Global burden of cardiovascular disease attributable to smoking, 1990-2019: an analysis of the 2019 Global Burden of Disease Study.

AIMS: This study aims to investigate the trends in the global cardiovascular disease (CVD) burden attributable to smoking from 1990 to 2019. METHODS AND RESULTS: Global Burden of Disease Study 2019 was used to analyse the burden of CVD attributable to smoking (i.e. ischaemic heart disease, peripheral artery disease, stroke, atrial fibrillation and flutter, and aortic aneurysm). Age-standardized mortality rates (ASMRs) per 100 000 and age-standardized disability-adjusted life year rates (ASDRs) per 100 000, as well as an estimated annual percentage change (EAPC) in ASMR and ASDR, were determined by age, sex, year, socio-demographic index (SDI), regions, and countries or territories. The global ASMR of smoking-attributed CVD decreased from 57.16/100 000 [95% uncertainty interval (UI) 54.46-59.97] in 1990 to 33.03/100 000 (95% UI 30.43-35.51) in 2019 [EAPC -0.42 (95% UI -0.47 to -0.38)]. Similarly, the ASDR of smoking-attributed CVD decreased between 1990 and 2019. All CVD subcategories showed a decline in death burden between 1990 and 2019. The burden of smoking-attributed CVD was higher in men than in women. Significant geographic and regional variations existed such that Eastern Europe had the highest ASMR and Andean Latin America had the lowest ASMR in 2019. In 2019, the ASMR of smoking-attributed CVD was lowest in high SDI regions. CONCLUSION: Smoking-attributed CVD morbidity and mortality are declining globally, but significant variation persists, indicating a need for targeted interventions to reduce smoking-related CVD burden.

The burden of cardiovascular disease (CVD) attributed to smoking declined worldwide between 1990 and 2019. The burden of smoking-attributed CVD was higher in men than in women in 2019. There were significant variations between different countries and regions such that Eastern Europe had the highest death rate and Andean Latin America had the lowest death rate in 2019. Also, countries with high socio-economic status had lower death rates from smoking-attributed CVD. This highlights the need for targeted interventions to reduce the burden of smoking-attributed CVD. The overall age-adjusted deaths from CVD attributed to smoking declined from 57.16/100 000 in 1990 to 33.03/100 000 in 2019.In 2019, ischaemic heart disease was the leading cause of smoking-attributed CVD deaths.

The Evolving Paradigm of Revascularization in Ischemic Cardiomyopathy: from Recovery of Systolic Function to Protection Against Future Ischemic Events.

PURPOSE OF REVIEW: We aim to reevaluate how the assessment of myocardial viability can guide optimal treatment strategies for patients with ischemic cardiomyopathy (ICM) based on a more contemporary understanding of the mechanism of benefit of revascularization. RECENT FINDINGS: The assessment of viability in left ventricular (LV) segments with diminished contraction has been proposed as key to predict the benefit of revascularization and, therefore, as a requisite for the selection of patients to undergo this form of treatment. However, data from prospective trials have diverged from earlier retrospective studies. Traditional binary viability assessment may oversimplify ICM's complexity and the nuances of revascularization benefits. A conceptual shift from the traditional paradigm centered on the assessment of viability as a dichotomous variable to a more comprehensive approach encompassing a thorough understanding of ICM's complex pathophysiology and the salutary effect of revascularization in the prevention of myocardial infarction and ventricular arrhythmias is required.

Nationwide Analysis of Cardiac Arrest Outcomes During the COVID-19 Pandemic.

