Optimal medical therapy with or without surgical revascularization and long-term outcomes in ischemic cardiomyopathy.
Ontology highlight
ABSTRACT:
SUBMITTER: Farsky PS
PROVIDER: S-EPMC8260609 | biostudies-literature |
REPOSITORIES: biostudies-literature
Similar Datasets
Project description:Aims:Hypertension (HTN) is a well-known contributor to cardiovascular disease, including heart failure (HF) and coronary artery disease, and is the leading risk factor for premature death world-wide. A J- or U-shaped relationship has been suggested between blood pressure (BP) and clinical outcomes in different studies. However, there is little information about the significance of BP on the outcomes of patients with coronary artery disease and left ventricular dysfunction. This study aimed to determine the relationship between BP and mortality outcomes in patients with ischaemic cardiomyopathy. Methods and results:The influence of BP during a median follow-up of 9.8 years was studied in a total of 1212 patients with ejection fraction ≤35% and coronary disease amenable to coronary artery bypass grafting (CABG) who were randomized to CABG or medical therapy alone (MED) in the STICH (Surgical Treatment for Ischaemic Heart Failure) trial. Landmark analyses were performed starting at 1, 2, 3, 4, and 5 years after randomization, in which previous systolic BP values were averaged and related to subsequent mortality through the end of follow-up with a median of 9.8 years. Neither a previous history of HTN nor baseline BP had any significant influence on long-term mortality outcomes, nor did they have a significant interaction with MED or CABG treatment. The landmark analyses showed a progressive U-shaped relationship that became strongest at 5 years (χ2 and P-values: 7.08, P = 0.069; 8.72, P = 0.033; 9.86; P = 0.020; 8.31, P = 0.040; 14.52, P = 0.002; at 1, 2, 3, 4, and 5-year landmark analyses, respectively). The relationship between diastolic BP (DBP) and outcomes was similar. The most favourable outcomes were observed in the SBP range 120-130, and DBP 75-85 mmHg, whereas lower and higher BP were associated with worse outcomes. There were no differences in BP-lowering medications between groups. Conclusion:A strong U-shaped relationship between BP and mortality outcomes was evident in ischaemic HF patients. The results imply that the optimal SBP might be in the range 120-130 mmHg after intervention, and possibly be subject to pharmacologic action regarding high BP. Further, low BP was a marker of poor outcomes that might require other interactions and treatment strategies. Clinical Trial Registration:URL: http://www.clinicaltrials.gov. Unique identifier: NCT00023595.
| S-EPMC6166135 | biostudies-literature
Project description:BackgroundThe role of assessment of myocardial viability in identifying patients with ischemic cardiomyopathy who might benefit from surgical revascularization remains controversial. Furthermore, although improvement in left ventricular function is one of the goals of revascularization, its relationship to subsequent outcomes is unclear.MethodsAmong 601 patients who had coronary artery disease that was amenable to coronary-artery bypass grafting (CABG) and who had a left ventricular ejection fraction of 35% or lower, we prospectively assessed myocardial viability using single-photon-emission computed tomography, dobutamine echocardiography, or both. Patients were randomly assigned to undergo CABG and receive medical therapy or to receive medical therapy alone. Left ventricular ejection fraction was measured at baseline and after 4 months of follow-up in 318 patients. The primary end point was death from any cause. The median duration of follow-up was 10.4 years.ResultsCABG plus medical therapy was associated with a lower incidence of death from any cause than medical therapy alone (182 deaths among 298 patients in the CABG group vs. 209 deaths among 303 patients in the medical-therapy group; adjusted hazard ratio, 0.73; 95% confidence interval, 0.60 to 0.90). However, no significant interaction was observed between the presence or absence of myocardial viability and the beneficial effect of CABG plus medical therapy over medical therapy alone (P = 0.34 for interaction). An increase in left ventricular ejection fraction was observed only among patients with myocardial viability, irrespective of treatment assignment. There was no association between changes in left ventricular ejection fraction and subsequent death.ConclusionsThe findings of this study do not support the concept that myocardial viability is associated with a long-term benefit of CABG in patients with ischemic cardiomyopathy. The presence of viable myocardium was associated with improvement in left ventricular systolic function, irrespective of treatment, but such improvement was not related to long-term survival. (Funded by the National Institutes of Health; STICH ClinicalTrials.gov number, NCT00023595.).
