Myocardial revascularization improves myocardial function and prognosis in ischemic cardiomyopathy

"The largest randomized trial in ICM (STITCH) suggests that surgical revascularization improves patients' prognosis at long-term follow-up, whereas evidence shows no benefit of percutaneous coronary intervention," stated the article. "Data from randomized controlled trials do not favour myocardial ischemia or viability testing for guiding treatment."

Based on the findings, Riccardo Liga, University of Pisa, Italy, and colleagues proposed an algorithm for the workup of patients with ICM considering clinical presentation, surgical risk, and imaging results.

The investigators searched for randomized controlled trials assessing the prognostic impact of revascularization in ICM and the value of viability imaging for patient management. 4 randomized controlled trials enrolling 2480 patients were included out of 1397 publications. Three trials (STICH, HEART, and REVIVED ‐BCIS2) randomized patients to optimal medical therapy or revascularization.

The research revealed the following findings:

• HEART was stopped prematurely without showing any significant difference between treatment strategies.

· STICH showed a 16% lower mortality with bypass surgery compared with optimal medical therapy at a median follow‐up of 9.8 years.

· Neither the presence/extent of left ventricle viability nor ischemia interacted with treatment outcomes.

· REVIVED‐BCIS2 showed no difference in the primary endpoint between percutaneous revascularization or optimal medical therapy.

· PARR‐2 (Positron Emission Tomography and Recovery Following Revascularization) randomized patients to imaging‐guided revascularization versus standard care, with neutral results overall. Information regarding the consistency of patient management with viability testing results was available in ≈65% of patients (n=1623).

· No difference in survival was revealed according to adherence or no adherence to viability imaging.

The research showed that neither the myocardial viability nor the extent of left inducible ventricular ischemia appears to interact with treatment strategies, favourably affecting outcomes.

Also, the role of pretreatment assessment of myocardial viability in guiding treatment and predicting the patient's benefit from myocardial revascularization can be affirmed and refuted.

The authors conclude, "the available evidence supports surgical revascularization in patients with CAD (coronary artery disease) and severely depressed systolic function. However, the benefit of coronary bypass surgery over optimal medical therapy appears to become significant only late during a long‐term follow‐up."

Reference:

The study, "Myocardial Revascularization in Patients With Ischemic Cardiomyopathy: For Whom and How" was published in the Journal of the American Heart Association. https://www.ahajournals.org/doi/full/10.1161/JAHA.122.026943