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Lee Chuy K, Velazquez EJ, Lansky AJ, Jamil Y, Ahmad Y. Current Landscape and Future Directions of Coronary Revascularization in Ischemic Systolic Heart Failure: A Review. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2023; 2:101197. [PMID: 39131064 PMCID: PMC11307589 DOI: 10.1016/j.jscai.2023.101197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 09/25/2023] [Accepted: 09/26/2023] [Indexed: 08/13/2024]
Abstract
Ischemic heart disease is the largest cause of death worldwide and the most common cause of heart failure (HF). The incidence and prevalence of HF are increasing owing to an aging population and improvements in the acute cardiac care of previously fatal conditions such as myocardial infarction. Strategies to improve outcomes in patients with ischemic systolic HF are urgently needed. There is systematic underutilization of testing for coronary artery disease in patients with HF, and revascularization is performed in an even smaller minority despite evidence for reduced mortality with coronary artery bypass grafting (CABG) over medical therapy in the Surgical Treatment for Ischemic Heart Failure Extension Study. Percutaneous coronary intervention (PCI) is a less-invasive approach to coronary revascularization; however, the recent Revascularization for Ischemic Ventricular Dysfunction (REVIVED)-British Cardiovascular Intervention Society (BCIS2) trial failed to demonstrate a benefit of PCI compared with that of medical therapy in patients with ischemic systolic HF. The comparative effectiveness of PCI and CABG for patients with ischemic systolic HF remains unknown, particularly in the era of contemporary medical therapy. In this review, we discuss the benefit of CABG in ischemic systolic HF, its underutilization, and the unmet clinical need. We also review the recent REVIVED-BCIS2 trial comparing PCI to medical therapy, as well as upcoming randomized controlled trials of PCI for ischemic systolic HF and persistent evidence gaps that will exist despite anticipated data from ongoing trials. There remains a need for an adequately powered randomized controlled trials to establish the comparative clinical effectiveness of PCI vs CABG in ischemic systolic HF in the era of contemporary revascularization approaches and medical therapy, as well as trials of coronary revascularization in patients with HF with preserved ejection fraction or less severe forms of left ventricular systolic dysfunction.
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Affiliation(s)
- Katherine Lee Chuy
- Division of Cardiology, Loma Linda University Medical Center, Loma Linda, California
| | - Eric J. Velazquez
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Alexandra J. Lansky
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Yasser Jamil
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Yousif Ahmad
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
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2
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Iaconelli A, Pellicori P, Dolce P, Busti M, Ruggio A, Aspromonte N, D'Amario D, Galli M, Princi G, Caiazzo E, Rezig AOM, Maffia P, Pecorini G, Crea F, Cleland JGF. Coronary revascularization for heart failure with coronary artery disease: A systematic review and meta-analysis of randomized trials. Eur J Heart Fail 2023; 25:1094-1104. [PMID: 37211964 DOI: 10.1002/ejhf.2911] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 05/09/2023] [Accepted: 05/11/2023] [Indexed: 05/23/2023] Open
Abstract
AIMS Coronary artery disease (CAD) is a common cause of heart failure (HF). Whether coronary revascularization improves outcomes in patients with HF receiving guideline-recommended pharmacological therapy (GRPT) remains uncertain; therefore, we conducted a systematic review and meta-analysis of relevant randomized controlled trials (RCTs). METHODS AND RESULTS We searched in public databases for RCTs published between 1 January 2001 and 22 November 2022, investigating the effects of coronary revascularization on morbidity and mortality in patients with chronic HF due to CAD. All-cause mortality was the primary outcome. We included five RCTs that enrolled, altogether, 2842 patients (most aged <65 years; 85% men; 67% with left ventricular ejection fraction ≤35%). Overall, compared to medical therapy alone, coronary revascularization was associated with a lower risk of all-cause mortality (hazard ratio [HR] 0.88, 95% confidence interval [CI] 0.79-0.99; p = 0.0278) and cardiovascular mortality (HR 0.80, 95% CI 0.70-0.93; p = 0.0024) but not the composite of hospitalization for HF or all-cause mortality (HR 0.87, 95% CI 0.74-1.01; p = 0.0728). There were insufficient data to show whether the effects of coronary artery bypass graft surgery or percutaneous coronary intervention were similar or differed. CONCLUSIONS For patients with chronic HF and CAD enrolled in RCTs, the effect of coronary revascularization on all-cause mortality was statistically significant but neither substantial (HR 0.88) nor robust (upper 95% CI close to 1.0). RCTs were not blinded, which may bias reporting of the cause-specific reasons for hospitalization and mortality. Further trials are required to determine which patients with HF and CAD obtain a substantial benefit from coronary revascularization by either coronary artery bypass graft surgery or percutaneous coronary intervention.
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Affiliation(s)
- Antonio Iaconelli
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Pierpaolo Pellicori
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Pasquale Dolce
- Department of Public Health, University of Naples Federico II, Naples, Italy
| | - Matteo Busti
- Department of Cardiovascular Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Aureliano Ruggio
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Nadia Aspromonte
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Domenico D'Amario
- Department of Translational Medicine, University of Eastern Piedmont, Novara, Italy
- Division of Cardiology, Azienda Ospedaliero Universitaria 'Maggiore della Carità', Novara, Italy
| | - Mattia Galli
- Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
| | - Giuseppe Princi
- Department of Cardiovascular Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Elisabetta Caiazzo
- Department of Pharmacy, School of Medicine and Surgery, University of Naples Federico II, Naples, Italy
- School of Infection and Immunity, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Asma O M Rezig
- School of Infection and Immunity, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Pasquale Maffia
- Department of Pharmacy, School of Medicine and Surgery, University of Naples Federico II, Naples, Italy
- School of Infection and Immunity, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Giovanni Pecorini
- Cardiovascular Internal Medicine Unit, Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Filippo Crea
- Department of Cardiovascular Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - John G F Cleland
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
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Mori M, Mark DB, Khera R, Lin H, Jones P, Huang C, Lu Y, Geirsson A, Velazquez EJ, Spertus JA, Krumholz HM. Identifying quality of life outcome patterns to inform treatment choices in ischemic cardiomyopathy. Am Heart J 2022; 254:12-22. [PMID: 35932911 DOI: 10.1016/j.ahj.2022.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 06/14/2022] [Accepted: 07/28/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND The Surgical Treatment for Ischemic Heart Failure (STICH) trial found that routine use of coronary artery bypass surgery (CABG) improved mean quality of life (QoL) scores relative to guideline-directed medical therapy (GDMT) in patients with ischemic cardiomyopathy. However, mean differences in QoL scores do not provide what patients want to know when facing a high-risk/high-benefit treatment choice. METHODS We analyzed Kansas City Cardiomyopathy Questionnaire (KCCQ) Overall Summary scores in CABG and GDMT patients over 36 months using a combination of statistical methods to group QoL data into clinically relevant outcome patterns (phenotype trajectories) and to then identify the main baseline predictors of each phenotype. QoL outcome phenotypes were developed using mixture models to define the dominant phenotype trajectories present in STICH QoL data. Logistic regression models were used to predict each patient's probability of achieving each outcome pattern with each treatment. RESULTS In STICH, 592 patients underwent CABG and 607 were managed with GDMT. Our analyses identified 3 phenotype trajectory patterns in both treatment groups. Two of the 3 trajectories showed improving patterns, and were classified as "good QoL trajectories," seen in 498 (84.1%) CABG and 449 (73.9%) GDMT patients. Defining a consequential CABG-GDMT treatment difference as a >10% higher absolute predicted probability of belonging to good QoL trajectories, 277 (23.5%) patients were more likely to have good outcome with CABG while 45 (3.8%) patients were more likely to have a good outcome with GDMT. For 644 (54.7%) patients, CABG and GDMT probabilities of a good outcome were within 5% of each other. CONCLUSIONS The pattern of QoL outcomes after CABG compared with GDMT in STICH followed 3 main phenotypic trajectories, which could be predicted based on individual baseline features. Patient-specific predictions about expected QoL outcomes with different treatment choices provide an intuitive framework for personalizing patient decision making.
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Affiliation(s)
- Makoto Mori
- Division of Cardiac Surgery, Yale School of Medicine, New Haven, CT; Center for Outcomes Research and Evaluation, YaleNew Haven Hospital, New Haven, CT
| | - Daniel B Mark
- Duke Clinical Research Institute, Duke University, Durham, NC
| | - Rohan Khera
- Center for Outcomes Research and Evaluation, YaleNew Haven Hospital, New Haven, CT; Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Haiqun Lin
- Division of Nursing Science, School of Nursing & Department of Biostatistics and Epidemiology, School of Public Health, Rutgers University, Newark, NJ
| | - Philip Jones
- Saint Luke's Mid America Heart Institute, Kansas City, MO; Department of Biomedical and Health Informatics, University of Missouri, Kansas City, MO
| | - Chenxi Huang
- Center for Outcomes Research and Evaluation, YaleNew Haven Hospital, New Haven, CT
| | - Yuan Lu
- Center for Outcomes Research and Evaluation, YaleNew Haven Hospital, New Haven, CT; Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Arnar Geirsson
- Division of Cardiac Surgery, Yale School of Medicine, New Haven, CT
| | - Eric J Velazquez
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - John A Spertus
- Saint Luke's Mid America Heart Institute, Kansas City, MO; Department of Biomedical and Health Informatics, University of Missouri, Kansas City, MO
| | - Harlan M Krumholz
- Center for Outcomes Research and Evaluation, YaleNew Haven Hospital, New Haven, CT; Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine and the Department of Health Policy and Management, Yale School of Public Health, New Haven, CT.
