Early revascularization lowers mortality risk in myocardial ischemic regardless of LVEF status: JACC
USA: Early myocardial revascularization may be beneficial over medical therapy for a significant reduction in mortality among patients with severe inducible ischemia on SPECT testing, a recent observational analysis suggests. The benefit was seen regardless of the baseline left ventricular ejection fraction (LVEF), according to the study published in the Journal of the American College of Cardiology (JACC).
There is no information on the use of performing early myocardial revascularization in patients presenting with inducible myocardial ischemia and low left ventricular ejection fraction. To fill this knowledge gap, Alan Rozanski, Mount Sinai Morningside Hospital and Mount Sinai Heart, New York, New York, USA, and colleagues aimed to assess the relationship between stress-induced myocardial ischemia, revascularization, and all-cause mortality (ACM) among patients with normal vs low LVEF.
For this purpose, the researchers evaluated 43,443 patients undergoing a stress-rest single-photon emission computed tomography myocardial perfusion imaging from 1998 to 2017 and followed for a median of 11.4 years. An assessment of myocardial ischemia was done for its interaction between early revascularization and mortality.
To adjust for nonrandomization to revascularization, a propensity score was used followed by multivariable Cox modeling adjusted for the propensity score and clinical variables to predict ACM.
The findings of the study were as follows:
- The frequency of myocardial ischemia varied markedly according to LVEF and angina, ranging from 6.7% among patients with LVEF ≥55% and no typical angina to 64.0% among patients with LVEF <45% and typical angina.
- Among 39,883 patients with LVEF ≥45%, early revascularization was associated with increased mortality risk among patients without ischemia and lower mortality risk among patients with severe (≥15%) ischemia (HR: 0.70).
- Among 3,560 patients with LVEF <45%, revascularization was not associated with mortality benefit among patients with no or mild ischemia and was associated with decreased mortality among patients with moderate (10%-14%) (HR: 0.67) and severe (≥15%) (HR: 0.55) ischemia.
"Early myocardial revascularization within this cohort was associated with a significant reduction in mortality among both patients with normal LVEF and severe inducible myocardial ischemia and patients with low LVEF and moderate or severe inducible myocardial ischemia," the researchers concluded.
Reference:
Rozanski A, Miller RJH, Gransar H, et al. Benefit of early ischemia based on inducible ischemia and left ventricular ejection fraction. J Am Coll Cardiol. 2022;80:202-215.
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