Invasive approach to stable ischemic heart disease may benefit in HF, LV dysfunction
Patients with stable ischemic heart disease and HF and/or left ventricular dysfunction experienced worse outcomes compared with patients who did not and may benefit more from invasive treatment strategies, researchers reported.
The findings, presented at the virtual European Society of Cardiology Congress and published in Circulation, were from a subgroup analysis of patients with stable ischemic heart disease enrolled in the ISCHEMIA trial. Researchers compared participants with HF and/or LVEF between 35% and 45% with those without it.
Healio previously reported the top-line results from the ISCHEMIA trial at the American Heart Association Scientific Sessions in November 2019.
“A previous trial showed that patients with left ventricular ejection fraction less than 35% or a New York Heart Association class III or IV derive long-term benefits after initial increased risk from revascularization with CABG, with a 16% reduction in death at 10 years,” Renato D. Lopes, MD, MHS, PhD, professor of medicine at the Duke University School of Medicine and member in the Duke Clinical Research Institute, said during the presentation. “However less is known about patients with heart failure and/or left ventricular ejection fraction between 35% and 45%. Therefore, the ISCHEMIA trial will provide us with a unique opportunity to explore the potential benefit of an invasive strategy in this subgroup of patients.”
For this study, investigators assessed clinical outcomes among patients with HF and/or LV dysfunction and then compared outcomes among patients who received invasive or conservative treatments. Patients with HF and/or LV dysfunction comprised 7.7% of the overall cohort.
Investigators found that patients with stable ischemic heart disease and a history of HF and or LVEF between 35% and 45% had worse outcomes compared with those without HF or LV dysfunction for the following:
- composite primary outcome of CV death, nonfatal MI or hospitalization for unstable angina (HR = 1.43; 95% CI, 1.12-1.82);
- CV death or MI (HR = 1.37; 95% CI, 1.06-1.78);
- all-cause mortality (HR = 1.58; 95% CI, 1.13-2.22);
- CV death (HR = 1.89; 95% CI, 1.30-2.77);
- primary MI (HR = 1.22; 95% CI, 0.89-1.67); and
- HF hospitalization (HR = 2.73; 95% CI, 1.57-4.75)
When investigators compared patients within this subgroup based on treatment type, they observed that patients who underwent invasive treatment had a lower 4-year cumulative incidence of the composite primary endpoint (difference in invasive group vs. conservative group event rates, –12.1%; 95% CI, –22.6 to –1.6). This difference was much smaller in patients without HF or LV dysfunction (difference in invasive group vs. conservative group event rates, –1.6%; 95% CI, –3.8 to 0.7; P for interaction = .055).
Lopes said there were similar trends for the outcome of CV death or MI (P for interaction = .061).
“An invasive approach may be beneficial in this subgroup of high risk-patients with moderate to severe ischemia and a history of heart failure or left ventricular dysfunction,” Lopes said during the presentation. “Further follow-up to provide additional information for the potential longer-term benefits of the invasive approach in this high-risk group of patients with heart failure or ventricular dysfunction is planned.”
Reference:
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Lopes RD, et al. Late-breaking science in coronary artery disease. Presented at: European Society of Cardiology Congress; Aug. 29-Sept. 1, 2020 (virtual meeting).