The coronavirus disease 2019 (COVID-19) pandemic had a significant impact on the chain of survival following cardiac arrest. However, large population-based reports of COVID-19 in patients hospitalized after cardiac arrest are limited. The National Inpatient Sample database was queried for cardiac arrest admissions during 2020 in the United States. Propensity score matching was used to match patients with and without concurrent COVID-19 according to age, race, sex, and comorbidities. Multivariate logistic regression analysis was used to identify predictors of mortality. A weighted total of 267,845 hospitalizations for cardiac arrest were identified, among which 44,105 patients (16.5%) had a concomitant diagnosis of COVID-19. After propensity matching, cardiac arrest patients with concomitant COVID-19 had higher rate of acute kidney injury requiring dialysis (64.9% vs 54.8%) mechanical ventilation >24 hours (53.6% vs 44.6%) and sepsis (59.4% vs 40.4%) compared to cardiac arrest patients without COVID-19. In contrast, cardiac arrest patients with COVID-19 had lower rates of cardiogenic shock (3.2% vs 5.4%, P < 0.001), ventricular tachycardia (9.6% vs 11.7%, P < 0.001), and ventricular fibrillation (6.7% vs 10.8%, P < 0.001), and a lower utilization of cardiac procedures. In-hospital mortality was higher in patients with COVID-19 (86.9% vs 65.5%, P < 0.001) and, on multivariate analysis, a diagnosis of COVID-19 was an independent predictor of mortality. Among patients hospitalized following a cardiac arrest during 2020, concomitant COVID-19 infection was associated with significantly worse outcomes characterized by an increased risk of sepsis, pulmonary and renal dysfunction, and death.

Pharmacotherapies in Heart Failure With Preserved Ejection Fraction: A Systematic Review and Network Meta-Analysis.

Various pharmacotherapies exist for heart failure with preserved ejection fraction (HFpEF), but with unclear comparative efficacy. We searched EMBASE, Medline, and Cochrane Library from inception through August 2021 for all randomized clinical trials in HFpEF (EF >40%) that evaluated beta-blockers, mineralocorticoid receptor antagonist (MRA), angiotensin-converting enzyme inhibitors (ACE), angiotensin receptor blockers (ARB), angiotensin receptor-neprilysin inhibitor (ARNI), and sodium-glucose cotransporter-2 inhibitors (SGLT2i). Outcomes assessed were cardiovascular mortality, all-cause mortality, and HF hospitalization. A frequentist network meta-analysis was performed with a random-effects model. We included 22 randomized clinical trials (30,673 participants; mean age = 71.7 ± 4.2 years; females = 49.3 ± 7.7%; median follow-up = 24.4 ± 11.1 months). Compared with placebo, there was no statistically significant difference in cardiovascular mortality [beta-blockers; odds ratio (OR) 0.79 (0.46-1.34), MRA; OR 0.90 (0.70-1.14), ACE OR 0.95 (0.59-1.53), ARB; OR 1.02 (0.87-1.19), ARNI; OR 0.97 (0.74-1.26) and SGLT2i; OR 1.00 (0.84-1.18)] or all-cause mortality [beta blockers; OR 0.75 (0.54-1.04), MRA; OR 0.90 (0.75-1.08) ACE; OR 1.05 (0.71-1.54), ARB; OR 1.03 (0.91-1.15), ARNI; OR 0.99 (0.82-1.20) and SGLT2i; OR 1.00 (0.89-1.13)]. The certainty in these estimates was low or very low. There was a significantly reduction in HF hospitalization with the use of SGLT2i [OR 0.71 (0.62-0.82), moderate certainty], ARNI [OR 0.77 (0.63-0.94), low certainty], and MRA [OR 0.81 (0.66-0.98), moderate certainty]; with corresponding P scores of 0.84, 0.68, and 0.58, respectively. In HFpEF, the use of beta-blockers, MRA, ACE/ARB/ARNI, or SGLT2i was not associated with improved cardiovascular or all-cause mortality. SGLT2i, ARNI, and MRA reduced the risk of HF hospitalizations.

The Challenge of Pregnancy in Women With Hypertrophic Cardiomyopathy.

Hypertrophic cardiomyopathy is a genetic disease that frequently presents at a young age. Pregnancy represents a state of high physiological stress to the cardiovascular system. Thus, pregnant women with hypertrophic cardiomyopathy face the potential for higher morbidity and, therefore, their management may become a significant challenge when complications develop. Physiologic changes that occur during pregnancy, that is, decreased vascular resistance, increased blood volume, and increased heart rate can lead to worsening heart failure in women with hypertrophic cardiomyopathy. In addition, pregnant women with hypertrophic cardiomyopathy are at higher risk for arrhythmias. The hemodynamic effects of atrial fibrillation and ventricular tachycardia are significant and can be dangerous for the mother and the fetus. In addition, they can lead to heart failure exacerbation. Atrial fibrillation is of particular interest in this population subgroup. Pregnancy is a hypercoagulable state and atrial fibrillation is an arrhythmia associated with significant thromboembolic complications. Patients with hypertrophic cardiomyopathy that develop atrial fibrillation are especially at a higher risk of thrombosis. Anticoagulation is recommended regardless of CHA2DS2-VASc score. Anticoagulation during pregnancy is challenging not only because of the teratogenic effects of some drugs and the lack of evidence for some others, but also the differences in the plasma concentration of many anticoagulants. Overall, the potential for high morbidity in pregnant women with hypertrophic cardiomyopathy is not negligible. Major cardiac events such as arrhythmias and heart failure are common. However, early recognition and treatment of these complications can lead to full-term pregnancy and successful delivery.

