Inducible myocardial ischemia and outcomes in patients with coronary artery disease and left ventricular dysfunction

Julio A. Panza, Thomas A. Holly, Federico M. Asch, Lilin She, Patricia Pellikka, Eric J. Velazquez, Kerry L. Lee, Salvador Borges-Neto, Pedro S. Farsky, Robert H. Jones, Daniel S. Berman, Robert O. Bonow

Research output: Contribution to journalArticle

103 Citations (Scopus)

Abstract

Objectives: The study objectives were to test the hypotheses that ischemia during stress testing has prognostic value and identifies those patients with coronary artery disease (CAD) with left ventricular (LV) dysfunction who derive the greatest benefit from coronary artery bypass grafting (CABG) compared with medical therapy. Background: The clinical significance of stress-induced ischemia in patients with CAD and moderately to severely reduced LV ejection fraction (EF) is largely unknown. Methods: The STICH (Surgical Treatment for IsChemic Heart Failure) trial randomized patients with CAD and EF ≤35% to CABG or medical therapy. In the current study, we assessed the outcomes of those STICH patients who underwent a radionuclide (RN) stress test or a dobutamine stress echocardiogram (DSE). A test was considered positive for ischemia by RN testing if the summed difference score (difference in tracer activity between stress and rest) was ≥4 or if ≥2 of 16 segments were ischemic during DSE. Clinical endpoints were assessed by intention to treat during a median follow-up of 56 months. Results: Of the 399 study patients (51 women, mean EF 26 ± 8%), 197 were randomized to CABG and 202 were randomized to medical therapy. Myocardial ischemia was induced during stress testing in 256 patients (64% of the study population). Patients with and without ischemia were similar in age, multivessel CAD, previous myocardial infarction, LV EF, LV volumes, and treatment allocation (all p = NS). There was no difference between patients with and without ischemia in all-cause mortality (hazard ratio: 1.08; 95% confidence interval: 0.77 to 1.50; p = 0.66), cardiovascular mortality, or all-cause mortality plus cardiovascular hospitalization. There was no interaction between ischemia and treatment for any clinical endpoint. Conclusions: In CAD with severe LV dysfunction, inducible myocardial ischemia does not identify patients with worse prognosis or those with greater benefit from CABG over optimal medical therapy. (Comparison of Surgical and Medical Treatment for Congestive Heart Failure and Coronary Artery Disease [STICH]; NCT00023595)

Original languageEnglish (US)
Pages (from-to)1860-1870
Number of pages11
JournalJournal of the American College of Cardiology
Volume61
Issue number18
DOIs
StatePublished - May 7 2013

Fingerprint

Left Ventricular Dysfunction
Myocardial Ischemia
Coronary Artery Disease
Ischemia
Coronary Artery Bypass
Heart Failure
Therapeutics
Dobutamine
Radioisotopes
Stroke Volume
Mortality
Exercise Test
Hospitalization
Myocardial Infarction
Confidence Intervals

Keywords

  • coronary artery disease
  • heart failure
  • left ventricular dysfunction
  • myocardial ischemia
  • outcomes

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine

Cite this

Inducible myocardial ischemia and outcomes in patients with coronary artery disease and left ventricular dysfunction. / Panza, Julio A.; Holly, Thomas A.; Asch, Federico M.; She, Lilin; Pellikka, Patricia; Velazquez, Eric J.; Lee, Kerry L.; Borges-Neto, Salvador; Farsky, Pedro S.; Jones, Robert H.; Berman, Daniel S.; Bonow, Robert O.

In: Journal of the American College of Cardiology, Vol. 61, No. 18, 07.05.2013, p. 1860-1870.

Research output: Contribution to journalArticle

Panza, JA, Holly, TA, Asch, FM, She, L, Pellikka, P, Velazquez, EJ, Lee, KL, Borges-Neto, S, Farsky, PS, Jones, RH, Berman, DS & Bonow, RO 2013, 'Inducible myocardial ischemia and outcomes in patients with coronary artery disease and left ventricular dysfunction', Journal of the American College of Cardiology, vol. 61, no. 18, pp. 1860-1870. https://doi.org/10.1016/j.jacc.2013.02.014
Panza, Julio A. ; Holly, Thomas A. ; Asch, Federico M. ; She, Lilin ; Pellikka, Patricia ; Velazquez, Eric J. ; Lee, Kerry L. ; Borges-Neto, Salvador ; Farsky, Pedro S. ; Jones, Robert H. ; Berman, Daniel S. ; Bonow, Robert O. / Inducible myocardial ischemia and outcomes in patients with coronary artery disease and left ventricular dysfunction. In: Journal of the American College of Cardiology. 2013 ; Vol. 61, No. 18. pp. 1860-1870.
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abstract = "Objectives: The study objectives were to test the hypotheses that ischemia during stress testing has prognostic value and identifies those patients with coronary artery disease (CAD) with left ventricular (LV) dysfunction who derive the greatest benefit from coronary artery bypass grafting (CABG) compared with medical therapy. Background: The clinical significance of stress-induced ischemia in patients with CAD and moderately to severely reduced LV ejection fraction (EF) is largely unknown. Methods: The STICH (Surgical Treatment for IsChemic Heart Failure) trial randomized patients with CAD and EF ≤35{\%} to CABG or medical therapy. In the current study, we assessed the outcomes of those STICH patients who underwent a radionuclide (RN) stress test or a dobutamine stress echocardiogram (DSE). A test was considered positive for ischemia by RN testing if the summed difference score (difference in tracer activity between stress and rest) was ≥4 or if ≥2 of 16 segments were ischemic during DSE. Clinical endpoints were assessed by intention to treat during a median follow-up of 56 months. Results: Of the 399 study patients (51 women, mean EF 26 ± 8{\%}), 197 were randomized to CABG and 202 were randomized to medical therapy. Myocardial ischemia was induced during stress testing in 256 patients (64{\%} of the study population). Patients with and without ischemia were similar in age, multivessel CAD, previous myocardial infarction, LV EF, LV volumes, and treatment allocation (all p = NS). There was no difference between patients with and without ischemia in all-cause mortality (hazard ratio: 1.08; 95{\%} confidence interval: 0.77 to 1.50; p = 0.66), cardiovascular mortality, or all-cause mortality plus cardiovascular hospitalization. There was no interaction between ischemia and treatment for any clinical endpoint. Conclusions: In CAD with severe LV dysfunction, inducible myocardial ischemia does not identify patients with worse prognosis or those with greater benefit from CABG over optimal medical therapy. (Comparison of Surgical and Medical Treatment for Congestive Heart Failure and Coronary Artery Disease [STICH]; NCT00023595)",
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AU - Pellikka, Patricia

AU - Velazquez, Eric J.

AU - Lee, Kerry L.

AU - Borges-Neto, Salvador

AU - Farsky, Pedro S.

AU - Jones, Robert H.

AU - Berman, Daniel S.

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