Nuclear stress testing may identify those likely to benefit from early revascularization
Click Here to Manage Email Alerts
Early revascularization may confer mortality benefit in patients with moderate to severe myocardial ischemia identified on nuclear stress testing, regardless of left ventricular ejection fraction, researchers reported.
However, early revascularization for patients with no myocardial ischemia or mild myocardial ischemia on nuclear stress testing was not associated with mortality benefits, according to data published in the Journal of the American College of Cardiology.
“There is keen interest in assessing how measurement of myocardial ischemia during stress testing can help shape physicians’ decision to refer patients for coronary revascularization procedures, but this issue has not been well studied among patients who have underlying heart damage,” Alan Rozanski, MD, professor of medicine (cardiology) at the Icahn School of Medicine at Mount Sinai, director of nuclear cardiology and cardiac stress testing and chief academic officer for the department of cardiology at Mount Sinai Morningside, said in a press release. “Our study, which evaluated a large number of patients with preexisting heart damage who underwent cardiac stress testing, finally addresses this clinical void.”
Researchers identified 43,443 patients who underwent stress/rest stress-rest single-photon emission CT myocardial perfusion imaging at the Cedars-Sinai Medical Center from 1998 to 2017 (mean age, 62 years; 56% men). During a median follow-up of 11.4 years, researchers evaluated revascularization for stress-induced myocardial ischemia among patients with LVEF less than 45% and LVEF of 45% or more.
Compared with patients who underwent medical therapy, those who underwent early revascularization were older, more often men, with a higher proportion of known CAD, typical angina, hypertension, hypercholesterolemia, diabetes, MI, myocardial scar in all abnormal categories, transient ischemic dilation and low LVEF.
Stress testing to guide myocardial ischemia management
The prevalence of myocardial ischemia identified using nuclear stress testing ranged from 6.7% in patients with LVEF greater than 55% with no typical angina to 64% in patients with LVEF less than 45% and typical angina (P < .001), according to the study.
Researchers reported that among patients with LVEF more than 45%, early revascularization was associated with increased risk for mortality among those without ischemia and decreased risk for mortality among those with severe ischemia identified using nuclear stress testing (HR = 0.7; 95% CI, 0.52-0.95).
Moreover, among patients with LVEF more than 45%, early revascularization was not linked to a mortality benefit in those with no or mild ischemia, and was associated with decreased risk for mortality in those with moderate ischemia (HR = 0.67; 95% CI, 0.49-0.91) and severe ischemia identified using nuclear stress testing (HR = 0.55; 95% CI, 0.38-0.8).
‘Aggressive management’ of severe ischemia
“These results confirm the benefits of stress testing for clinical management. What you want from any test when considering coronary revascularization procedures is that the test will identify a large percentage of patients who are at low clinical risk and do so correctly, while identifying only a small percentage of patients who are at high clinical risk and do so correctly. That is what we found with nuclear stress testing in this study,” Rozanski said in the release. “Importantly, the presence of severe ischemia does not necessarily mean that coronary revascularization should be applied. New data from a large clinical trial suggests that when medical therapy is optimized it may be as effective as coronary revascularization in such patients. But regardless, the presence of severe ischemia indicates high clinical risk which then requires aggressive management to reduce clinical risk.”
Reference:
- Stress testing can help determine which patients are likely to benefit from heart procedures to improve survival. https://www.newswise.com/articles/stress-testing-can-help-determine-which-patients-are-likely-to-benefit-from-heart-procedures-to-improve-survival. Published July 11, 2022. Accessed July 11, 2022.
Collapse
Click Here to Manage Email Alerts