Trends in 10-Year Predicted Risk of Cardiovascular Disease Associated With Food Insecurity, 2007-2016.

Introduction: Consumption of a healthy diet improves cardiovascular (CV) risk factors and reduces the development of cardiovascular disease (CVD). Food insecure (FIS) adults often consume an unhealthy diet, which can promote obesity, type 2 diabetes mellitus (T2DM), hypertension (HTN), and hyperlipidemia (HLD). The Supplemental Nutrition Assistance Program (SNAP) is designed to combat food insecurity by increasing access to healthy foods. However, there is a paucity of data on the association of SNAP participation among FIS adults and these CVD risk factors. Methods: The National Health and Nutrition Examination Survey (NHANES) is a publicly available, ongoing survey administered by the Centers for Disease Control and Prevention and the National Center for Health Statistics. We analyzed five survey cycles (2007-2016) of adult participants who responded to the CVD risk profile questionnaire data. We estimated the burden of select CVD risk factors among the FIS population and the association with participation in SNAP. Results: Among 10,449 adult participants of the survey, 3,485 (33.3%) identified themselves as FIS. Food insecurity was more common among those who were younger, female, Hispanic, and Black. Among the FIS, SNAP recipients, when compared to non-SNAP recipients, had a lower prevalence of HLD (36.3 vs. 40.1% p = 0.02), whereas rates of T2DM, HTN, and obesity were similar. Over the 10-year survey period, FIS SNAP recipients demonstrated a reduction in the prevalence of HTN (p < 0.001) and HLD (p < 0.001) which was not evident among those not receiving SNAP. However, obesity decreased only among those not receiving SNAP. The prevalence of T2DM did not change over the study period in either group. Conclusion: Over a 10-year period, FIS adults who received SNAP demonstrated a reduction in the prevalence of HTN and HLD, which was not seen among those not receiving SNAP. However, the prevalence of obesity and T2DM did not decline among SNAP recipients, suggesting that additional approaches are required to impact these important CVD risk factors.

Ecpella 5.5: An Evolution in the Management of Mechanical Circulatory Support.

There are several endovascular options for temporary mechanical circulatory support in patients with refractory cardiogenic shock. These devices are often utilized in tandem to provide maximal support, including the combination of venoarterial extracorporeal membrane oxygenation with the Impella device, termed ECPELLA. An underappreciated characteristic of mechanical circulatory support is whether they provide cardiac "replacement" and/or cardiac "assistance." Within this framework, we propose an evolution in the approach to ECPELLA utilizing the Impella 5.5, with a focus on the Impella 5.5 as the primary support device.

Cost-Effectiveness of Coronary Artery Bypass Surgery Versus Medicine in Ischemic Cardiomyopathy: The STICH Randomized Clinical Trial.

BACKGROUND: The STICH Randomized Clinical Trial (Surgical Treatment for Ischemic Heart Failure) demonstrated that coronary artery bypass grafting (CABG) reduced all-cause mortality rates out to 10 years compared with medical therapy alone (MED) in patients with ischemic cardiomyopathy and reduced left ventricular function (ejection fraction ≤35%). We examined the economic implications of these results. METHODS: We used a decision-analytic patient-level simulation model to estimate the lifetime costs and benefits of CABG and MED using patient-level resource use and clinical data collected in the STICH trial. Patient-level costs were calculated by applying externally derived US cost weights to resource use counts during trial follow-up. A 3% discount rate was applied to both future costs and benefits. The primary outcome was the incremental cost-effectiveness ratio assessed from the US health care sector perspective. RESULTS: For the CABG arm, we estimated 6.53 quality-adjusted life-years (95% CI, 5.70-7.53) and a lifetime cost of $140 059 (95% CI, $106 401 to $180 992). For the MED arm, the corresponding estimates were 5.52 (95% CI, 5.06-6.09) quality-adjusted life-years and $74 894 lifetime cost (95% CI, $58 372 to $93 541). The incremental cost-effectiveness ratio for CABG compared with MED was $63 989 per quality-adjusted life-year gained. At a societal willingness-to-pay threshold of $100 000 per quality-adjusted life-year gained, CABG was found to be economically favorable compared with MED in 87% of microsimulations. CONCLUSIONS: In the STICH trial, in patients with ischemic cardiomyopathy and reduced left ventricular function, CABG was economically attractive relative to MED at current benchmarks for value in the United States. REGISTRATION: URL: https://www. CLINICALTRIALS: gov; Unique identifier: NCT00023595.

