibrosis (MF) is defined as excessive production and deposition of extra-cellular matrix proteins that result in pathologic myocardial remodeling. Three types of MF have been identified: replacement fibrosis from tissue necrosis, reactive fibrosis from myocardial stress, and infiltrative interstitial fibrosis from progressive deposition of nondegradable material such as amyloid. Although echocardiography, nuclear medicine, and CT play important roles in the assessment of MF, MRI is pivotal in the evaluation of MF, with the late gadolinium enhancement (LGE) technique used as a primary end point. The LGE technique focuses on the pattern and distribution of gadolinium accumulation in the myocardium and assists in the diagnosis and establishment of the cause of both ischemic and nonischemic cardiomyopathy. LGE MRI also aids prognostication and risk stratification. In addition, LGE MRI is used to guide the management of patients considered for ablation for arrhythmias. Parametric mapping techniques, including T1 mapping and extracellular volume measurement, allow detection and quantification of diffuse fibrosis, which may not be detected by LGE MRI. These techniques also allow monitoring of disease progression and therapy response. This review provides an update on the imaging of MF, including prognostication and risk stratification tools, electrophysiologic considerations, and disease monitoring.

Revascularisation in Left Ventricular Systolic Dysfunction: A Meta-analysis of Kaplan-Meier Reconstructed Individual Patient Data

BACKGROUND

Coronary artery disease is a common cause of ischemic left ventricular systolic dysfunction (LVSD), for which the optimal revascularisation strategy remains unclear. We aimed to determine whether percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) results in greater survival advantage in patients with LVSD.

METHODS

Study-level (SLMA) and reconstructed individual patient data (rIPDMA) meta-analyses from Kaplan-Meier (KM) survival curves were performed. A systematic search of Medline, Embase, and Cochrane Library was conducted for observational and randomised studies published after 2010 that compared PCI and CABG in patients with left ventricular ejection fraction ≤ 40%. The primary outcome was all-cause mortality at longest follow-up. The secondary outcomes were myocardial infarction (MI), stroke, repeated revascularisation, cardiovascular mortality, and major adverse cardiovascular and cerebrovascular events (MACCE) at longest follow-up.

RESULTS

Fourteen studies (11 observational, 3 randomised, 13,063 patients) were eligible for the SLMA. Seven contained digitisable KM curves from which individual patient data could be reconstructed. Study-level analysis found PCI to be associated with increased all-cause mortality (hazard ratio [HR] 1.41, 95% confidence interval [CI] 1.18-1.69), MI (HR 2.10, 95% CI 1.62-2.72), repeated revascularisation (HR 2.39, 95% CI 1.37-4.17), and MACCE (HR 1.58, 95% CI 1.23-2.03), without significant differences in stroke (HR 0.86, 95% CI 0.39-1.92) or cardiovascular mortality (HR 1.42, 95% CI 0.78-2.59). In the rIPDMA, PCI resulted in increased all-cause mortality (HR 1.57, 95% CI 1.34-1.87) and repeated revascularisation (HR 3.63, 95% CI 3.12-4.21) but overall lower risk of stroke (HR 0.62, 95% CI 0.39-0.99) owing to fewer events during initial follow-up.

CONCLUSIONS

In patients with ischemic LVSD, PCI was associated with higher risk of all-cause mortality and repeated revascularisation than CABG, but lower risk of short-term stroke. (PROSPERO: CRD42021291408).

2024 update in heart failure

In the last years, major progress has occurred in heart failure (HF) management. The 2023 ESC focused update of the 2021 HF guidelines introduced new key recommendations based on the results of the last years of science. First, two drugs, sodium-glucose co-transporter-2 (SGLT2) inhibitors and finerenone, a novel nonsteroidal, selective mineralocorticoid receptor antagonist (MRA), are recommended for the prevention of HF in patients with diabetic chronic kidney disease (CKD). Second, SGLT2 inhibitors are now recommended for the treatment of HF across the entire left ventricular ejection fraction spectrum. The benefits of quadruple therapy in patients with HF with reduced ejection fraction (HFrEF) are well established. Its rapid and early up-titration along with a close follow-up with frequent clinical and laboratory re-assessment after an episode of acute HF (the so-called 'high-intensity care' strategy) was associated with better outcomes in the STRONG-HF trial. Patients experiencing an episode of worsening HF might require a fifth drug, vericiguat. In the STEP-HFpEF-DM and STEP-HFpEF trials, semaglutide 2.4 mg once weekly administered for 1 year decreased body weight and significantly improved quality of life and the 6 min walk distance in obese patients with HF with preserved ejection fraction (HFpEF) with or without a history of diabetes. Further data on safety and efficacy, including also hard endpoints, are needed to support the addition of acetazolamide or hydrochlorothiazide to a standard diuretic regimen in patients hospitalized due to acute HF. In the meantime, PUSH-AHF supported the use of natriuresis-guided diuretic therapy. Further options and most recent evidence for the treatment of HF, including specific drugs for cardiomyopathies (i.e., mavacamten in hypertrophic cardiomyopathy and tafamidis in transthyretin cardiac amyloidosis), device therapies, cardiac contractility modulation and percutaneous treatment of valvulopathies, with the recent finding from the TRILUMINATE Pivotal trial, are also reviewed in this article.