| S-EPMC6814246 | biostudies-literature
Project description:BackgroundPatients with heart failure and reduced ejection fraction in low resource settings may not have access to devices and expensive therapeutic options. We followed up a cohort of patients with non-ischemic dilated cardiomyopathy (DCM) with very low left ventricle ejection fraction (LVEF≤19%) on low cost medical therapy alone. By selecting patients with such low LVEF, this study was restricted to patients with severe disease. We studied long-term transplant free survival of these patients.Methods and resultsThe study enrolled 130 patients (83 men and 47 women) of DCM cohort with LVEF≤19% from April 2003-December 2018 on medical therapy alone. Mean age was 40.35 ± 13.9 years. Mean follow-up was 45.6 ± 39 months while median follow-up was 39 months (range: 0-176 months). Patients on devices (ICD/CRT) for heart failure management were excluded. Fifty-four patients died and three underwent transplant during the study. Median survival was 86 months (S.E. 22.38). 113 patients had follow-up till end of study. In the worst case scenario, if all 17 patients who were lost to final follow-up were assumed to be dead, the median survival was still 57 (S.E.9.28) months. Higher baseline NYHA class, recurrent heart failure hospitalizations, absence of treatment with beta-blockers, angiotensin converting enzyme inhibitors/angiotensin receptor blockers and aldosterone antagonists were predictors of death on univariate analysis whereas none of these parameters were significant on multivariate analysis.ConclusionsMedian survival of our DCM cohort with LVEF≤19% on medical therapy was over 7 years.
| S-EPMC7772597 | biostudies-literature
Project description:AIMS:The landmark STICH trial found that surgical revascularization compared to medical therapy alone improved survival in patients with heart failure (HF) of ischaemic aetiology and an ejection fraction (EF) ≤ 35%. However, the interaction between the burden of medical co-morbidities and the benefit from surgical revascularization has not been previously described in patients with ischaemic cardiomyopathy. METHODS AND RESULTS:The STICH trial (ClinicalTrials.gov Identifier: NCT00023595) enrolled patients ≥ 18 years of age with coronary artery disease amenable to coronary artery bypass grafting (CABG) and an EF ≤ 35%. Eligible participants were randomly assigned 1:1 to receive medical therapy (MED) (n = 602) or MED/CABG (n = 610). A modified Charlson co-morbidity index (CCI) based on the availability of data and study definitions was calculated by summing the weighted points for all co-morbid conditions. Patients were divided into mild/moderate (CCI 1-4) and severe (CCI ≥ 5) co-morbidity. Cox proportional hazards models were used to evaluate the association between CCI and outcomes and the interaction between severity of co-morbidity and treatment effect. The study population included 349 patients (29%) with a mild/moderate CCI score and 863 patients (71%) with a severe CCI score. Patients with a severe CCI score had greater functional limitations based on 6-min walk test and impairments in health-related quality of life as assessed by the Kansas City Cardiomyopathy Questionnaire. A total of 161 patients (Kaplan-Meier rate = 50%) with a mild/moderate CCI score and 579 patients (Kaplan-Meier rate = 69%) with a severe CCI score died over a median follow-up of 9.8 years. After adjusting for baseline confounders, patients with a severe CCI score were at higher risk for all-cause mortality (hazard ratio 1.44, 95% confidence interval 1.19-1.74; P < 0.001). There was no interaction between CCI score and treatment effect on survival (P = 0.756). CONCLUSIONS:More than 70% of patients had a severe burden of medical co-morbidities at baseline, which was independently associated with increased risk of death. There was not a differential benefit of surgical revascularization with respect to survival based on severity of co-morbidity.
| S-EPMC6818499 | biostudies-literature
Project description:ImportanceThe optimal conduits for coronary artery bypass grafting (CABG) remain controversial in multivessel coronary artery disease.ObjectiveTo compare the long-term clinical outcomes of total arterial revascularization (TAR) vs non-TAR (CABG with at least 1 arterial and 1 saphenous vein graft) in a multicenter population-based study.Design, setting, and participantsThis multicenter population-based cohort study using propensity score matching took place from October 2008 to March 2017 in Ontario, Canada, with a mean and maximum follow-up of 4.6 and 9.0 years, respectively. Individuals with primary isolated CABG were identified, with at least 1 arterial graft. Exclusion criteria were individuals from out of province and younger than 18 years. Patients undergoing a cardiac reoperation or those in cardiogenic shock were also excluded because these conditions would potentially bias the surgeon toward not performing TAR. Analysis began April 2019.ExposuresTotal arterial revascularization.Main outcomes and measuresPrimary outcome was time to first event of a composite of death, myocardial infarction, stroke, or repeated revascularization (major adverse cardiac and cerebrovascular events). Secondary outcomes included the individual components of the primary outcome.ResultsOf 49 404 individuals with primary isolated CABG, 2433 (4.9%) received TAR, with the total number of bypasses being 2, 3, and 4 or more vessels in 1521 (62.5%), 865 (35.6%), and 47 individuals (1.9%), respectively. The mean (SD) age was 61.2 (10.4) years and 1983 (81.5%) were men. After propensity score matching, 2132 patient pairs were formed, with equal total number of bypasses (mean [SD], 2.4 [0.5]) but with more arterial grafts in the TAR group (mean [SD], 2.4 [0.5] vs 1.2 [0.4]; P < .01). In-hospital death (15 [0.7%] vs 21 [1.0%]; P = .32) did not differ between TAR vs non-TAR groups after propensity score matching. Throughout 8 years, TAR was associated with improved freedom from major adverse cardiac and cerebrovascular events (hazard ratio, 0.78; 95% CI, 0.68-0.89), death (hazard ratio, 0.80; 95% CI, 0.66-0.97), and myocardial infarction (hazard ratio, 0.69; 95% CI, 0.51-0.92). There was no difference in stroke and repeated revascularization.Conclusions and relevanceTotal arterial revascularization was associated with improved long-term freedom from major adverse cardiac and cerebrovascular events, death, and myocardial infarction and may be the procedure of choice for patients with reasonable life expectancy requiring CABG.
