Revascularization vs. Medical Therapy in Stable Ischemic Heart Disease.
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ABSTRACT:
SUBMITTER: Weiss S
PROVIDER: S-EPMC5774643 | biostudies-literature | 2015 Nov-Dec
REPOSITORIES: biostudies-literature
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Revascularization vs. Medical Therapy in Stable Ischemic Heart Disease.
Weiss Sandra S Weintraub William W
Progress in cardiovascular diseases 20150721 3
The keynote COURAGE and BARI-2D trials changed the way the interventional community selects patients for revascularization. What we now consider appropriate, especially for percutaneous coronary intervention, has narrowed significantly in scope compared to previous practice a decade ago. Medical therapy has been shown to be both safe and effective as a primary treatment modality for patients with stable ischemic heart disease on the whole. However, it appears that patients with a heavy ischemic ...[more]
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Project description:BackgroundRandomized studies have shown optimal medical therapy to be as efficacious as revascularization in stable ischemic heart disease (IHD). It is not known if these efficacy results are reflected by real-world effectiveness.ObjectiveTo evaluate the comparative effectiveness of routine medical therapy versus revascularization with percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) in stable IHD.DesignObservational cohort study.PatientsStable IHD patients from 1 October 2008 to 30 September 2011, identified using a Registry of all angiography patients in Ontario, Canada.InterventionRevascularization, defined as PCI/CABG within 90 days after index angiography.Main measuresDeath, myocardial infarction (MI) or repeat PCI/CABG. Revascularization was compared to medical therapy using a) multivariable Cox-proportional hazard models with therapy strategy treated as a time-varying covariate; and b) a propensity score matched analysis. Post-angiography medication use was determined.Key resultsWe identified 39,131 stable IHD patients, of whom 15,139 were treated medically, and 23,992 were revascularized (PCI = 15,604; CABG = 8,388). Mean follow-up was 2.5 years. Revascularization was associated with fewer deaths (HR 0.76; 95 % CI 0.68-0.84; p < 0.001) ,MIs (HR 0.78; 95 % CI 0.72-0.85; p < 0.001) and repeat PCI/CABG (HR 0.59; 95 % CI 0.50-0.70; p < 0.001) than medical therapy. In the propensity-matched analysis of 12,362 well-matched pairs of revascularized and medical therapy patients, fewer deaths (8.6 % vs 12.7 %; HR 0.75; 95 % CI 0.69-0.81; p < 0.001) , MIs (11.7 % vs 14.4 %; HR 0.84; 95 % CI 0.77-0.93 p < 0.001) and repeat PCI/CABG ( 17.4 % vs 24.1 %;HR 0.67; 95 % 0.63-0.71; p < 0.001) occurred in revascularized patients, over the 4.1 years of follow-up. The revascularization patients had higher uptake of clopidogrel (70.3 % vs 27.2 %; p < 0.001), ?-blockers (78.2 % vs 76.7 %; p = 0.010), and statins (94.7 % vs 91.5 %, p < 0.001) in the 1-year post-angiogram.ConclusionsStable IHD patients treated with revascularization had improved risk-adjusted outcomes in clinical practice, potentially due to under-treatment of medical therapy patients.
| S-EPMC4061359 | biostudies-literature
Project description:Patients with heart failure (HF) syndromes have been categorized as those with reduced ejection fraction (EF) or preserved EF (HFpEF), and ischemia plays a key role in both types. HF remains a major cause of morbidity and mortality worldwide, and with the aging of our population this burden continues to rise, predominantly as a result of hospitalizations for HFpEF. Patients with obstructive coronary artery disease more likely have HF with reduced EF, rather than HFpEF, secondary to acute ischemic injury resulting in myocardial infarction, and large outcomes trials of treatments with neurohumoral inhibition have documented reduced adverse outcomes. In contrast, similar treatments in patients with HFpEF have not proven beneficial. This therapeutic dilemma may be attributed, in part, to heterogeneity in the underlying pathophysiology with different systemic and myocardial signaling pathways, despite similar clinical presentations and findings, in patients with HFpEF. Also, emerging evidence indicates that impaired myocardial perfusion and inflammation secondary to multiple comorbidities are key mechanisms in HFpEF. We will thoroughly review the role of ischemic heart disease in the pathogenesis of HF with reduced EF and HFpEF, and discuss the medical management strategies available for these conditions.