Optimal medical therapy with or without surgical revascularization and long-term outcomes in ischemic cardiomyopathy.

OBJECTIVES: Optimal medical therapy in patients with heart failure and coronary artery disease is associated with improved outcomes. However, whether this association is influenced by the performance of coronary artery bypass grafting is less well established. Thus, the aim of this study was to determine the possible relationship between coronary artery bypass grafting and optimal medical therapy and its effect on the outcomes of patients with ischemic cardiomyopathy. METHODS: The Surgical Treatment for Ischemic Heart Failure trial randomized 1212 patients with coronary artery disease and left ventricular ejection fraction 35% or less to coronary artery bypass grafting with medical therapy or medical therapy alone with a median follow-up over 9.8 years. For the purpose of this study, optimal medical therapy was collected at baseline and 4 months, and defined as the combination of 4 drugs: angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, beta-blocker, statin, and 1 antiplatelet drug. RESULTS: At baseline and 4 months, 58.7% and 73.3% of patients were receiving optimal medical therapy, respectively. These patients had no differences in important parameters such as left ventricular ejection fraction and left ventricular volumes. In a multivariable Cox model, optimal medical therapy at baseline was associated with a lower all-cause mortality (hazard ratio, 0.78; 95% confidence interval, 0.66-0.91; P = .001). When landmarked at 4 months, optimal medical therapy was also associated with a lower all-cause mortality (hazard ratio, 0.82; 95% confidence interval, 0.62-0.99; P = .04). There was no interaction between the benefit of optimal medical therapy and treatment allocation. CONCLUSIONS: Optimal medical therapy was associated with improved long-term survival and lower cardiovascular mortality in patients with ischemic cardiomyopathy and should be strongly recommended.

Role of MicroRNA in Heart Transplant.

The need for noninvasive biomarkers for diagnostic, prognostic, and therapeutic purposes is increasingly being recognized in the field of heart transplantation. MicroRNAs are a class of novel biomarkers that control gene expression and influence cellular functions, including differentiation, proliferation, and functional regulation of the immune system. They can be detected in the serum, plasma, and urine and may serve as early noninvasive biomarkers for various disease processes. Despite significant advances in heart transplantation, challenges remain in the short and long term with early graft injury and dysfunction, both cellular and antibody-mediated rejection, infections of varying types and severity, and cardiac allograft vasculopathy, which require an interventional approach for diagnosis and management. In this article, we review the current knowledge on the role of microRNAs in heart transplantation and its related complications and discuss their potential impact in future strategies to manage heart transplantation.

Differences in Short-Term Outcomes and Hospital-Based Resource Utilization Between Septal Reduction Strategies for Hypertrophic Obstructive Cardiomyopathy.

BACKGROUND: Given clinical equipoise in a subset of obstructive hypertrophic cardiomyopathy (OHCM) patients who are candidates for both alcohol septal ablation (ASA) or septal myectomy (SM), other considerations such as cost, readmissions, and hospital length of stay (LOS) may be important to optimize healthcare resource utilization and inform shared decision making. METHODS: In this retrospective observational analysis of the United States Nationwide Readmissions Database years 2012-2014, we identified adults who underwent isolated septal reduction (SR) for OHCM. We studied the differences in short-term outcomes (inpatient mortality and 90-day readmission rate) and in-hospital resource utilization (LOS and costs) between the SR strategies. RESULTS: Of the 2250 patients in this study, ASA was performed in 1113 (49.5%) and SM in 1137 (50.5%). Inpatient mortality occurred in 21 patients (0.9%), with similar rates between strategies (10 SM patients [0.9%] vs 11 ASA patients [1.0%]; P=.30). Of the 2229 patients who survived to discharge, 298 (13.4%) were readmitted 386 times within 90 days with a similar readmission rate between SM (14.9%) and ASA (11.8%; P=.16). During the index admission, average LOS and cost were significantly lower for ASA (3.9 days, United States [US] $20,322) compared with SM (7.6 days, US $39,470; P<.001). Average LOS and cost during 90-day readmissions were similar between ASA and SM. Combining index admissions and readmissions, patients undergoing ASA had significantly lower LOS and hospitalization costs. CONCLUSIONS: In this non-randomized observational study of OHCM patients undergoing isolated septal reduction, ASA was associated with similar short-term outcomes, including mortality, but substantially lower hospitalization costs and LOS compared with SM.