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Doenst T, Haddad H, Stebbins A, Hill JA, Velazquez EJ, Lee KL, Rouleau JL, Sopko G, Farsky PS, Al-Khalidi HR. Renal function and coronary bypass surgery in patients with ischemic heart failure. J Thorac Cardiovasc Surg 2022; 163:663-672.e3. [PMID: 32386761 PMCID: PMC7541611 DOI: 10.1016/j.jtcvs.2020.02.136] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 01/24/2020] [Accepted: 02/13/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Chronic kidney disease is a known risk factor in cardiovascular disease, but its influence on treatment effect of bypass surgery remains unclear. We assessed the influence of chronic kidney disease on 10-year mortality and cardiovascular outcomes in patients with ischemic heart failure treated with medical therapy (medical treatment) with or without coronary artery bypass grafting. METHODS We calculated the baseline estimated glomerular filtration rate (Chronic Kidney Disease Epidemiology Collaboration formula, chronic kidney disease stages 1-5) from 1209 patients randomized to medical treatment or coronary artery bypass grafting in the Surgical Treatment for IsChemic Heart failure trial and assessed its effect on outcome. RESULTS In the overall Surgical Treatment for IsChemic Heart failure cohort, patients with chronic kidney disease stages 3 to 5 were older than those with stages 1 and 2 (66-71 years vs 54-59 years) and had more comorbidities. Multivariable modeling revealed an inverse association between estimated glomerular filtration rate and risk of death, cardiovascular death, or cardiovascular rehospitalization (all P < .001, but not for stroke, P = .697). Baseline characteristics of the 2 treatment arms were equal for each chronic kidney disease stage. There were significant improvements in death or cardiovascular rehospitalization with coronary artery bypass grafting (stage 1: hazard ratio, 0.71; confidence interval, 0.53-0.96, P = .02; stage 2: hazard ratio, 0.71; confidence interval, 0.59-0.84, P < .0001; stage 3: hazard ratio, 0.76; confidence interval, 0.53-0.96, P = .03). These data were inconclusive in stages 4 and 5 for insufficient patient numbers (N = 28). There was no significant interaction of estimated glomerular filtration rate with the treatment effect of coronary artery bypass grafting (P = .25 for death and P = .54 for death or cardiovascular rehospitalization). CONCLUSIONS Chronic kidney disease is an independent risk factor for mortality in patients with ischemic heart failure with or without coronary artery bypass grafting. However, mild to moderate chronic kidney disease does not appear to influence long-term treatment effects of coronary artery bypass grafting.
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Affiliation(s)
- Torsten Doenst
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich-Schiller-University of Jena, Jena, Germany.
| | - Haissam Haddad
- Department of Medicine, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | | | - James A Hill
- Division of Cardiovascular Medicine, Department of Medicine, University of Florida, Malcom Randal VAMC, Gainesville, Fla
| | - Eric J Velazquez
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Conn
| | - Kerry L Lee
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Duke Clinical Research Institute, Durham, NC
| | - Jean L Rouleau
- Montreal Heart Institute, University of Montreal, Montreal, Québec, Canada
| | - George Sopko
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Md
| | - Pedro S Farsky
- Department of Cardiology, Instituto Dante Pazzanese de Cardiologia, Sao Paulo, Brazil; Department of Cardiology, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Hussein R Al-Khalidi
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Duke Clinical Research Institute, Durham, NC
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Hassanabad AF, MacQueen KT, Ali I. Surgical Treatment for Ischemic Heart Failure (STICH) trial: A review of outcomes. J Card Surg 2019; 34:1075-1082. [DOI: 10.1111/jocs.14166] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Ali Fatehi Hassanabad
- Section of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, Faculty of MedicineUniversity of Calgary Calgary Canada
| | - Kelsey T. MacQueen
- Section of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, Faculty of MedicineUniversity of Calgary Calgary Canada
| | - Imtiaz Ali
- Section of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, Faculty of MedicineUniversity of Calgary Calgary Canada
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Vickneson K, Chan SP, Li Y, Bin Abdul Aziz MN, Luo HD, Kang GS, Caleb MG, Sorokin V. Coronary artery bypass grafting in patients with low ejection fraction: what are the risk factors? THE JOURNAL OF CARDIOVASCULAR SURGERY 2019; 60:396-405. [PMID: 30916532 DOI: 10.23736/s0021-9509.19.10670-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Left ventricular (LV) dysfunction alone is insufficient as an independent predictor of postoperative complications and mortality in coronary artery bypass graft (CABG) surgery. Our objective was to identify additional independent risk factors in patients with low left ventricle ejection fraction (EF) who underwent CABG. METHODS We retrospectively analyzed CABG results of 346 consecutive patients with low EF (≤30%) in a single institution between 2009 and 2015. The primary study endpoint was 30-day all-cause mortality. The secondary endpoints were the development of major adverse cardiac events (MACE) and renal complications after operation. A subgroup of patients underwent additional analyses of the interaction between extents of viable myocardium and postoperative endpoints. RESULTS The analysis showed that preoperative hemodynamic instability (AOR=4.57; 95% CI: 1.53-13.7, P=0.007) and serum creatinine >166 µmol/L (AOR=3.46; 95% CI: 1.12-10.7, P=0.031) were independent predictors of 30-day death. Both urgent and emergency operations were predictors for MACE (P=0.038; P=0.005) and renal complications (P=0.004; P=0.007). Pre-existing diabetes mellitus increased the likelihood of renal complications (P=0.020). In the sub-analysis of patients with viable myocardium, the mortality was significantly lower with predicted mortality (P=0.014). CONCLUSIONS Patients with significant LV dysfunction undergoing isolated CABG have fair short-term survival even with EF less than 30%. Hemodynamic instability prior to operation and preoperative kidney dysfunction are strong predictors of mortality in patients with low EF. Favorable coronary targets, meticulous operative techniques, and optimal surgical timing before hemodynamic deterioration occurs are essential to minimize the risk of revascularization complications and early postoperative mortality.
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Affiliation(s)
| | - Siew-Pang Chan
- Cardiovascular Research Institute, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,College of Science, Health and Engineering, La Trobe University, Melbourne, Australia
| | - Yue Li
- Department of Cardiac, Thoracic, and Vascular Surgery, National University Hospital, National University Health System, Singapore
| | | | - Hai D Luo
- Department of Cardiac, Thoracic, and Vascular Surgery, National University Hospital, National University Health System, Singapore
| | - Giap S Kang
- Department of Cardiac, Thoracic, and Vascular Surgery, National University Hospital, National University Health System, Singapore
| | - Michael G Caleb
- Department of Cardiac, Thoracic, and Vascular Surgery, National University Hospital, National University Health System, Singapore
| | - Vitaly Sorokin
- Department of Cardiac, Thoracic, and Vascular Surgery, National University Hospital, National University Health System, Singapore - .,Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Ambrosy AP, Stevens SR, Al-Khalidi HR, Rouleau JL, Bouabdallaoui N, Carson PE, Adlbrecht C, Cleland JGF, Dabrowski R, Golba KS, Pina IL, Sueta CA, Roy A, Sopko G, Bonow RO, Velazquez EJ. Burden of medical co-morbidities and benefit from surgical revascularization in patients with ischaemic cardiomyopathy. Eur J Heart Fail 2019; 21:373-381. [PMID: 30698316 DOI: 10.1002/ejhf.1404] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Revised: 11/03/2018] [Accepted: 11/25/2018] [Indexed: 11/10/2022] Open
Abstract
AIMS The landmark STICH trial found that surgical revascularization compared to medical therapy alone improved survival in patients with heart failure (HF) of ischaemic aetiology and an ejection fraction (EF) ≤ 35%. However, the interaction between the burden of medical co-morbidities and the benefit from surgical revascularization has not been previously described in patients with ischaemic cardiomyopathy. METHODS AND RESULTS The STICH trial (ClinicalTrials.gov Identifier: NCT00023595) enrolled patients ≥ 18 years of age with coronary artery disease amenable to coronary artery bypass grafting (CABG) and an EF ≤ 35%. Eligible participants were randomly assigned 1:1 to receive medical therapy (MED) (n = 602) or MED/CABG (n = 610). A modified Charlson co-morbidity index (CCI) based on the availability of data and study definitions was calculated by summing the weighted points for all co-morbid conditions. Patients were divided into mild/moderate (CCI 1-4) and severe (CCI ≥ 5) co-morbidity. Cox proportional hazards models were used to evaluate the association between CCI and outcomes and the interaction between severity of co-morbidity and treatment effect. The study population included 349 patients (29%) with a mild/moderate CCI score and 863 patients (71%) with a severe CCI score. Patients with a severe CCI score had greater functional limitations based on 6-min walk test and impairments in health-related quality of life as assessed by the Kansas City Cardiomyopathy Questionnaire. A total of 161 patients (Kaplan-Meier rate = 50%) with a mild/moderate CCI score and 579 patients (Kaplan-Meier rate = 69%) with a severe CCI score died over a median follow-up of 9.8 years. After adjusting for baseline confounders, patients with a severe CCI score were at higher risk for all-cause mortality (hazard ratio 1.44, 95% confidence interval 1.19-1.74; P < 0.001). There was no interaction between CCI score and treatment effect on survival (P = 0.756). CONCLUSIONS More than 70% of patients had a severe burden of medical co-morbidities at baseline, which was independently associated with increased risk of death. There was not a differential benefit of surgical revascularization with respect to survival based on severity of co-morbidity.
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Affiliation(s)
- Andrew P Ambrosy
- Division of Cardiology, The Permanente Medical Group, San Francisco, CA, USA.,Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Susanna R Stevens
- Department of Biostatistics and Bioinformatics, Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Hussein R Al-Khalidi
- Department of Biostatistics and Bioinformatics, Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Jean L Rouleau
- Research Center, Montreal Heart Institute, Montreal, Quebec, Canada
| | | | - Peter E Carson
- Department of Cardiology, Washington Veterans Affairs Medical Center, Washington, DC, USA
| | - Christopher Adlbrecht
- 4th Medical Department, Karl Landsteiner Institute for Cardiovascular and Critical Care Research, Hietzing Hospital, Vienna, Austria
| | - John G F Cleland
- Robertson Centre for Biostatistics and Clinical Trials, University of Glasgow, Glasgow, Scotland, UK
| | - Rafal Dabrowski
- 2nd Department of Coronary Artery Disease, Institute of Cardiology, Warsaw, Poland
| | - Krzysztof S Golba
- Department of Electrocardiology and Heart Failure, School of Health Sciences, Medical University of Silesia, Katowice, Poland
| | - Ileana L Pina
- Albert Einstein College of Medicine, Montefiore Medical Center, New York, NY, USA
| | - Carla A Sueta
- Division of Cardiology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Ambuj Roy
- Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India
| | - George Sopko
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Robert O Bonow
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Eric J Velazquez
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
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Revascularización quirúrgica en pacientes con disfunción ventricular severa. REVISTA COLOMBIANA DE CARDIOLOGÍA 2016. [DOI: 10.1016/j.rccar.2016.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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9
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Johansson I, Dahlström U, Edner M, Näsman P, Rydén L, Norhammar A. Prognostic Implications of Type 2 Diabetes Mellitus in Ischemic and Nonischemic Heart Failure. J Am Coll Cardiol 2016; 68:1404-1416. [DOI: 10.1016/j.jacc.2016.06.061] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Revised: 06/17/2016] [Accepted: 06/21/2016] [Indexed: 12/20/2022]
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10
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Underutilization of Coronary Artery Disease Testing Among Patients Hospitalized With New-Onset Heart Failure. J Am Coll Cardiol 2016; 68:450-458. [DOI: 10.1016/j.jacc.2016.05.060] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Accepted: 05/03/2016] [Indexed: 01/22/2023]
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Briceno N, Perera D. To Revascularise or Not To Revascularise, That Is the Question: the Diagnostic and Management Conundrum of Ischaemic Cardiomyopathy. Curr Cardiol Rep 2016; 18:54. [PMID: 27115418 PMCID: PMC4846708 DOI: 10.1007/s11886-016-0726-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Ischaemic cardiomyopathy is an important cardiovascular condition that has differing pathophysiological substrates and clinical manifestations. Contemporary management involves the administration of heart failure pharmacotherapy and device therapy where indicated, which has good prognostic data to support it. Whilst the role of revascularisation is clear in those patients presenting with an acute coronary syndrome or angina, the role in those patients presenting either incidentally, with predominant heart failure symptoms, or in those presenting with acute heart failure with an associated elevated troponin is less well defined and lacks randomised outcome data to support its adoption. The aim of this review is therefore to discuss the challenges in the diagnosis of ischaemic cardiomyopathy with a review of the existing imaging modalities that can facilitate, and to revisit the variety of clinical presentations that can occur, with particular emphasis on the contemporary role of revascularisation in these cohorts of patients.