| S-EPMC6534154 | biostudies-literature
Project description:The relationship between appropriateness score, treatment strategy and quality of life (QOL) among patients with stable ischemic heart disease (SIHD) is not known. In this prospective cohort study, we evaluated changes in generic and cardiac-specific quality of life in patients with documented SIHD, comparing patients with revascularization versus those with medical therapy alone, stratified by their appropriateness scores.Consecutive patients with SIHD undergoing elective coronary angiogram from November 1st 2008 to December 1st 2009 completed the Seattle Angina Questionnaire (SAQ) and EQ-5D at the time of procedure and at 1 year. The appropriateness for coronary revascularization was determined at the time of coronary angiography.Our final cohort consisted of 425 patients, 69.4% of whom underwent revascularization. In the overall cohort, 272 (64.0%) had appropriate indications for revascularization, while 57 (13.4%) had inappropriate indications and 96 (22.6%) had uncertain indications. On average, patients improved in most QOL domains, regardless of treatment strategy and appropriateness score. In patients with appropriate indications, revascularized patients had greater improvements in both generic (0.073; 95% CI 0.003-0.144; p-value 0.04) and disease-specific indices, including angina stability (14.6; 95% CI 0.85-28.3; p-value 0.04), physical limitation (9.3; 95% CI 0.71-17.8; p-value 0.03) and disease perception (12.7; 95% CI4.3-21.1; p-value 0.003) compared to medically treated patients. However, patients with uncertain and inappropriate indications also had improvements in physical limitation and disease perception with revascularization compared to medical therapy.Patients who had appropriate revascularization derived the greatest improvement in QOL compared with medical therapy.
| S-EPMC4195906 | biostudies-other
Project description:We investigated national trends in volume and outcomes of percutaneous coronary angioplasty (PCI), coronary artery bypass grafting (CABG), and ischemic heart disease-related mortality in Israel.Using International Classification of Diseases 9th and 10th revision codes, we linked 5 Israeli national databases, including the Israel Center for Disease Control National PCI and CABG Registries, the Ministry of Health Hospitalization Report, the Center of Bureau of Statistics, and the Ministry of Interior Mortality Report, to assess the annual PCI and CABG volume, procedural mortality, comorbidities, and ischemic heart disease-related mortality between 2002 and 2014. Trends over time were analyzed using linear regression, assuming a Poisson distribution. A total of 298 390 revascularization procedures (PCI: 255 724, CABG: 42 666) were performed during the study period. PCI volume increased by 9% from 2002 to 2008 (387.4/100 000 to 423.2/100 000), steadily decreasing by 10.5% to 378.5/100 000 in 2014 (P=0.70 for the trend). CABG volume decreased by 59% (109.0/100 000 to 45.2/100 000) from 2002 to 2013, leveling at 46.4/100 000 (P<0.0001). PCI/CABG ratio increased from 3.6 in 2002 to 8.5 in 2013, slightly decreasing to 8.2 by 2014 (P<0.0001). In-hospital procedural mortality remained stable (PCI: 1.2-1.6%, P=0.34, CABG: 3.7-4.4%, P=0.29) despite a significant change in patient clinical profile. During the course of the study, ischemic heart disease-related mortality decreased by 46% (84.6-46/100 000, P<0.001).We observed a dramatic change in coronary revascularization procedures type and volume, and a marked decrease in ischemic heart disease-related mortality in Israel. The reasons for the observed changes remain unclear and need to be further investigated.
| S-EPMC5523769 | biostudies-other
Project description:ObjectivesOptimal 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.MethodsThe 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.ResultsAt 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.ConclusionsOptimal medical therapy was associated with improved long-term survival and lower cardiovascular mortality in patients with ischemic cardiomyopathy and should be strongly recommended.
| S-EPMC8260609 | biostudies-literature
Project description:BackgroundA higher prevalence of airflow limitation (AL) has been described in patients with ischemic heart disease (IHD). Although small airway dysfunction (SAD) is an early feature of AL, there is little information about its occurrence in IHD patients. Our objective was to describe the prevalence of SAD in IHD patients, while comparing patient-related outcomes and future health risk among IHD patients with AL, SAD and normal lung function.MethodsIn 118 consecutive smoking patients with stable IHD, comorbidities, utilization of healthcare resources, current treatment, blood biochemistry and health status were recorded. SAD was evaluated by impulse oscillometry, and pre- and post-bronchodilator spirometry was performed.ResultsThe prevalence of AL and SAD were 20.3 (95% CI, 13.1-27.6%) and 26.3% (95% CI, 18.3-34.2%), respectively. Compared to the normal lung function group, patients with SAD and without AL had lower spirometric values, poorer quality of life and higher levels of C-reactive protein (CRP), as well as increased cardiovascular risk and more vascular age. In patients with normal spirometry, the presence of SAD was independently associated with pack-years, HDL-cholesterol and CRP levels.ConclusionIn patients with IHD, the presence of SAD is common and that it is associated with reduced health status and increased future cardiac risk.
