Cardiovascular events in patients with coronary artery disease with and without myocardial ischemia: Long-term follow-up.

BACKGROUND: After the results of the ISCHEMIA Trial, the role of myocardial ischemia in the prognosis of coronary artery disease (CAD) was under debate. We sought to comparatively evaluate the long-term prognosis of patients with multivessel CAD with or without documented myocardial ischemia. METHODS: This is a single-center, retrospective, observational cohort study that included patients with CAD obtained from the research protocols database of "The Medicine, Angioplasty or Surgery Study," the MASS Study Group. Patients were stratified according to the presence or absence of myocardial ischemia. Cardiovascular events (overall mortality and myocardial infarction) were tracked from the registry entry up to a median follow-up of 8.7 years. Myocardial ischemia was assessed at baseline by a functional test with or without imaging. RESULTS: From 1995 to 2018, 2015 patients with multivessel CAD were included. Of these, 1001 presented with conclusive tests at registry entry, 790 (79%) presenting with ischemia and 211 (21%) without ischemia. The median follow-up was 8.7 years (IQR 4.04 to 10.07). The primary outcome occurred in 228 (28.9%) patients with ischemia and in 64 (30.3%) patients without ischemia (plog-rank=0.60). No significant interaction was observed with the presence of myocardial ischemia and treatment strategies in the occurrence of the combined primary outcome (pinteration=0.14). CONCLUSIONS: In this sample, myocardial ischemia was not associated with a worse prognosis compared with no ischemia in patients with multivessel CAD. These results refer to debates about the role of myocardial ischemia in the occurrence of cardiovascular events.

Ischemic left ventricle systolic dysfunction: An evidence-based approach in diagnostic tools and therapeutics.

Coronary artery disease (CAD) associated with left ventricular systolic dysfunction is a condition related to poor prognosis. There is a lack of robust evidence in many aspects related to this condition, from definition to treatment. Ischemic cardiomyopathy is a spectrum ranging from stunned myocardium associated with myocardial fibrosis to hibernating myocardium and repetitive episodes of ischemia. In clinical practice, relevance lies in identifying the myocardium that has the ability to recover its contractile reserve after revascularization. Methods to evaluate cellular integrity tend to have higher sensitivity, while the ones assessing contractile reserve have greater specificity, since a larger mass of viable myocytes is required in order to generate contractility change. Since there are many methods and different ways to detect viability, sensitivity and specificity vary widely. Dobutamine-cardiac magnetic resonance with late gadolinium enhancement has the best accuracy is this setting, giving important predictors of prognostic and revascularization benefit such as scar burden, contractile reserve and end-systolic volume index. The latter has shown differential benefit with revascularization in some recent trials. Finally, authors discuss interventional procedures in this population, focusing on coronary artery bypass grafting and evolution of evidence from CASS to post-STICH era.

Ischemic left ventricle systolic dysfunction: An evidence-based approach in diagnostic tools and therapeutics / Miocardiopatia isquêmica: uma abordagem diagnóstica e terapêutica baseada em evidências

Summary Coronary artery disease (CAD) associated with left ventricular systolic dysfunction is a condition related to poor prognosis. There is a lack of robust evidence in many aspects related to this condition, from definition to treatment. Ischemic cardiomyopathy is a spectrum ranging from stunned myocardium associated with myocardial fibrosis to hibernating myocardium and repetitive episodes of ischemia. In clinical practice, relevance lies in identifying the myocardium that has the ability to recover its contractile reserve after revascularization. Methods to evaluate cellular integrity tend to have higher sensitivity, while the ones assessing contractile reserve have greater specificity, since a larger mass of viable myocytes is required in order to generate contractility change. Since there are many methods and different ways to detect viability, sensitivity and specificity vary widely. Dobutamine-cardiac magnetic resonance with late gadolinium enhancement has the best accuracy is this setting, giving important predictors of prognostic and revascularization benefit such as scar burden, contractile reserve and end-systolic volume index. The latter has shown differential benefit with revascularization in some recent trials. Finally, authors discuss interventional procedures in this population, focusing on coronary artery bypass grafting and evolution of evidence from CASS to post-STICH era.

Resumo A doença arterial coronariana (DAC) associada à disfunção sistólica do ventrículo esquerdo é uma condição relacionada a mau prognóstico. Há uma falta de evidência robusta em muitos aspectos relacionados a essa condição, desde a definição ao tratamento. A cardiomiopatia isquêmica é um espectro que varia de miocárdio atordoado por fibrose miocárdica, passando por miocárdio hibernante, a episódios repetitivos de isquemia. Na prática clínica, a importância do problema é identificar o miocárdio que tem a capacidade de recuperar sua reserva contrátil após revascularização. Métodos para avaliar a integridade celular tendem a ter maior sensibilidade, enquanto os que avaliam a reserva contrátil têm maior especificidade, uma vez que uma maior massa de miócitos viáveis para gerar uma mudança de contratilidade é necessária. Tendo em vista que existem muitos métodos e diferentes formas de detecção de viabilidade, a sensibilidade e a especificidade variam amplamente. O uso da ressonância magnética cardíaca com detecção de realce tardio associada a estresse com dobutamina tem a melhor acurácia na avaliação de viabilidade, além de fornecer importantes preditores de benefício prognóstico com a revascularização, tais como carga de cicatriz, reserva contrátil e índice de volume sistólico final. Finalmente, os autores discutem sobre procedimentos intervencionistas nessa população, com foco na revascularização cirúrgica do miocárdio e na evolução da evidência desde o estudo CASS até os trials da era pós-STICH.