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Affiliation(s)
- Natalia Briceno
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre, Cardiovascular Division, St Thomas' Hospital Campus, Kings College London, London, UK
| | - Divaka Perera
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre, Cardiovascular Division, St Thomas' Hospital Campus, Kings College London, London, UK.
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12
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Velazquez EJ, Lee KL, Jones RH, Al-Khalidi HR, Hill JA, Panza JA, Michler RE, Bonow RO, Doenst T, Petrie MC, Oh JK, She L, Moore VL, Desvigne-Nickens P, Sopko G, Rouleau JL. Coronary-Artery Bypass Surgery in Patients with Ischemic Cardiomyopathy. N Engl J Med 2016; 374:1511-20. [PMID: 27040723 PMCID: PMC4938005 DOI: 10.1056/nejmoa1602001] [Citation(s) in RCA: 659] [Impact Index Per Article: 82.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND The survival benefit of a strategy of coronary-artery bypass grafting (CABG) added to guideline-directed medical therapy, as compared with medical therapy alone, in patients with coronary artery disease, heart failure, and severe left ventricular systolic dysfunction remains unclear. METHODS From July 2002 to May 2007, a total of 1212 patients with an ejection fraction of 35% or less and coronary artery disease amenable to CABG were randomly assigned to undergo CABG plus medical therapy (CABG group, 610 patients) or medical therapy alone (medical-therapy group, 602 patients). The primary outcome was death from any cause. Major secondary outcomes included death from cardiovascular causes and death from any cause or hospitalization for cardiovascular causes. The median duration of follow-up, including the current extended-follow-up study, was 9.8 years. RESULTS A primary outcome event occurred in 359 patients (58.9%) in the CABG group and in 398 patients (66.1%) in the medical-therapy group (hazard ratio with CABG vs. medical therapy, 0.84; 95% confidence interval [CI], 0.73 to 0.97; P=0.02 by log-rank test). A total of 247 patients (40.5%) in the CABG group and 297 patients (49.3%) in the medical-therapy group died from cardiovascular causes (hazard ratio, 0.79; 95% CI, 0.66 to 0.93; P=0.006 by log-rank test). Death from any cause or hospitalization for cardiovascular causes occurred in 467 patients (76.6%) in the CABG group and in 524 patients (87.0%) in the medical-therapy group (hazard ratio, 0.72; 95% CI, 0.64 to 0.82; P<0.001 by log-rank test). CONCLUSIONS In a cohort of patients with ischemic cardiomyopathy, the rates of death from any cause, death from cardiovascular causes, and death from any cause or hospitalization for cardiovascular causes were significantly lower over 10 years among patients who underwent CABG in addition to receiving medical therapy than among those who received medical therapy alone. (Funded by the National Institutes of Health; STICH [and STICHES] ClinicalTrials.gov number, NCT00023595.).
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Affiliation(s)
- Eric J Velazquez
- From the Division of Cardiology (E.J.V.), Departments of Biostatistics and Bioinformatics (K.L.L., H.R.A.-K.) and Surgery (R.H.J.), and Duke Clinical Research Institute (L.S., V.L.M.), Duke University Medical Center, Durham, NC; the University of Florida, Gainesville (J.A.H.); Westchester Medical Center and New York Medical College, Valhalla (J.A.P.), and Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York (R.E.M.); Northwestern University Feinberg School of Medicine, Chicago (R.O.B.); the Department of Cardiothoracic Surgery, University Hospital Jena, Friedrich-Schiller-University of Jena, Jena, Germany (T.D.); Glasgow University and Golden Jubilee National Hospital, Glasgow, United Kingdom (M.C.P.); Mayo Clinic, Rochester, MN (J.K.O.); the Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (P.D.-N., G.S.); and University of Montreal, Montreal Heart Institute, Montreal (J.L.R.)
| | - Kerry L Lee
- From the Division of Cardiology (E.J.V.), Departments of Biostatistics and Bioinformatics (K.L.L., H.R.A.-K.) and Surgery (R.H.J.), and Duke Clinical Research Institute (L.S., V.L.M.), Duke University Medical Center, Durham, NC; the University of Florida, Gainesville (J.A.H.); Westchester Medical Center and New York Medical College, Valhalla (J.A.P.), and Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York (R.E.M.); Northwestern University Feinberg School of Medicine, Chicago (R.O.B.); the Department of Cardiothoracic Surgery, University Hospital Jena, Friedrich-Schiller-University of Jena, Jena, Germany (T.D.); Glasgow University and Golden Jubilee National Hospital, Glasgow, United Kingdom (M.C.P.); Mayo Clinic, Rochester, MN (J.K.O.); the Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (P.D.-N., G.S.); and University of Montreal, Montreal Heart Institute, Montreal (J.L.R.)
| | - Robert H Jones
- From the Division of Cardiology (E.J.V.), Departments of Biostatistics and Bioinformatics (K.L.L., H.R.A.-K.) and Surgery (R.H.J.), and Duke Clinical Research Institute (L.S., V.L.M.), Duke University Medical Center, Durham, NC; the University of Florida, Gainesville (J.A.H.); Westchester Medical Center and New York Medical College, Valhalla (J.A.P.), and Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York (R.E.M.); Northwestern University Feinberg School of Medicine, Chicago (R.O.B.); the Department of Cardiothoracic Surgery, University Hospital Jena, Friedrich-Schiller-University of Jena, Jena, Germany (T.D.); Glasgow University and Golden Jubilee National Hospital, Glasgow, United Kingdom (M.C.P.); Mayo Clinic, Rochester, MN (J.K.O.); the Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (P.D.-N., G.S.); and University of Montreal, Montreal Heart Institute, Montreal (J.L.R.)
| | - Hussein R Al-Khalidi
- From the Division of Cardiology (E.J.V.), Departments of Biostatistics and Bioinformatics (K.L.L., H.R.A.-K.) and Surgery (R.H.J.), and Duke Clinical Research Institute (L.S., V.L.M.), Duke University Medical Center, Durham, NC; the University of Florida, Gainesville (J.A.H.); Westchester Medical Center and New York Medical College, Valhalla (J.A.P.), and Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York (R.E.M.); Northwestern University Feinberg School of Medicine, Chicago (R.O.B.); the Department of Cardiothoracic Surgery, University Hospital Jena, Friedrich-Schiller-University of Jena, Jena, Germany (T.D.); Glasgow University and Golden Jubilee National Hospital, Glasgow, United Kingdom (M.C.P.); Mayo Clinic, Rochester, MN (J.K.O.); the Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (P.D.-N., G.S.); and University of Montreal, Montreal Heart Institute, Montreal (J.L.R.)
| | - James A Hill
- From the Division of Cardiology (E.J.V.), Departments of Biostatistics and Bioinformatics (K.L.L., H.R.A.-K.) and Surgery (R.H.J.), and Duke Clinical Research Institute (L.S., V.L.M.), Duke University Medical Center, Durham, NC; the University of Florida, Gainesville (J.A.H.); Westchester Medical Center and New York Medical College, Valhalla (J.A.P.), and Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York (R.E.M.); Northwestern University Feinberg School of Medicine, Chicago (R.O.B.); the Department of Cardiothoracic Surgery, University Hospital Jena, Friedrich-Schiller-University of Jena, Jena, Germany (T.D.); Glasgow University and Golden Jubilee National Hospital, Glasgow, United Kingdom (M.C.P.); Mayo Clinic, Rochester, MN (J.K.O.); the Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (P.D.-N., G.S.); and University of Montreal, Montreal Heart Institute, Montreal (J.L.R.)
| | - Julio A Panza
- From the Division of Cardiology (E.J.V.), Departments of Biostatistics and Bioinformatics (K.L.L., H.R.A.-K.) and Surgery (R.H.J.), and Duke Clinical Research Institute (L.S., V.L.M.), Duke University Medical Center, Durham, NC; the University of Florida, Gainesville (J.A.H.); Westchester Medical Center and New York Medical College, Valhalla (J.A.P.), and Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York (R.E.M.); Northwestern University Feinberg School of Medicine, Chicago (R.O.B.); the Department of Cardiothoracic Surgery, University Hospital Jena, Friedrich-Schiller-University of Jena, Jena, Germany (T.D.); Glasgow University and Golden Jubilee National Hospital, Glasgow, United Kingdom (M.C.P.); Mayo Clinic, Rochester, MN (J.K.O.); the Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (P.D.-N., G.S.); and University of Montreal, Montreal Heart Institute, Montreal (J.L.R.)
| | - Robert E Michler
- From the Division of Cardiology (E.J.V.), Departments of Biostatistics and Bioinformatics (K.L.L., H.R.A.-K.) and Surgery (R.H.J.), and Duke Clinical Research Institute (L.S., V.L.M.), Duke University Medical Center, Durham, NC; the University of Florida, Gainesville (J.A.H.); Westchester Medical Center and New York Medical College, Valhalla (J.A.P.), and Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York (R.E.M.); Northwestern University Feinberg School of Medicine, Chicago (R.O.B.); the Department of Cardiothoracic Surgery, University Hospital Jena, Friedrich-Schiller-University of Jena, Jena, Germany (T.D.); Glasgow University and Golden Jubilee National Hospital, Glasgow, United Kingdom (M.C.P.); Mayo Clinic, Rochester, MN (J.K.O.); the Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (P.D.-N., G.S.); and University of Montreal, Montreal Heart Institute, Montreal (J.L.R.)