Influence of diabetes mellitus interactions with cardiovascular risk factors on post-myocardial infarction heart failure hospitalizations.

OBJECTIVE: There is a paucity of information regarding how cardiovascular risk factors (RF) modulate the impact of diabetes mellitus (DM) on the heart failure hospitalization (HFH) risk following an acute myocardial infarction (AMI). METHODS: Adult survivors of an AMI were retrospectively identified from the 2014 US Nationwide Readmissions Database. The impact of DM on the risk for a 6-month HFH was studied in subgroups of RFs using multivariable logistic regression to adjust for baseline risk differences. Individual interactions of DM with RFs were tested. RESULTS: Of 237,549 AMI survivors, 37.2% patients had DM. Primary outcome occurred in 12,934 patients (5.4%), at a 106% higher rate in DM patients (7.9% vs 4.0%, p < 0.001), which was attenuated to a 45% higher adjusted risk. Higher HFH risk in DM patients was consistent across subgroups and significant interactions were present between DM and other RFs. The increased HFH risk with DM was more pronounced in patients without certain HF RFs compared with those with these RFs [age < 65: OR for DM 1.84 (1.58-2.13) vs age ≥ 65: OR 1.34 (1.24-1.45); HF absent during index AMI: OR for DM 1.87 (1.66-2.10) vs HF present: OR 1.24 (1.14-1.34); atrial fibrillation absent: OR for DM 1.57 (1.46-1.68) vs present: OR 1.19 (1.06-1.33); Pinteraction < 0.001 for all]. Similar results were noted for hypertension and chronic kidney disease. CONCLUSIONS: AMI survivors with DM had a higher risk of 6-month HFHs. The impact of DM on the increased HFH risk was more pronounced in patients without certain RFs suggesting that more aggressive preventive strategies related to DM and HF are needed in these subgroups to prevent or delay the onset of HFHs.

Myocardial Viability Assessment Before Surgical Revascularization in Ischemic Cardiomyopathy: JACC Review Topic of the Week.

Ischemic cardiomyopathy results from the combination of scar with fibrosis replacement and areas of dysfunctional but viable myocardium that may improve contractile function with revascularization. Observational studies reported that only patients with substantial amounts of myocardial viability had better outcomes following surgical revascularization. Accordingly, dedicated noninvasive techniques have evolved to quantify viable myocardium with the objective of selecting patients for this form of therapeutic intervention. However, prospective trials have not confirmed the interaction between myocardial viability and the treatment effect of revascularization. Furthermore, recent observations indicate that recovery of left ventricular function is not the principal mechanism by which surgical revascularization improves prognosis. In this paper, the authors describe a more contemporary application of viability testing that is founded on the alternative concept that the main goal of surgical revascularization is to prevent further damage by protecting the residual viable myocardium from subsequent acute coronary events.

Mental health disorders among patients with acute myocardial infarction in the United States.