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Project description:BackgroundCardiac troponin concentrations are used to identify patients who would benefit from urgent revascularization for acute coronary syndromes. We hypothesized that they might be used in patients with stable ischemic heart disease to identify those at high risk for cardiovascular events who might also benefit from prompt coronary revascularization.MethodsWe measured the cardiac troponin T concentration at baseline with a high-sensitivity assay in 2285 patients who had both type 2 diabetes and stable ischemic heart disease and were enrolled in the Bypass Angioplasty Revascularization Investigation in Type 2 Diabetes trial. We tested for an association between the troponin T concentration and a composite end point of death from cardiovascular causes, myocardial infarction, or stroke; we then evaluated whether random assignment to prompt revascularization reduced the rate of the composite end point in patients with an abnormal troponin T concentration (≥14 ng per liter) as compared with those with a normal troponin T concentration (<14 ng per liter).ResultsOf the 2285 patients, 2277 (99.6%) had detectable (≥3 ng per liter) troponin T concentrations and 897 (39.3%) had abnormal troponin T concentrations at baseline. The 5-year rate of the composite end point was 27.1% among the patients who had had abnormal troponin T concentrations at baseline, as compared with 12.9% among those who had had normal baseline troponin T concentrations. In models that were adjusted for cardiovascular risk factors, severity of diabetes, electrocardiographic abnormalities, and coronary anatomy, the hazard ratio for the composite end point among patients with abnormal troponin T concentrations was 1.85 (95% confidence interval [CI], 1.48 to 2.32; P<0.001). Among patients with abnormal troponin T concentrations, random assignment to prompt revascularization, as compared with medical therapy alone, did not result in a significant reduction in the rate of the composite end point (hazard ratio, 0.96; 95% CI, 0.74 to 1.25).ConclusionsThe cardiac troponin T concentration was an independent predictor of death from cardiovascular causes, myocardial infarction, or stroke in patients who had both type 2 diabetes and stable ischemic heart disease. An abnormal troponin T value of 14 ng per liter or higher did not identify a subgroup of patients who benefited from random assignment to prompt coronary revascularization. (Funded by the National Institutes of Health and Roche Diagnostics; BARI 2D ClinicalTrials.gov number, NCT00006305.).
| S-EPMC4627639 | biostudies-literature
Project description:BackgroundCardiomyopathies is a group of heart diseases that directly affects the heart muscle, and their causes is not just high blood pressure, congenital and pericardial diseases but ischemic cardiomyopathy disease are also caused by vascular disorders, and to confirm the diagnosis, angiography is required. There are several methods for treating and controlling ischemic cardiomyopathy in world health systems and especially in the Iran health system, which include medical treatment, percutaneous coronary intervention (PCI), and coronary artery bypass graft (CABG).MethodsThis systematic review will includes observational and interventional studies in English and Persian languages and evaluates effectiveness of revascularization interventions and medical therapy in patients with ischemic cardiomyopathy. Animal studies will not be considered. In this systematic review, our sources of information will be electronic databases, trial registries, and different types of grey literature. An electronic search is performed through PubMed, Cochrane library, Scopus, Web of Science, EMBASE, Tufts Medical Center Cost-Effectiveness Analysis Registry, NHS Economic Evaluations Database. To integrate the results of studies with similar results, meta-analysis will be used, for which Comprehensive Meta-Analysis (CMA) software will be used. Results are provided using relative risk with a 95% confidence interval for information.ResultsThe results of this systematic review will be published in a peer-reviewed journal.ConclusionTo our knowledge, this systematic review will be the first to evaluate existing research on the effectiveness of revascularization interventions compared with medical therapy in patients with ischemic cardiomyopathy. The review will benefit patients, healthcare providers, and policymakers.
| S-EPMC5882430 | biostudies-literature
Project description:BackgroundHeart rate variability (HRV) is reduced in stable ischemic heart disease (SIHD) patients and is associated with sudden cardiac death (SCD). We evaluated the impact of traditional acupuncture (TA) on cardiac autonomic function measured by HRV in SIHD patients.MethodsWe conducted a randomized controlled study of TA, sham acupuncture (SA), and waiting control (WC) in 151 SIHD subjects. The TA group received needle insertion at acupuncture sites, the SA group received a sham at non-acupuncture sites, while the WC group received nothing. The TA and SA groups received 3 treatments/week for 12 weeks. 24-Hour, mental arithmetic stress, and cold pressor (COP) HRV was collected at entry and exit, along with BP, lipids, insulin resistance, hs-CRP, salivary cortisol, peripheral endothelial function by tonometry (PAT), and psychosocial variables.ResultsMean age was 63 ± 10; 50% had prior myocardial infarction. Comparison of WC and SA groups demonstrated differences consistent with the unblinded WC status; therefore by design, the control groups were not merged. Exit mental stress HRV was higher in TA vs. SA for markers of parasympathetic tone (p ≤ 0.025), including a 17% higher vagal activity (p=0.008). There were no differences in exit 24-hour or COP HRV, BP, lipids, insulin resistance, hs-CRP, salivary cortisol, PAT, or psychosocial variables.ConclusionsTA results in intermediate effects on autonomic function in SIHD patients. TA effect on HRV may be clinically relevant and should be explored further. These data document feasibility and provide sample size estimation for a clinical trial of TA in SIHD patients for the prevention of SCD.Condensed abstractWe conducted a randomized, single-blind trial of traditional acupuncture (TA) vs. sham acupuncture (SA) vs waiting control (WC) in stable ischemic heart disease (SIHD) patients to evaluate cardiac autonomic function measured by heart rate variability (HRV). Exit mental stress HRV was higher in the TA compared to SA group for time and frequency domain markers of parasympathetic tone (all p ≤ 0.025), including a 17% higher vagal activity (p=0.008). These data document feasibility and provide sample size estimation for an outcome-based clinical trial of TA in SIHD patients for the prevention of sudden cardiac death.
| S-EPMC4160354 | biostudies-literature
Project description: Not available
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