| | - Robert O Bonow
- From the Division of Cardiology (E.J.V.), Departments of Biostatistics and Bioinformatics (K.L.L., H.R.A.-K.) and Surgery (R.H.J.), and Duke Clinical Research Institute (L.S., V.L.M.), Duke University Medical Center, Durham, NC; the University of Florida, Gainesville (J.A.H.); Westchester Medical Center and New York Medical College, Valhalla (J.A.P.), and Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York (R.E.M.); Northwestern University Feinberg School of Medicine, Chicago (R.O.B.); the Department of Cardiothoracic Surgery, University Hospital Jena, Friedrich-Schiller-University of Jena, Jena, Germany (T.D.); Glasgow University and Golden Jubilee National Hospital, Glasgow, United Kingdom (M.C.P.); Mayo Clinic, Rochester, MN (J.K.O.); the Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (P.D.-N., G.S.); and University of Montreal, Montreal Heart Institute, Montreal (J.L.R.)
| | - Torsten Doenst
- From the Division of Cardiology (E.J.V.), Departments of Biostatistics and Bioinformatics (K.L.L., H.R.A.-K.) and Surgery (R.H.J.), and Duke Clinical Research Institute (L.S., V.L.M.), Duke University Medical Center, Durham, NC; the University of Florida, Gainesville (J.A.H.); Westchester Medical Center and New York Medical College, Valhalla (J.A.P.), and Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York (R.E.M.); Northwestern University Feinberg School of Medicine, Chicago (R.O.B.); the Department of Cardiothoracic Surgery, University Hospital Jena, Friedrich-Schiller-University of Jena, Jena, Germany (T.D.); Glasgow University and Golden Jubilee National Hospital, Glasgow, United Kingdom (M.C.P.); Mayo Clinic, Rochester, MN (J.K.O.); the Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (P.D.-N., G.S.); and University of Montreal, Montreal Heart Institute, Montreal (J.L.R.)
| | - Mark C Petrie
- From the Division of Cardiology (E.J.V.), Departments of Biostatistics and Bioinformatics (K.L.L., H.R.A.-K.) and Surgery (R.H.J.), and Duke Clinical Research Institute (L.S., V.L.M.), Duke University Medical Center, Durham, NC; the University of Florida, Gainesville (J.A.H.); Westchester Medical Center and New York Medical College, Valhalla (J.A.P.), and Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York (R.E.M.); Northwestern University Feinberg School of Medicine, Chicago (R.O.B.); the Department of Cardiothoracic Surgery, University Hospital Jena, Friedrich-Schiller-University of Jena, Jena, Germany (T.D.); Glasgow University and Golden Jubilee National Hospital, Glasgow, United Kingdom (M.C.P.); Mayo Clinic, Rochester, MN (J.K.O.); the Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (P.D.-N., G.S.); and University of Montreal, Montreal Heart Institute, Montreal (J.L.R.)
| | - Jae K Oh
- From the Division of Cardiology (E.J.V.), Departments of Biostatistics and Bioinformatics (K.L.L., H.R.A.-K.) and Surgery (R.H.J.), and Duke Clinical Research Institute (L.S., V.L.M.), Duke University Medical Center, Durham, NC; the University of Florida, Gainesville (J.A.H.); Westchester Medical Center and New York Medical College, Valhalla (J.A.P.), and Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York (R.E.M.); Northwestern University Feinberg School of Medicine, Chicago (R.O.B.); the Department of Cardiothoracic Surgery, University Hospital Jena, Friedrich-Schiller-University of Jena, Jena, Germany (T.D.); Glasgow University and Golden Jubilee National Hospital, Glasgow, United Kingdom (M.C.P.); Mayo Clinic, Rochester, MN (J.K.O.); the Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (P.D.-N., G.S.); and University of Montreal, Montreal Heart Institute, Montreal (J.L.R.)
| | - Lilin She
- From the Division of Cardiology (E.J.V.), Departments of Biostatistics and Bioinformatics (K.L.L., H.R.A.-K.) and Surgery (R.H.J.), and Duke Clinical Research Institute (L.S., V.L.M.), Duke University Medical Center, Durham, NC; the University of Florida, Gainesville (J.A.H.); Westchester Medical Center and New York Medical College, Valhalla (J.A.P.), and Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York (R.E.M.); Northwestern University Feinberg School of Medicine, Chicago (R.O.B.); the Department of Cardiothoracic Surgery, University Hospital Jena, Friedrich-Schiller-University of Jena, Jena, Germany (T.D.); Glasgow University and Golden Jubilee National Hospital, Glasgow, United Kingdom (M.C.P.); Mayo Clinic, Rochester, MN (J.K.O.); the Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (P.D.-N., G.S.); and University of Montreal, Montreal Heart Institute, Montreal (J.L.R.)
| | - Vanessa L Moore
- From the Division of Cardiology (E.J.V.), Departments of Biostatistics and Bioinformatics (K.L.L., H.R.A.-K.) and Surgery (R.H.J.), and Duke Clinical Research Institute (L.S., V.L.M.), Duke University Medical Center, Durham, NC; the University of Florida, Gainesville (J.A.H.); Westchester Medical Center and New York Medical College, Valhalla (J.A.P.), and Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York (R.E.M.); Northwestern University Feinberg School of Medicine, Chicago (R.O.B.); the Department of Cardiothoracic Surgery, University Hospital Jena, Friedrich-Schiller-University of Jena, Jena, Germany (T.D.); Glasgow University and Golden Jubilee National Hospital, Glasgow, United Kingdom (M.C.P.); Mayo Clinic, Rochester, MN (J.K.O.); the Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (P.D.-N., G.S.); and University of Montreal, Montreal Heart Institute, Montreal (J.L.R.)
| | - Patrice Desvigne-Nickens
- From the Division of Cardiology (E.J.V.), Departments of Biostatistics and Bioinformatics (K.L.L., H.R.A.-K.) and Surgery (R.H.J.), and Duke Clinical Research Institute (L.S., V.L.M.), Duke University Medical Center, Durham, NC; the University of Florida, Gainesville (J.A.H.); Westchester Medical Center and New York Medical College, Valhalla (J.A.P.), and Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York (R.E.M.); Northwestern University Feinberg School of Medicine, Chicago (R.O.B.); the Department of Cardiothoracic Surgery, University Hospital Jena, Friedrich-Schiller-University of Jena, Jena, Germany (T.D.); Glasgow University and Golden Jubilee National Hospital, Glasgow, United Kingdom (M.C.P.); Mayo Clinic, Rochester, MN (J.K.O.); the Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (P.D.-N., G.S.); and University of Montreal, Montreal Heart Institute, Montreal (J.L.R.)
| | - George Sopko
- From the Division of Cardiology (E.J.V.), Departments of Biostatistics and Bioinformatics (K.L.L., H.R.A.-K.) and Surgery (R.H.J.), and Duke Clinical Research Institute (L.S., V.L.M.), Duke University Medical Center, Durham, NC; the University of Florida, Gainesville (J.A.H.); Westchester Medical Center and New York Medical College, Valhalla (J.A.P.), and Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York (R.E.M.); Northwestern University Feinberg School of Medicine, Chicago (R.O.B.); the Department of Cardiothoracic Surgery, University Hospital Jena, Friedrich-Schiller-University of Jena, Jena, Germany (T.D.); Glasgow University and Golden Jubilee National Hospital, Glasgow, United Kingdom (M.C.P.); Mayo Clinic, Rochester, MN (J.K.O.); the Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (P.D.-N., G.S.); and University of Montreal, Montreal Heart Institute, Montreal (J.L.R.)
| | - Jean L Rouleau
- From the Division of Cardiology (E.J.V.), Departments of Biostatistics and Bioinformatics (K.L.L., H.R.A.-K.) and Surgery (R.H.J.), and Duke Clinical Research Institute (L.S., V.L.M.), Duke University Medical Center, Durham, NC; the University of Florida, Gainesville (J.A.H.); Westchester Medical Center and New York Medical College, Valhalla (J.A.P.), and Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York (R.E.M.); Northwestern University Feinberg School of Medicine, Chicago (R.O.B.); the Department of Cardiothoracic Surgery, University Hospital Jena, Friedrich-Schiller-University of Jena, Jena, Germany (T.D.); Glasgow University and Golden Jubilee National Hospital, Glasgow, United Kingdom (M.C.P.); Mayo Clinic, Rochester, MN (J.K.O.); the Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (P.D.-N., G.S.); and University of Montreal, Montreal Heart Institute, Montreal (J.L.R.)
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13
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Stone GW, Hochman JS, Williams DO, Boden WE, Ferguson TB, Harrington RA, Maron DJ. Medical Therapy With Versus Without Revascularization in Stable Patients With Moderate and Severe Ischemia: The Case for Community Equipoise. J Am Coll Cardiol 2016; 67:81-99. [PMID: 26616030 PMCID: PMC5545795 DOI: 10.1016/j.jacc.2015.09.056] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Revised: 09/10/2015] [Accepted: 09/22/2015] [Indexed: 12/21/2022]
Abstract
All patients with stable ischemic heart disease (SIHD) should be managed with guideline-directed medical therapy (GDMT), which reduces progression of atherosclerosis and prevents coronary thrombosis. Revascularization is also indicated in patients with SIHD and progressive or refractory symptoms, despite medical management. Whether a strategy of routine revascularization (with percutaneous coronary intervention or coronary artery bypass graft surgery as appropriate) plus GDMT reduces rates of death or myocardial infarction, or improves quality of life compared to an initial approach of GDMT alone in patients with substantial ischemia is uncertain. Opinions run strongly on both sides, and evidence may be used to support either approach. Careful review of the data demonstrates the limitations of our current knowledge, resulting in a state of community equipoise. The ongoing ISCHEMIA trial (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches) is being performed to determine the optimal approach to managing patients with SIHD, moderate-to-severe ischemia, and symptoms that can be controlled medically. (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches [ISCHEMIA]; NCT01471522).
