Survival benefit of coronary revascularization after myocardial perfusion SPECT: The role of ischemia.

BACKGROUND: Survival benefit of revascularization over medical therapy (MT) in patients with stable ischemic heart disease (SIHD) is uncertain. We evaluated the prognostic effects of revascularization in patients with SIHD undergoing single-photon emission computed tomography myocardial perfusion imaging (SPECT-MPI). METHODS: Of 47,894 patients, 7973 had ischemia ≥ 5% of the left ventricle. Of these, 1837 underwent early revascularization (≤ 60 days after SPECT-MPI). The rest were MT subgroup. Follow-up period was 4.04 ± 1.86 years. Statin therapy intensity and adherence were assessed. Outcomes were all-cause mortality, death + non-fatal myocardial infarction (MI), and MACE [major adverse cardiac event = death + MI + late revascularization (> 60 days after SPECT-MPI)]. RESULTS: Among patients with moderate-severe ischemia (≥ 10%), death rate was lower in early revascularization compared to MT subgroup (1.42%/year vs 3.12%/year, adjusted hazard ratio (HR) 0.67 (95% CI 0.50-0.90, P = .008). Death + MI and MACE rates were also lower, adjusted HR 0.69 (0.55-0.88, P = .003) and 0.80 (0.69-0.92, P = .003). Revascularization was beneficial in optimal statin therapy subgroup (death rate 1.04%/year vs 2.36%/year, adjusted HR 0.51 (0.30-0.86, P = .012). In mild ischemia (5%-9%), revascularization did not improve survival or MI-free survival, and was associated with higher MACE rate (8.86%/year vs 7.67%/year, adjusted HR 1.30 (1.12-1.52, P < .001). CONCLUSION: Compared to MT, revascularization was associated with reduced risk of death, death + MI, and MACE in patients with moderate-severe ischemia, incremental over optimal statin therapy. In mild ischemia, revascularization was associated with higher risk of MACE, driven by late revascularization, with no impact on death and death + MI.

Torsade de pointes due to noncardiac drugs: most patients have easily identifiable risk factors.

Numerous medications, including drugs prescribed for noncardiac indications, can lead to QT prolongation and trigger torsade de pointes. Although this complication occurs only rarely, it may have lethal consequences. It is therefore important to know if patients with torsade de pointes associated with noncardiac drugs have risk factors that are easy to identify. We reviewed reports of drug-induced torsade de pointes and analyzed each case of torsade de pointes associated with a noncardiac drug for the presence of risk factors for the long QT syndrome that can be easily identified from the medical history or clinical evaluation (female gender, heart disease, electrolyte disturbances, excessive dosing, drug interactions, and history of familial long QT syndrome). We identified 249 patients with torsade de pointes caused by noncardiac drugs. The most commonly identified risk factor was female gender (71%). Other risk factors were frequently present (18%-41%). Virtually all patients had at least 1 of these risk factors, and 71% of patients had 2 or more risk factors. Our study suggests that almost all patients with torsade de pointes secondary to noncardiac drugs have risk factors that can be easily identified from the medical history before the initiation of therapy with the culprit drug.