Postmyocardial Infarction Ventricular Aneurysm: JACC Focus Seminar 5/5

Ventricular aneurysm represents a rare complication of transmural acute myocardial infarction, although other cardiac, congenital, or metabolic diseases may also predispose to such condition. Ventricular expansion includes all the cardiac layers, usually with a large segment involved. Adverse events include recurrent angina, reduced ventricular stroke volume with congestive heart failure, mitral regurgitation, thromboembolism, and ventricular arrhythmias. Multimodality imaging is paramount to provide comprehensive assessment, allowing for appropriate therapeutic decision-making. When indicated, surgical intervention remains the gold standard, although additional therapy (heart failure, anticoagulation, and advanced antiarrhythmic treatment) might be required. However, the STICH (Surgical Treatment for Ischemic Heart Failure) trial did not show any advantage from adding surgical ventricular reconstruction to coronary artery bypass surgery in terms of survival, rehospitalization or symptoms, compared with revascularization alone. Finally, implantable cardiac defibrillator may reduce the risk of fatal arrhythmias.

A Narrative Review of Revascularization in Chronic Coronary Syndrome/Disease: Concepts and Misconceptions

Ischemic heart disease represents a significant global burden of morbidity and mortality. While revascularization strategies are well defined in acute settings, there are uncertainties regarding chronic coronary artery disease treatment. Recent trials have raised doubts about the necessity of revascularization for "stable", chronic coronary syndromes or disease, leading to a shift towards a more conservative approach. However, the issue remains far from settled. In this narrative review, we offer a summary of the most pertinent evidence regarding revascularization for chronic coronary disease, while reflecting on less-often-discussed details of major clinical trials. The cumulative evidence available indicates that there can be a prognostic benefit from revascularization in chronic coronary syndrome patients, provided there is significant ischemia, as demonstrated by either imaging or coronary physiology. Trials that have effectively met this criterion consistently demonstrate a reduction in rates of spontaneous myocardial infarction, which holds both prognostic and clinical significance. The prognostic benefit of revascularization in patients with heart failure with reduced ejection fraction remains especially problematic, with a single contemporary trial favouring surgical revascularization. The very recent publication of a trial focused on revascularizing non-flow-limiting "vulnerable" plaques adds further complexity to the field. The ongoing debates surrounding revascularization in chronic coronary syndromes emphasize the importance of personalized strategies. Revascularization, added to the foundational pillar of medical therapy, should be considered, taking into account symptoms, patient preferences, coronary anatomy and physiology, ischemia tests and intra-coronary imaging.

Impact of preventive substrate catheter ablation on implantable cardioverter-defibrillator interventions in patients with ischaemic cardiomyopathy and infarct-related coronary chronic total occlusion

AIMS

Primary prevention patients with ischaemic cardiomyopathy and chronic total occlusion of an infarct-related coronary artery (CTO) are at a particularly high risk of implantable cardioverter-defibrillator (ICD) therapy occurrence. The trial was designed to evaluate the efficacy of preventive CTO-related substrate ablation strategy in ischaemic cardiomyopathy patients undergoing primary prevention ICD implantation.

METHODS AND RESULTS

The PREVENTIVE VT study was a prospective, multicentre, randomized trial including ischaemic patients with ejection fraction ≤40%, no documented ventricular arrhythmias (VAs), and evidence of scar related to the coronary CTO. Patients were randomly assigned 1:1 to a preventive substrate ablation before ICD implantation or standard therapy with ICD implantation only. The primary outcome was a composite of appropriate ICD therapy or unplanned hospitalization for VAs. Secondary outcomes included the primary outcome's components, the incidence of appropriate ICD therapies, cardiac hospitalization, electrical storm, and cardiovascular (CV) mortality. Sixty patients were included in the study. During the mean follow-up of 44.7 ± 20.7 months, the primary outcome occurred in 5 (16.7%) patients undergoing preventive substrate ablation and in 13 (43.3%) patients receiving only ICD [hazard ratio (HR): 0.33; 95% confidence interval (CI): 0.12-0.94; P = 0.037]. Patients in the preventive ablation group also had fewer appropriate ICD therapies (P = 0.039) and the electrical storms (Log-rank: P = 0.01). While preventive ablation also reduced cardiac hospitalizations (P = 0.006), it had no significant impact on CV mortality (P = 0.151).