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Affiliation(s)
- Gregg W Stone
- Department of Medicine, Columbia University Medical Center, New York Presbyterian Hospital and the Cardiovascular Research Foundation, New York, New York.
| | - Judith S Hochman
- Department of Medicine, Cardiovascular Clinical Research Center, New York University School of Medicine, New York, New York
| | - David O Williams
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - William E Boden
- Department of Medicine, Samuel S. Stratton VA Medical Center, Albany Medical Center and Albany Medical College, Albany, New York
| | - T Bruce Ferguson
- Department of Cardiovascular Sciences, East Carolina Heart Institute, East Carolina University, Greenville, North Carolina
| | - Robert A Harrington
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - David J Maron
- Department of Medicine, Stanford University School of Medicine, Stanford, California
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14
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Wrobel K, Stevens SR, Jones RH, Selzman CH, Lamy A, Beaver TM, Djokovic LT, Wang N, Velazquez EJ, Sopko G, Kron IL, DiMaio JM, Michler RE, Lee KL, Yii M, Leng CY, Zembala M, Rouleau JL, Daly RC, Al-Khalidi HR. Influence of Baseline Characteristics, Operative Conduct, and Postoperative Course on 30-Day Outcomes of Coronary Artery Bypass Grafting Among Patients With Left Ventricular Dysfunction: Results From the Surgical Treatment for Ischemic Heart Failure (STICH) Trial. Circulation 2015; 132:720-30. [PMID: 26304663 DOI: 10.1161/circulationaha.114.014932] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Patients with severe left ventricular dysfunction, ischemic heart failure, and coronary artery disease suitable for coronary artery bypass grafting (CABG) are at higher risk for surgical morbidity and mortality. Paradoxically, those patients with the most severe coronary artery disease and ventricular dysfunction who derive the greatest clinical benefit from CABG are also at the greatest operative risk, which makes decision making regarding whether to proceed to surgery difficult in such patients. To better inform such decision making, we analyzed the Surgical Treatment for Ischemic Heart Failure (STICH) CABG population for detailed information on perioperative risk and outcomes. METHODS AND RESULTS In both STICH trials (hypotheses), 2136 patients with a left ventricular ejection fraction of ≤35% and coronary artery disease were allocated to medical therapy, CABG plus medical therapy, or CABG with surgical ventricular reconstruction. Relationships of baseline characteristics and operative conduct with morbidity and mortality at 30 days were evaluated. There were a total of 1460 patients randomized to and receiving surgery, and 346 (≈25%) of these high-risk patients developed a severe complication within 30 days. Worsening renal insufficiency, cardiac arrest with cardiopulmonary resuscitation, and ventricular arrhythmias were the most frequent complications and those most commonly associated with death. Mortality at 30 days was 5.1% and was generally preceded by a serious complication (65 of 74 deaths). Left ventricular size, renal dysfunction, advanced age, and atrial fibrillation/flutter were significant preoperative predictors of mortality within 30 days. Cardiopulmonary bypass time was the only independent surgical variable predictive of 30-day mortality. CONCLUSIONS CABG can be performed with relatively low 30-day mortality in patients with left ventricular dysfunction. Serious postoperative complications occurred in nearly 1 in 4 patients and were associated with mortality. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00023595.
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Affiliation(s)
- Krzysztof Wrobel
- From Allenort Hospital, Warsaw, Poland and John Paul II Hospital, Krakow, Poland (K.W.); Duke Clinical Research Institute, Durham, NC (S.R.S.); Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC (R.H.J., E.J.V., K.L.L., H.R.A.); University of Utah, Salt Lake City, UT (C.H.S.); Hamilton General Hospital/McMaster University, Hamilton, ON, Canada (A.L.); Shands Hospital at the University of Florida, Gainesville (T.M.B.); Dedinje Cardiovascular Institute, Belgrade, Serbia (L.T.D.); Loma Linda University Medical Center, CA (N.W.); National Institutes of Health/National Heart, Blood, and Lung Institute, Bethesda, MD (G.S.); University of Virginia, Charlottesville (I.L.K.); Baylor University Medical Center, Dallas, TX (J.M.D.); Montefiore Medical Center and Albert Einstein College of Medicine, New York (R.E.M.); St. Vincent's Hospital Melbourne and University of Melbourne, Australia (M.Y.); National Heart Centre Singapore (C.Y.L.); Silesian Center for Heart Diseases in Zabrze, Poland (M.Z.); Montreal Heart Institute, University de Montréal, Canada (J.L.R.); and Mayo Clinic, Rochester, MN (R.C.D.)
| | - Susanna R Stevens
- From Allenort Hospital, Warsaw, Poland and John Paul II Hospital, Krakow, Poland (K.W.); Duke Clinical Research Institute, Durham, NC (S.R.S.); Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC (R.H.J., E.J.V., K.L.L., H.R.A.); University of Utah, Salt Lake City, UT (C.H.S.); Hamilton General Hospital/McMaster University, Hamilton, ON, Canada (A.L.); Shands Hospital at the University of Florida, Gainesville (T.M.B.); Dedinje Cardiovascular Institute, Belgrade, Serbia (L.T.D.); Loma Linda University Medical Center, CA (N.W.); National Institutes of Health/National Heart, Blood, and Lung Institute, Bethesda, MD (G.S.); University of Virginia, Charlottesville (I.L.K.); Baylor University Medical Center, Dallas, TX (J.M.D.); Montefiore Medical Center and Albert Einstein College of Medicine, New York (R.E.M.); St. Vincent's Hospital Melbourne and University of Melbourne, Australia (M.Y.); National Heart Centre Singapore (C.Y.L.); Silesian Center for Heart Diseases in Zabrze, Poland (M.Z.); Montreal Heart Institute, University de Montréal, Canada (J.L.R.); and Mayo Clinic, Rochester, MN (R.C.D.)
| | - Robert H Jones
- From Allenort Hospital, Warsaw, Poland and John Paul II Hospital, Krakow, Poland (K.W.); Duke Clinical Research Institute, Durham, NC (S.R.S.); Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC (R.H.J., E.J.V., K.L.L., H.R.A.); University of Utah, Salt Lake City, UT (C.H.S.); Hamilton General Hospital/McMaster University, Hamilton, ON, Canada (A.L.); Shands Hospital at the University of Florida, Gainesville (T.M.B.); Dedinje Cardiovascular Institute, Belgrade, Serbia (L.T.D.); Loma Linda University Medical Center, CA (N.W.); National Institutes of Health/National Heart, Blood, and Lung Institute, Bethesda, MD (G.S.); University of Virginia, Charlottesville (I.L.K.); Baylor University Medical Center, Dallas, TX (J.M.D.); Montefiore Medical Center and Albert Einstein College of Medicine, New York (R.E.M.); St. Vincent's Hospital Melbourne and University of Melbourne, Australia (M.Y.); National Heart Centre Singapore (C.Y.L.); Silesian Center for Heart Diseases in Zabrze, Poland (M.Z.); Montreal Heart Institute, University de Montréal, Canada (J.L.R.); and Mayo Clinic, Rochester, MN (R.C.D.)
| | - Craig H Selzman
- From Allenort Hospital, Warsaw, Poland and John Paul II Hospital, Krakow, Poland (K.W.); Duke Clinical Research Institute, Durham, NC (S.R.S.); Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC (R.H.J., E.J.V., K.L.L., H.R.A.); University of Utah, Salt Lake City, UT (C.H.S.); Hamilton General Hospital/McMaster University, Hamilton, ON, Canada (A.L.); Shands Hospital at the University of Florida, Gainesville (T.M.B.); Dedinje Cardiovascular Institute, Belgrade, Serbia (L.T.D.); Loma Linda University Medical Center, CA (N.W.); National Institutes of Health/National Heart, Blood, and Lung Institute, Bethesda, MD (G.S.); University of Virginia, Charlottesville (I.L.K.); Baylor University Medical Center, Dallas, TX (J.M.D.); Montefiore Medical Center and Albert Einstein College of Medicine, New York (R.E.M.); St. Vincent's Hospital Melbourne and University of Melbourne, Australia (M.Y.); National Heart Centre Singapore (C.Y.L.); Silesian Center for Heart Diseases in Zabrze, Poland (M.Z.); Montreal Heart Institute, University de Montréal, Canada (J.L.R.); and Mayo Clinic, Rochester, MN (R.C.D.)
| | - Andre Lamy
- From Allenort Hospital, Warsaw, Poland and John Paul II Hospital, Krakow, Poland (K.W.); Duke Clinical Research Institute, Durham, NC (S.R.S.); Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC (R.H.J., E.J.V., K.L.L., H.R.A.); University of Utah, Salt Lake City, UT (C.H.S.); Hamilton General Hospital/McMaster University, Hamilton, ON, Canada (A.L.); Shands Hospital at the University of Florida, Gainesville (T.M.B.); Dedinje Cardiovascular Institute, Belgrade, Serbia (L.T.D.); Loma Linda University Medical Center, CA (N.W.); National Institutes of Health/National Heart, Blood, and Lung Institute, Bethesda, MD (G.S.); University of Virginia, Charlottesville (I.L.K.); Baylor University Medical Center, Dallas, TX (J.M.D.); Montefiore Medical Center and Albert Einstein College of Medicine, New York (R.E.M.); St. Vincent's Hospital Melbourne and University of Melbourne, Australia (M.Y.); National Heart Centre Singapore (C.Y.L.); Silesian Center for Heart Diseases in Zabrze, Poland (M.Z.); Montreal Heart Institute, University de Montréal, Canada (J.L.R.); and Mayo Clinic, Rochester, MN (R.C.D.)
| | - Thomas M Beaver
- From Allenort Hospital, Warsaw, Poland and John Paul II Hospital, Krakow, Poland (K.W.); Duke Clinical Research Institute, Durham, NC (S.R.S.); Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC (R.H.J., E.J.V., K.L.L., H.R.A.); University of Utah, Salt Lake City, UT (C.H.S.); Hamilton General Hospital/McMaster University, Hamilton, ON, Canada (A.L.); Shands Hospital at the University of Florida, Gainesville (T.M.B.); Dedinje Cardiovascular Institute, Belgrade, Serbia (L.T.D.); Loma Linda University Medical Center, CA (N.W.); National Institutes of Health/National Heart, Blood, and Lung Institute, Bethesda, MD (G.S.); University of Virginia, Charlottesville (I.L.K.); Baylor University Medical Center, Dallas, TX (J.M.D.); Montefiore Medical Center and Albert Einstein College of Medicine, New York (R.E.M.); St. Vincent's Hospital Melbourne and University of Melbourne, Australia (M.Y.); National Heart Centre Singapore (C.Y.L.); Silesian Center for Heart Diseases in Zabrze, Poland (M.Z.); Montreal Heart Institute, University de Montréal, Canada (J.L.R.); and Mayo Clinic, Rochester, MN (R.C.D.)
| | - Ljubomir T Djokovic
- From Allenort Hospital, Warsaw, Poland and John Paul II Hospital, Krakow, Poland (K.W.); Duke Clinical Research Institute, Durham, NC (S.R.S.); Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC (R.H.J., E.J.V., K.L.L., H.R.A.); University of Utah, Salt Lake City, UT (C.H.S.); Hamilton General Hospital/McMaster University, Hamilton, ON, Canada (A.L.); Shands Hospital at the University of Florida, Gainesville (T.M.B.); Dedinje Cardiovascular Institute, Belgrade, Serbia (L.T.D.); Loma Linda University Medical Center, CA (N.W.); National Institutes of Health/National Heart, Blood, and Lung Institute, Bethesda, MD (G.S.); University of Virginia, Charlottesville (I.L.K.); Baylor University Medical Center, Dallas, TX (J.M.D.); Montefiore Medical Center and Albert Einstein College of Medicine, New York (R.E.M.); St. Vincent's Hospital Melbourne and University of Melbourne, Australia (M.Y.); National Heart Centre Singapore (C.Y.L.); Silesian Center for Heart Diseases in Zabrze, Poland (M.Z.); Montreal Heart Institute, University de Montréal, Canada (J.L.R.); and Mayo Clinic, Rochester, MN (R.C.D.)