OBJECTIVE: To assess the prevalence, temporal trends and sex- and racial/ethnic differences in the burden of mental health disorders (MHD) and outcomes among patients with myocardial infarction (MI) in the United States. METHODS: Using the National Inpatient Sample Database, we evaluated a contemporary cohort of patients hospitalized for acute MI in the United States over 10 years period from 2008 to 2017. We used multivariable logistic regression analysis for in-hospital outcomes, yearly trends and estimated annual percent change (APC) in odds of MHD among MI patients. RESULTS: We included a total sample of 6,117,804 hospitalizations for MI (ST elevation MI in 30.4%), with a mean age of 67.2 â€‹± â€‹0.04 years and 39% females. Major depression (6.2%) and anxiety disorders (6.0%) were the most common MHD, followed by bipolar disorder (0.9%), schizophrenia/psychotic disorders (0.8%) and post-traumatic stress disorder (PTSD) (0.3%). Between 2008 and 2017, the prevalences significantly increased for major depression (4.7%-7.4%, APC +6.2%, p â€‹< â€‹.001), anxiety disorders (3.2%-8.9%, APC +13.5%, p â€‹< â€‹.001), PTSD (0.2%-0.6%, +12.5%, p â€‹< â€‹.001) and bipolar disorder (0.7%-1.0%, APC +4.0%, p â€‹< â€‹.001). Significant sex- and racial/ethnic-differences were also noted. Major depression, bipolar disorder or schizophrenia/psychotic disorders were associated with a lower likelihood of coronary revascularization. CONCLUSION: MHD are common among patients with acute MI and there was a concerning increase in the prevalence of major depression, bipolar disorder, anxiety disorders and PTSD over this 10-year period. Focused mental health interventions are warranted to address the increasing burden of comorbid MHD among acute MI.

Left Ventricular Assist Device Implantation in Hypertrophic and Restrictive Cardiomyopathy: A Systematic Review.

Left ventricular assist device (LVAD) implantation in patients with advanced heart failure due to hypertrophic or restrictive cardiomyopathy (HCM/RCM) presents technical and physiologic challenges. We conducted a systematic review of observational studies to evaluate the utilization and clinical outcomes associated with LVAD implantation in patients with HCM/RCM and compared these to patients with dilated or ischemic cardiomyopathy (DCM/ICM). We searched MEDLINE, EMBASE, and Scopus from inception through May 2019 and included appropriate studies describing the use of an LVAD in patients with HCM/RCM. We identified six studies with a total of 2,766 patients with HCM/RCM and advanced heart failure, among whom 338 patients (12.2%) underwent LVAD implantation. In patients listed for transplant, the rate of LVAD implantation was significantly lower in patients with HCM/RCM compared to that in patients with DCM/ICM (4.4% vs. 18.2%, p < 0.001). Adverse clinical outcomes were significantly higher in HCM/RCM than in DCM/ICM, including operative/short-term mortality (14.0% vs. 9.0%), right ventricular failure (50.0% vs. 21.0%), infection (15.5% vs. 11.2%), bleeding (40.2% vs. 12.5%), renal failure (15.0% vs. 5.1%), stroke (5.0% vs. 2.4%), and arrhythmias (18.0% vs. 7.7%) (all p values <0.001).

Optimal medical therapy with or without surgical revascularization and long-term outcomes in ischemic cardiomyopathy

Objectives: Optimal medical therapy in patients with heart failure and coronary artery disease is associated with improved outcomes. However, whether this association is influenced by the performance of coronary artery bypass grafting is less well established. Thus, the aim of this study was to determine the possible relationship between coronary artery bypass grafting and optimal medical therapy and its effect on the outcomes of patients with ischemic cardiomyopathy. Methods: The Surgical Treatment for Ischemic Heart Failure trial randomized 1212 patients with coronary artery disease and left ventricular ejection fraction 35% or less to coronary artery bypass grafting with medical therapy or medical therapy alone with a median follow-up over 9.8 years. For the purpose of this study, optimal medical therapy was collected at baseline and 4 months, and defined as the combination of 4 drugs: angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, beta-blocker, statin, and 1 antiplatelet drug. Results: At baseline and 4 months, 58.7% and 73.3% of patients were receiving optimal medical therapy, respectively. These patients had no differences in important parameters such as left ventricular ejection fraction and left ventricular volumes. In a multivariable Cox model, optimal medical therapy at baseline was associated with a lower all-cause mortality (hazard ratio, 0.78; 95% confidence interval, 0.66-0.91; P » .001). When landmarked at 4 months, optimal medical therapy was also associated with a lower all-cause mortality (hazard ratio, 0.82; 95% confidence interval, 0.62-0.99; P » .04). There was no interaction between the benefit of optimal medical therapy and treatment allocation. Conclusions: Optimal medical therapy was associated with improved long-term survival and lower cardiovascular mortality in patients with ischemic cardiomyopathy and should be strongly recommended.