CONCLUSION

Preventive ablation of the coronary CTO-related substrate in patients undergoing primary ICD implantation is associated with the reduced risk of appropriate ICD therapy or unplanned hospitalization due to VAs.

Outcomes of Percutaneous Revascularization in Severe Ischemic Left Ventricular Dysfunction

PURPOSE OF REVIEW

This article presents a comprehensive review of coronary revascularization versus optimal medical therapy (OMT) in patients with severe ischemic left ventricular dysfunction.

RECENT FINDINGS

The REVIVED-BCIS2 trial randomized 700 patients with extensive coronary artery disease and left ventricular (LV) ejection fraction (LVEF) ≤ 35% and viability in more than four dysfunctional myocardial segments to percutaneous coronary intervention (PCI) plus OMT versus OMT alone. Over a median duration of 41 months, there was no difference in the composite of all-cause mortality, heart failure hospitalization, or improvement in LVEF with PCI plus OMT versus OMT alone at 6 and 12 months, quality of life scores at 24 months, or fatal ventricular arrhythmia. The STICH randomized trial was conducted between 2002 and 2007, involving patients with LV dysfunction and coronary artery disease. The patients were assigned to either CABG plus medical therapy or medical therapy alone. At the 5-year follow-up, the trial showed that CABG plus medical therapy reduced cardiovascular disease-related deaths and hospitalizations but no reduction in all-cause mortality. However, a 10-year follow-up showed a significant decrease in all-cause mortality with CABG. The currently available evidence showed no apparent benefit of PCI in severe ischemic cardiomyopathy as compared to OMT, but that CABG improves outcomes in this patient population. The paucity of data on the advantages of PCI in this patient population underscores the critical need for optimization of medical therapy for better survival and quality of life until further evidence from RCTs is available.

When to Consider Coronary Revascularization for Stable Coronary Artery Disease

Revascularization is an effective adjunct to medical therapy for some patients with chronic coronary disease. Despite numerous randomized trials, there remains significant uncertainty regarding if and how to revascularize many patients. Coronary artery bypass grafting is a class I indication for patients with significant left main stenosis or multivessel disease with ejection fraction ≤ 35%. For other patients, clinicians must carefully consider the potential benefits of symptom improvement and reduction of future myocardial infarction or CV death against the risk and cost of revascularization. Although guidelines provide a framework for these decisions, each individual patient will have distinct coronary anatomy, clinical factors, and preferences.

Medical Decision-Making and Revascularization in Ischemic Cardiomyopathy

Ischemic cardiomyopathy (ICM) is the most common underlying etiology of heart failure in the United States and is a significant contributor to deaths due to cardiovascular disease worldwide. The diagnosis and management of ICM has advanced significantly over the past few decades, and the evidence for medical therapy in ICM is both compelling and robust. This contrasts with evidence for coronary revascularization, which is more controversial and favors surgical approaches. This review will examine landmark clinical trial results in detail as well as provide a comprehensive overview of the current epidemiology, diagnostic approaches, and management strategies of ICM.

Selecting the appropriate patients for coronary artery bypass grafting in ischemic cardiomyopathy-importance of myocardial viability

Patients who undergo coronary artery bypass graft (CABG) surgery in ischemic cardiomyopathy have a survival advantage over medical therapy at 10 years. The survival advantage of CABG over medical therapy is due to its ability to reduce future myocardial infarction, and by conferring electrical stability. The presence of myocardial viability does not provide a differential survival advantage for CABG over medical therapy. Presence of angina and inducible ischemia are also less predictive of outcome. Moreover, CABG is associated with significant early mortality. Hence, careful patient selection is more important for reducing the early mortality and improving the long-term outcome than relying on results of myocardial viability. Younger patients with good exercise tolerance benefit the most, while patients who are frail and patients with renal dysfunction and dysfunctional right ventricle seem to have very high operative mortality. Elderly patients, because of poor life expectancy, do not benefit from CABG, but the age cutoff is not clear. Patients also need to have revascularizable targets, but this decision is often based on experience of the surgical team and heart team discussion. These recommendations are irrespective of the myocardial viability tests. Optimal medical treatment remains the cornerstone for management of ischemic cardiomyopathy.