| | - Nan Wang
- From Allenort Hospital, Warsaw, Poland and John Paul II Hospital, Krakow, Poland (K.W.); Duke Clinical Research Institute, Durham, NC (S.R.S.); Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC (R.H.J., E.J.V., K.L.L., H.R.A.); University of Utah, Salt Lake City, UT (C.H.S.); Hamilton General Hospital/McMaster University, Hamilton, ON, Canada (A.L.); Shands Hospital at the University of Florida, Gainesville (T.M.B.); Dedinje Cardiovascular Institute, Belgrade, Serbia (L.T.D.); Loma Linda University Medical Center, CA (N.W.); National Institutes of Health/National Heart, Blood, and Lung Institute, Bethesda, MD (G.S.); University of Virginia, Charlottesville (I.L.K.); Baylor University Medical Center, Dallas, TX (J.M.D.); Montefiore Medical Center and Albert Einstein College of Medicine, New York (R.E.M.); St. Vincent's Hospital Melbourne and University of Melbourne, Australia (M.Y.); National Heart Centre Singapore (C.Y.L.); Silesian Center for Heart Diseases in Zabrze, Poland (M.Z.); Montreal Heart Institute, University de Montréal, Canada (J.L.R.); and Mayo Clinic, Rochester, MN (R.C.D.)
| | - Eric J Velazquez
- From Allenort Hospital, Warsaw, Poland and John Paul II Hospital, Krakow, Poland (K.W.); Duke Clinical Research Institute, Durham, NC (S.R.S.); Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC (R.H.J., E.J.V., K.L.L., H.R.A.); University of Utah, Salt Lake City, UT (C.H.S.); Hamilton General Hospital/McMaster University, Hamilton, ON, Canada (A.L.); Shands Hospital at the University of Florida, Gainesville (T.M.B.); Dedinje Cardiovascular Institute, Belgrade, Serbia (L.T.D.); Loma Linda University Medical Center, CA (N.W.); National Institutes of Health/National Heart, Blood, and Lung Institute, Bethesda, MD (G.S.); University of Virginia, Charlottesville (I.L.K.); Baylor University Medical Center, Dallas, TX (J.M.D.); Montefiore Medical Center and Albert Einstein College of Medicine, New York (R.E.M.); St. Vincent's Hospital Melbourne and University of Melbourne, Australia (M.Y.); National Heart Centre Singapore (C.Y.L.); Silesian Center for Heart Diseases in Zabrze, Poland (M.Z.); Montreal Heart Institute, University de Montréal, Canada (J.L.R.); and Mayo Clinic, Rochester, MN (R.C.D.)
| | - George Sopko
- From Allenort Hospital, Warsaw, Poland and John Paul II Hospital, Krakow, Poland (K.W.); Duke Clinical Research Institute, Durham, NC (S.R.S.); Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC (R.H.J., E.J.V., K.L.L., H.R.A.); University of Utah, Salt Lake City, UT (C.H.S.); Hamilton General Hospital/McMaster University, Hamilton, ON, Canada (A.L.); Shands Hospital at the University of Florida, Gainesville (T.M.B.); Dedinje Cardiovascular Institute, Belgrade, Serbia (L.T.D.); Loma Linda University Medical Center, CA (N.W.); National Institutes of Health/National Heart, Blood, and Lung Institute, Bethesda, MD (G.S.); University of Virginia, Charlottesville (I.L.K.); Baylor University Medical Center, Dallas, TX (J.M.D.); Montefiore Medical Center and Albert Einstein College of Medicine, New York (R.E.M.); St. Vincent's Hospital Melbourne and University of Melbourne, Australia (M.Y.); National Heart Centre Singapore (C.Y.L.); Silesian Center for Heart Diseases in Zabrze, Poland (M.Z.); Montreal Heart Institute, University de Montréal, Canada (J.L.R.); and Mayo Clinic, Rochester, MN (R.C.D.)
| | - Irving L Kron
- From Allenort Hospital, Warsaw, Poland and John Paul II Hospital, Krakow, Poland (K.W.); Duke Clinical Research Institute, Durham, NC (S.R.S.); Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC (R.H.J., E.J.V., K.L.L., H.R.A.); University of Utah, Salt Lake City, UT (C.H.S.); Hamilton General Hospital/McMaster University, Hamilton, ON, Canada (A.L.); Shands Hospital at the University of Florida, Gainesville (T.M.B.); Dedinje Cardiovascular Institute, Belgrade, Serbia (L.T.D.); Loma Linda University Medical Center, CA (N.W.); National Institutes of Health/National Heart, Blood, and Lung Institute, Bethesda, MD (G.S.); University of Virginia, Charlottesville (I.L.K.); Baylor University Medical Center, Dallas, TX (J.M.D.); Montefiore Medical Center and Albert Einstein College of Medicine, New York (R.E.M.); St. Vincent's Hospital Melbourne and University of Melbourne, Australia (M.Y.); National Heart Centre Singapore (C.Y.L.); Silesian Center for Heart Diseases in Zabrze, Poland (M.Z.); Montreal Heart Institute, University de Montréal, Canada (J.L.R.); and Mayo Clinic, Rochester, MN (R.C.D.)
| | - J Michael DiMaio
- From Allenort Hospital, Warsaw, Poland and John Paul II Hospital, Krakow, Poland (K.W.); Duke Clinical Research Institute, Durham, NC (S.R.S.); Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC (R.H.J., E.J.V., K.L.L., H.R.A.); University of Utah, Salt Lake City, UT (C.H.S.); Hamilton General Hospital/McMaster University, Hamilton, ON, Canada (A.L.); Shands Hospital at the University of Florida, Gainesville (T.M.B.); Dedinje Cardiovascular Institute, Belgrade, Serbia (L.T.D.); Loma Linda University Medical Center, CA (N.W.); National Institutes of Health/National Heart, Blood, and Lung Institute, Bethesda, MD (G.S.); University of Virginia, Charlottesville (I.L.K.); Baylor University Medical Center, Dallas, TX (J.M.D.); Montefiore Medical Center and Albert Einstein College of Medicine, New York (R.E.M.); St. Vincent's Hospital Melbourne and University of Melbourne, Australia (M.Y.); National Heart Centre Singapore (C.Y.L.); Silesian Center for Heart Diseases in Zabrze, Poland (M.Z.); Montreal Heart Institute, University de Montréal, Canada (J.L.R.); and Mayo Clinic, Rochester, MN (R.C.D.)
| | - Robert E Michler
- From Allenort Hospital, Warsaw, Poland and John Paul II Hospital, Krakow, Poland (K.W.); Duke Clinical Research Institute, Durham, NC (S.R.S.); Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC (R.H.J., E.J.V., K.L.L., H.R.A.); University of Utah, Salt Lake City, UT (C.H.S.); Hamilton General Hospital/McMaster University, Hamilton, ON, Canada (A.L.); Shands Hospital at the University of Florida, Gainesville (T.M.B.); Dedinje Cardiovascular Institute, Belgrade, Serbia (L.T.D.); Loma Linda University Medical Center, CA (N.W.); National Institutes of Health/National Heart, Blood, and Lung Institute, Bethesda, MD (G.S.); University of Virginia, Charlottesville (I.L.K.); Baylor University Medical Center, Dallas, TX (J.M.D.); Montefiore Medical Center and Albert Einstein College of Medicine, New York (R.E.M.); St. Vincent's Hospital Melbourne and University of Melbourne, Australia (M.Y.); National Heart Centre Singapore (C.Y.L.); Silesian Center for Heart Diseases in Zabrze, Poland (M.Z.); Montreal Heart Institute, University de Montréal, Canada (J.L.R.); and Mayo Clinic, Rochester, MN (R.C.D.)
| | - Kerry L Lee
- From Allenort Hospital, Warsaw, Poland and John Paul II Hospital, Krakow, Poland (K.W.); Duke Clinical Research Institute, Durham, NC (S.R.S.); Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC (R.H.J., E.J.V., K.L.L., H.R.A.); University of Utah, Salt Lake City, UT (C.H.S.); Hamilton General Hospital/McMaster University, Hamilton, ON, Canada (A.L.); Shands Hospital at the University of Florida, Gainesville (T.M.B.); Dedinje Cardiovascular Institute, Belgrade, Serbia (L.T.D.); Loma Linda University Medical Center, CA (N.W.); National Institutes of Health/National Heart, Blood, and Lung Institute, Bethesda, MD (G.S.); University of Virginia, Charlottesville (I.L.K.); Baylor University Medical Center, Dallas, TX (J.M.D.); Montefiore Medical Center and Albert Einstein College of Medicine, New York (R.E.M.); St. Vincent's Hospital Melbourne and University of Melbourne, Australia (M.Y.); National Heart Centre Singapore (C.Y.L.); Silesian Center for Heart Diseases in Zabrze, Poland (M.Z.); Montreal Heart Institute, University de Montréal, Canada (J.L.R.); and Mayo Clinic, Rochester, MN (R.C.D.)
| | - Michael Yii
- From Allenort Hospital, Warsaw, Poland and John Paul II Hospital, Krakow, Poland (K.W.); Duke Clinical Research Institute, Durham, NC (S.R.S.); Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC (R.H.J., E.J.V., K.L.L., H.R.A.); University of Utah, Salt Lake City, UT (C.H.S.); Hamilton General Hospital/McMaster University, Hamilton, ON, Canada (A.L.); Shands Hospital at the University of Florida, Gainesville (T.M.B.); Dedinje Cardiovascular Institute, Belgrade, Serbia (L.T.D.); Loma Linda University Medical Center, CA (N.W.); National Institutes of Health/National Heart, Blood, and Lung Institute, Bethesda, MD (G.S.); University of Virginia, Charlottesville (I.L.K.); Baylor University Medical Center, Dallas, TX (J.M.D.); Montefiore Medical Center and Albert Einstein College of Medicine, New York (R.E.M.); St. Vincent's Hospital Melbourne and University of Melbourne, Australia (M.Y.); National Heart Centre Singapore (C.Y.L.); Silesian Center for Heart Diseases in Zabrze, Poland (M.Z.); Montreal Heart Institute, University de Montréal, Canada (J.L.R.); and Mayo Clinic, Rochester, MN (R.C.D.)
| | - Chua Yeow Leng
- From Allenort Hospital, Warsaw, Poland and John Paul II Hospital, Krakow, Poland (K.W.); Duke Clinical Research Institute, Durham, NC (S.R.S.); Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC (R.H.J., E.J.V., K.L.L., H.R.A.); University of Utah, Salt Lake City, UT (C.H.S.); Hamilton General Hospital/McMaster University, Hamilton, ON, Canada (A.L.); Shands Hospital at the University of Florida, Gainesville (T.M.B.); Dedinje Cardiovascular Institute, Belgrade, Serbia (L.T.D.); Loma Linda University Medical Center, CA (N.W.); National Institutes of Health/National Heart, Blood, and Lung Institute, Bethesda, MD (G.S.); University of Virginia, Charlottesville (I.L.K.); Baylor University Medical Center, Dallas, TX (J.M.D.); Montefiore Medical Center and Albert Einstein College of Medicine, New York (R.E.M.); St. Vincent's Hospital Melbourne and University of Melbourne, Australia (M.Y.); National Heart Centre Singapore (C.Y.L.); Silesian Center for Heart Diseases in Zabrze, Poland (M.Z.); Montreal Heart Institute, University de Montréal, Canada (J.L.R.); and Mayo Clinic, Rochester, MN (R.C.D.)
| | - Marian Zembala
- From Allenort Hospital, Warsaw, Poland and John Paul II Hospital, Krakow, Poland (K.W.); Duke Clinical Research Institute, Durham, NC (S.R.S.); Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC (R.H.J., E.J.V., K.L.L., H.R.A.); University of Utah, Salt Lake City, UT (C.H.S.); Hamilton General Hospital/McMaster University, Hamilton, ON, Canada (A.L.); Shands Hospital at the University of Florida, Gainesville (T.M.B.); Dedinje Cardiovascular Institute, Belgrade, Serbia (L.T.D.); Loma Linda University Medical Center, CA (N.W.); National Institutes of Health/National Heart, Blood, and Lung Institute, Bethesda, MD (G.S.); University of Virginia, Charlottesville (I.L.K.); Baylor University Medical Center, Dallas, TX (J.M.D.); Montefiore Medical Center and Albert Einstein College of Medicine, New York (R.E.M.); St. Vincent's Hospital Melbourne and University of Melbourne, Australia (M.Y.); National Heart Centre Singapore (C.Y.L.); Silesian Center for Heart Diseases in Zabrze, Poland (M.Z.); Montreal Heart Institute, University de Montréal, Canada (J.L.R.); and Mayo Clinic, Rochester, MN (R.C.D.)
| | - Jean L Rouleau
- From Allenort Hospital, Warsaw, Poland and John Paul II Hospital, Krakow, Poland (K.W.); Duke Clinical Research Institute, Durham, NC (S.R.S.); Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC (R.H.J., E.J.V., K.L.L., H.R.A.); University of Utah, Salt Lake City, UT (C.H.S.); Hamilton General Hospital/McMaster University, Hamilton, ON, Canada (A.L.); Shands Hospital at the University of Florida, Gainesville (T.M.B.); Dedinje Cardiovascular Institute, Belgrade, Serbia (L.T.D.); Loma Linda University Medical Center, CA (N.W.); National Institutes of Health/National Heart, Blood, and Lung Institute, Bethesda, MD (G.S.); University of Virginia, Charlottesville (I.L.K.); Baylor University Medical Center, Dallas, TX (J.M.D.); Montefiore Medical Center and Albert Einstein College of Medicine, New York (R.E.M.); St. Vincent's Hospital Melbourne and University of Melbourne, Australia (M.Y.); National Heart Centre Singapore (C.Y.L.); Silesian Center for Heart Diseases in Zabrze, Poland (M.Z.); Montreal Heart Institute, University de Montréal, Canada (J.L.R.); and Mayo Clinic, Rochester, MN (R.C.D.)
| | - Richard C Daly
- From Allenort Hospital, Warsaw, Poland and John Paul II Hospital, Krakow, Poland (K.W.); Duke Clinical Research Institute, Durham, NC (S.R.S.); Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC (R.H.J., E.J.V., K.L.L., H.R.A.); University of Utah, Salt Lake City, UT (C.H.S.); Hamilton General Hospital/McMaster University, Hamilton, ON, Canada (A.L.); Shands Hospital at the University of Florida, Gainesville (T.M.B.); Dedinje Cardiovascular Institute, Belgrade, Serbia (L.T.D.); Loma Linda University Medical Center, CA (N.W.); National Institutes of Health/National Heart, Blood, and Lung Institute, Bethesda, MD (G.S.); University of Virginia, Charlottesville (I.L.K.); Baylor University Medical Center, Dallas, TX (J.M.D.); Montefiore Medical Center and Albert Einstein College of Medicine, New York (R.E.M.); St. Vincent's Hospital Melbourne and University of Melbourne, Australia (M.Y.); National Heart Centre Singapore (C.Y.L.); Silesian Center for Heart Diseases in Zabrze, Poland (M.Z.); Montreal Heart Institute, University de Montréal, Canada (J.L.R.); and Mayo Clinic, Rochester, MN (R.C.D.)
| | - Hussein R Al-Khalidi
- From Allenort Hospital, Warsaw, Poland and John Paul II Hospital, Krakow, Poland (K.W.); Duke Clinical Research Institute, Durham, NC (S.R.S.); Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC (R.H.J., E.J.V., K.L.L., H.R.A.); University of Utah, Salt Lake City, UT (C.H.S.); Hamilton General Hospital/McMaster University, Hamilton, ON, Canada (A.L.); Shands Hospital at the University of Florida, Gainesville (T.M.B.); Dedinje Cardiovascular Institute, Belgrade, Serbia (L.T.D.); Loma Linda University Medical Center, CA (N.W.); National Institutes of Health/National Heart, Blood, and Lung Institute, Bethesda, MD (G.S.); University of Virginia, Charlottesville (I.L.K.); Baylor University Medical Center, Dallas, TX (J.M.D.); Montefiore Medical Center and Albert Einstein College of Medicine, New York (R.E.M.); St. Vincent's Hospital Melbourne and University of Melbourne, Australia (M.Y.); National Heart Centre Singapore (C.Y.L.); Silesian Center for Heart Diseases in Zabrze, Poland (M.Z.); Montreal Heart Institute, University de Montréal, Canada (J.L.R.); and Mayo Clinic, Rochester, MN (R.C.D.).
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New Insights in the Diagnosis and Treatment of Heart Failure. BIOMED RESEARCH INTERNATIONAL 2015; 2015:265260. [PMID: 26634204 PMCID: PMC4637457 DOI: 10.1155/2015/265260] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Accepted: 06/21/2015] [Indexed: 12/22/2022]
Abstract
Cardiovascular disease is the leading cause of mortality in the US and in westernized countries with ischemic heart disease accounting for the majority of these deaths. Paradoxically, the improvements in the medical and surgical treatments of acute coronary syndrome are leading to an increasing number of “survivors” who are then developing heart failure. Despite considerable advances in its management, the gold standard for the treatment of end-stage heart failure patients remains heart transplantation. Nevertheless, this procedure can be offered only to a small percentage of patients who could benefit from a new heart due to the limited availability of donor organs. The aim of this review is to evaluate the safety and efficacy of innovative approaches in the diagnosis and treatment of patients refractory to standard medical therapy and excluded from cardiac transplantation lists.
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Bonow RO, Castelvecchio S, Panza JA, Berman DS, Velazquez EJ, Michler RE, She L, Holly TA, Desvigne-Nickens P, Kosevic D, Rajda M, Chrzanowski L, Deja M, Lee KL, White H, Oh JK, Doenst T, Hill JA, Rouleau JL, Menicanti L. Severity of Remodeling, Myocardial Viability, and Survival in Ischemic LV Dysfunction After Surgical Revascularization. JACC Cardiovasc Imaging 2015; 8:1121-1129. [PMID: 26363840 PMCID: PMC4633018 DOI: 10.1016/j.jcmg.2015.03.013] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Revised: 02/23/2015] [Accepted: 03/05/2015] [Indexed: 01/22/2023]
Abstract
OBJECTIVES This study sought to test the hypothesis that end-systolic volume (ESV), as a marker of severity of left ventricular (LV) remodeling, influences the relationship between myocardial viability and survival in patients with coronary artery disease and LV systolic dysfunction. BACKGROUND Retrospective studies of ischemic LV dysfunction suggest that the severity of LV remodeling determines whether myocardial viability predicts improved survival with surgical compared with medical therapy, with coronary artery bypass grafting (CABG) only benefitting patients with viable myocardium who have smaller ESV. However, this has not been tested prospectively. METHODS Interactions of end-systolic volume index (ESVI), myocardial viability, and treatment with respect to survival were assessed in patients in the prospective randomized STICH (Comparison of Surgical and Medical Treatment for Congestive Heart Failure and Coronary Artery Disease) trial of CABG versus medical therapy who underwent viability assessment (n = 601; age 61 ± 9 years; ejection fraction ≤35%), with a median follow-up of 5.1 years. Median ESVI was 84 ml/m(2). Viability was assessed by single-photon emission computed tomography or dobutamine echocardiography using pre-specified criteria. RESULTS Mortality was highest among patients with larger ESVI and nonviability (p < 0.001), but no interaction was observed between ESVI, viability status, and treatment assignment (p = 0.491). Specifically, the effect of CABG versus medical therapy in patients with viable myocardium and ESVI ≤84 ml/m(2) (hazard ratio [HR]: 0.85; 95% confidence interval [CI]: 0.56 to 1.29) was no different than in patients with viability and ESVI >84 ml/m(2) (HR: 0.87; 95% CI: 0.57 to 1.31). Other ESVI thresholds yielded similar results, including ESVI ≤60 ml/m(2) (HR: 0.87; 95% CI: 0.44 to 1.74). ESVI and viability assessed as continuous rather than dichotomous variables yielded similar results (p = 0.562). CONCLUSIONS Among patients with ischemic cardiomyopathy, those with greater LV ESVI and no substantial viability had worse prognosis. However, the effect of CABG relative to medical therapy was not differentially influenced by the combination of these 2 factors. Lower ESVI did not identify patients in whom myocardial viability predicted better outcome with CABG relative to medical therapy. (Comparison of Surgical and Medical Treatment for Congestive Heart Failure and Coronary Artery Disease [STICH]; NCT00023595).
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Affiliation(s)
- Robert O Bonow
- Northwestern University Feinberg School of Medicine, Chicago, Illinois.
| | | | | | | | | | | | - Lilin She
- Duke University, Durham, North Carolina
| | - Thomas A Holly
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | | | - Miroslaw Rajda
- Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada
| | | | - Marek Deja
- Medical University of Silesia, Katowice, Poland
| | | | | | - Jae K Oh
- Mayo Clinic, Rochester, Minnesota
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Velazquez EJ, Bonow RO. Revascularization in Severe Left Ventricular Dysfunction. J Am Coll Cardiol 2015; 65:615-24. [DOI: 10.1016/j.jacc.2014.10.070] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Accepted: 10/07/2014] [Indexed: 01/04/2023]
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Bonow RO. Indications for revascularization in patients with left ventricular dysfunction: evidence and uncertainties. J Thorac Cardiovasc Surg 2014; 148:2461-5. [PMID: 25433865 DOI: 10.1016/j.jtcvs.2014.10.100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Robert O Bonow
- Department of Medicine, Center for Cardiovascular Innovation, Northwestern University Feinberg School of Medicine, Chicago, Ill.
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Panza JA, Velazquez EJ, She L, Smith PK, Nicolau JC, Favaloro RR, Gradinac S, Chrzanowski L, Prabhakaran D, Howlett JG, Jasinski M, Hill JA, Szwed H, Larbalestier R, Desvigne-Nickens P, Jones RH, Lee KL, Rouleau JL. Extent of coronary and myocardial disease and benefit from surgical revascularization in ischemic LV dysfunction [Corrected]. J Am Coll Cardiol 2014; 64:553-61. [PMID: 25104523 DOI: 10.1016/j.jacc.2014.04.064] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Revised: 04/17/2014] [Accepted: 04/21/2014] [Indexed: 12/22/2022]
Abstract
BACKGROUND Patients with ischemic left ventricular dysfunction have higher operative risk with coronary artery bypass graft surgery (CABG). However, those whose early risk is surpassed by subsequent survival benefit have not been identified. OBJECTIVES This study sought to examine the impact of anatomic variables associated with poor prognosis on the effect of CABG in ischemic cardiomyopathy. METHODS All 1,212 patients in the STICH (Surgical Treatment of IsChemic Heart failure) surgical revascularization trial were included. Patients had coronary artery disease (CAD) and ejection fraction (EF) of ≤35% and were randomized to receive CABG plus medical therapy or optimal medical therapy (OMT) alone. This study focused on 3 prognostic factors: presence of 3-vessel CAD, EF below the median (27%), and end-systolic volume index (ESVI) above the median (79 ml/m(2)). Patients were categorized as having 0 to 1 or 2 to 3 of these factors. RESULTS Patients with 2 to 3 prognostic factors (n = 636) had reduced mortality with CABG compared with those who received OMT (hazard ratio [HR]: 0.71; 95% confidence interval [CI]: 0.56 to 0.89; p = 0.004); CABG had no such effect in patients with 0 to 1 factor (HR: 1.08; 95% CI: 0.81 to 1.44; p = 0.591). There was a significant interaction between the number of factors and the effect of CABG on mortality (p = 0.022). Although 30-day risk with CABG was higher, a net beneficial effect of CABG relative to OMT was observed at >2 years in patients with 2 to 3 factors (HR: 0.53; 95% CI: 0.37 to 0.75; p<0.001) but not in those with 0 to 1 factor (HR: 0.88; 95% CI: 0.59 to 1.31; p = 0.535). CONCLUSIONS Patients with more advanced ischemic cardiomyopathy receive greater benefit from CABG. This supports the indication for surgical revascularization in patients with more extensive CAD and worse myocardial dysfunction and remodeling. (Comparison of Surgical and Medical Treatment for Congestive Heart Failure and Coronary Artery Disease [STICH]; NCT00023595).
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Affiliation(s)
- Julio A Panza
- Westchester Medical Center and New York Medical College, Valhalla, New York.
| | - Eric J Velazquez
- Duke Clinical Research Institute, Department of Medicine-Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Lilin She
- Duke Clinical Research Institute, Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC
| | - Peter K Smith
- Duke Clinical Research Institute, Department of Surgery-Cardiothoracic, Duke University School of Medicine, Durham, North Carolina
| | - José C Nicolau
- InCor Heart Institute, University of São Paulo Medical School, São Paulo, Brazil
| | | | | | | | | | | | | | - James A Hill
- Shands Hospital at the University of Florida, Gainesville, Florida
| | | | | | | | - Robert H Jones
- Duke Clinical Research Institute, Department of Surgery-Cardiothoracic, Duke University School of Medicine, Durham, North Carolina
| | - Kerry L Lee
- Duke Clinical Research Institute, Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC
| | - Jean L Rouleau
- Montréal Heart Institute, Université de Montréal, Montréal, Quebec, Canada
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21
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Hudson JE, Porrello ER. The non-coding road towards cardiac regeneration. J Cardiovasc Transl Res 2014; 6:909-23. [PMID: 23797382 DOI: 10.1007/s12265-013-9486-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2013] [Accepted: 06/05/2013] [Indexed: 12/31/2022]
Abstract
Our understanding of cardiovascular disease has evolved rapidly, leading to a number of treatments that have improved patient quality of life and mortality rates. However, there is still no cure for heart failure. This has led to the pursuit of cardiac regeneration to prevent, and ultimately cure, this debilitating condition. To this end, several approaches have been proposed, including activation of cardiomyocyte proliferation, activation of endogenous or exogenous stem/progenitor cells, delivery of de novo cardiomyocytes, and in situ direct reprogramming of cardiac fibroblasts. While these different methodologies are currently being intensely investigated, there are still a number of caveats limiting their application in the clinic. Given the emerging regulatory potential of non-coding RNAs for controlling diverse cellular processes, these molecules may offer potential solutions in this pursuit of cardiac regeneration. In this concise review, we discuss the potential role of non-coding RNAs in a variety of different cardiac regenerative approaches.
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Coronary artery disease in patients with heart failure: incidental, coincidental, or a target for therapy? Am J Med 2014; 127:574-8. [PMID: 24561111 DOI: 10.1016/j.amjmed.2014.01.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Revised: 01/29/2014] [Accepted: 01/29/2014] [Indexed: 02/05/2023]
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23
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An approach to the rational use of revascularization in heart failure patients. Can J Cardiol 2013; 30:281-7. [PMID: 24484914 DOI: 10.1016/j.cjca.2013.11.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2013] [Revised: 11/08/2013] [Accepted: 11/11/2013] [Indexed: 11/22/2022] Open
Abstract
The most common cause of heart failure with reduced ejection fraction (HFrEF) is coronary artery disease. A multitude of factors come into play when deciding whether a patient with HFrEF and coronary artery disease should have coronary artery bypass graft (CABG) surgery, percutaneous coronary intervention, or medical therapy alone. For candidates for percutaneous coronary intervention and CABG, evidence from large registries would suggest that patients with 2-vessel coronary artery diseases and proximal left anterior descending disease and all patients with 3-vessel coronary artery disease do better with CABG. For patients that are candidates for medical therapy with or without CABG, the results of the Surgical Treatment for Ischemic Heart Failure (STICH) trial indicate that with CABG, the reduction of mortality is not statistically significant (hazard ratio [HR], 0.86; P = 0.12). However, CABG is superior in reducing cardiovascular deaths (HR, 0.81; P = 0.05), and the combination of cardiovascular deaths and cardiovascular hospitalizations (HR, 0.74; P < 0.001). Patients undergoing CABG have an upfront risk that is eliminated by 2 years and thereafter do better. The assessment of cardiac viability or reversible ischemia does not appear to be helpful in determining which individuals will improve more with CABG. Patients with severe mitral regurgitation who undergo CABG appear to benefit from simultaneous valve repair but not from the addition of surgical ventricular reconstruction of the left ventricle, although in specific patients this might be considered. The totality of evidence would thus suggest that patients with HFrEF should be evaluated for the possibility of coronary revascularization if they are candidates for CABG.
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Moe GW, Ezekowitz JA, O'Meara E, Howlett JG, Fremes SE, Al-Hesayen A, Heckman GA, Ducharme A, Estrella-Holder E, Grzeslo A, Harkness K, Lepage S, McDonald M, McKelvie RS, Nigam A, Rajda M, Rao V, Swiggum E, Virani S, Van Le V, Zieroth S, Arnold JMO, Ashton T, D'Astous M, Dorian P, Giannetti N, Haddad H, Isaac DL, Kouz S, Leblanc MH, Liu P, Ross HJ, Sussex B, White M. The 2013 Canadian Cardiovascular Society Heart Failure Management Guidelines Update: focus on rehabilitation and exercise and surgical coronary revascularization. Can J Cardiol 2013; 30:249-63. [PMID: 24480445 DOI: 10.1016/j.cjca.2013.10.010] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Revised: 10/09/2013] [Accepted: 10/09/2013] [Indexed: 12/25/2022] Open
Abstract
The 2013 Canadian Cardiovascular Society Heart Failure Management Guidelines Update provides focused discussions on the management recommendations on 2 topics: (1) exercise and rehabilitation; and (2) surgical coronary revascularization in patients with heart failure. First, all patients with stable New York Heart Association class I-III symptoms should be considered for enrollment in a tailored exercise training program, to improve exercise tolerance and quality of life. Second, selected patients with suitable coronary anatomy should be considered for bypass graft surgery. As in previous updates, the topics were chosen in response to stakeholder feedback. The 2013 Update also includes recommendations, values and preferences, and practical tips to assist the clinicians and health care workers manage their patients with heart failure.
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Affiliation(s)
- Gordon W Moe
- St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
| | | | - Eileen O'Meara
- Institut de Cardiologie de Montréal, Montreal, Québec, Canada
| | | | - Steve E Fremes
- Sunnybrook Health Science Centre, Toronto, Ontario, Canada
| | - Abdul Al-Hesayen
- St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | - Anique Ducharme
- Institut de Cardiologie de Montréal, Montreal, Québec, Canada
| | | | - Adam Grzeslo
- Joseph Brant Memorial Hospital, Burlington, Ontario, Canada; Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Karen Harkness
- Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Serge Lepage
- Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Michael McDonald
- University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Robert S McKelvie
- Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Anil Nigam
- Institut de Cardiologie de Montréal, Montreal, Québec, Canada
| | - Miroslaw Rajda
- QE II Health Sciences Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Vivek Rao
- University Health Network, University of Toronto, Toronto, Ontario, Canada
| | | | - Sean Virani
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Vy Van Le
- Centre Hospitalier Universitaire de l'Université de Montréal, Québec, Canada
| | - Shelley Zieroth
- Cardiac Sciences Program, St Boniface General Hospital, Winnipeg, Manitoba, Canada
| | | | | | | | - Paul Dorian
- St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | - Simon Kouz
- Centre Hospitalier Régional de Lanaudière, Joliette, and Université Laval, Québec, Canada
| | | | - Peter Liu
- Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Heather J Ross
- University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Bruce Sussex
- Health Sciences Centre, St John's, Newfoundland, Canada
| | - Michel White
- Institut de Cardiologie de Montréal, Montreal, Québec, Canada
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25
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Shoaib A, Mabote T, Zuhair M, Kassianides X, Cleland JGF. Acute heart failure (suspected or confirmed): Initial diagnosis and subsequent evaluation with traditional and novel technologies. ACTA ACUST UNITED AC 2013. [DOI: 10.4236/wjcd.2013.33046] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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