| S-EPMC7042852 | biostudies-literature
Project description:ObjectiveTo determine whether high-risk patients with three-vessel disease (TVD) with and without prior stroke preferentially benefit from three strategies [percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG) and medical therapy (MT)].MethodsA total of 8943 patients with TVD were included in the study. Patients enrolled were stratified into two categories according to the presence or absence of prior stroke history. The primary endpoint was all-cause death. Secondary endpoints included stroke and major adverse cardiac and cerebrovascular event (MACCE), a composite of death, myocardial infarction (MI), unplanned revascularization and stroke.ResultsPrior stroke was present in 888 patients (9.9%). These patients were older and had higher rates of comorbidities. During a median follow-up of 7.5 years, patients with prior stroke were strongly associated with increased risks of all-cause death, cardiac death, stroke and MACCE, even after adjusting for confounding variables and results been consistent across either treatment subgroup (PCI, CABG and MT) (all adjusted P < 0.01). Notably, there was a significant interaction between prior stroke history and treatment strategies. Revascularization strategy (PCI or CABG) was associated with a lower incidence of all-cause death and MACCE compared with MT alone, and favorable rates of MACCE, MI and unplanned revascularization in the CABG group compared with the PCI group, but with similar rate of all-cause death regardless of prior stroke history. The prevalence of stroke was significantly higher after CABG when compared with PCI or MT in no prior stroke patients [hazard ratio (HR) = 1.429, 95% CI: 1.132-1.805 for CABG vs. MT; HR = 1.703, 95% CI: 1.371-2.116 for CABG vs. PCI].ConclusionsPatients with TVD and prior stroke have poor clinical outcomes. It is essential to balance benefit and risk when determining the optimal treatment strategy for TVD with and without prior stroke.
| S-EPMC9629998 | biostudies-literature
Project description:We evaluated the cardiac function recovery following skeletal myoblast cell-sheet transplantation and the long-term outcomes after applying this treatment in 23 patients with ischemic cardiomyopathy. We defined patients as "responders" when their left ventricular ejection fraction remained unchanged or improved at 6 months after treatment. At 6 months, 16 (69.6%) patients were defined as responders, and the average increase in left ventricular ejection fraction was 4.9%. The responders achieved greater improvement degrees in left ventricular and hemodynamic function parameters, and they presented improved exercise capacity. During the follow-up period (56 ± 28 months), there were four deaths and the overall 5-year survival rate was 95%. Although the responders showed higher freedom from mortality and/or heart failure admission (5-year, 81% versus 0%; p = 0.0002), both groups presented an excellent 5-year survival rate (5-year, 93% versus 100%; p = 0.297) that was higher than that predicted using the Seattle Heart Failure Model. The stepwise logistic regression analysis showed that the preoperative estimated glomerular filtration rate and the left ventricular end-systolic volume index were independently associated with the recovery progress. Approximately 70% of patients with "no-option" ischemic cardiomyopathy responded well to the cell-sheet transplantation. Preoperative renal and left ventricular function might predict the patients' response to this treatment.
| S-EPMC8058489 | biostudies-literature
Project description:BackgroundStress-induced cardiomyopathy (SCM) after subarachnoid hemorrhage (SAH) includes predominant apical or basal regional left ventricular dysfunction (RLVD) with concomitant changes in electrocardiogram or increase in cardiac enzymes. We hypothesized that difference in outcome is associated with the type of RLVD after SAH.MethodsWe studied a single-center retrospective cohort of SAH patients hospitalized between 2000 and 2010 with follow-up until 2013. We classified patients who had an echocardiogram for clinically indicated reasons according to the predominate location of RLVD as classic SCM-apical form and variant SCM-basal form. A Cox proportional hazard model and logistic regression were used to estimate the risk for death and hospital complications associated with different RLVD after adjustment for propensity to undergo echocardiography given clinical characteristics on admission.ResultsAmong 715 SAH patients, 28% (200/715) had an echocardiogram for clinical evidence of cardiac dysfunction during hospitalization, the most common being acute left ventricular dysfunction, suspected acute ischemic event, changes in electrocardiogram and cardiac enzymes, and arrhythmia. SCM was present in 59 patients (8% of all cohort and 30% of patients with echocardiogram, respectively) with similar distribution of SCM-basal (25/59) and SCM-apical forms (34/59). SAH patients who had an echocardiogram for clinically indicated reasons had a significantly decreased risk-adjusted long-term survival compared with those without an echocardiogram, regardless of the presence of RLVD. SCM-basal form was associated with cardiac complications (odds ratio, 6.1; 99% confidence interval, 1.8-20.2) and severe sepsis (odds ratio, 5.3; 99% confidence interval, 1.6-17.2).ConclusionsSAH patients with echocardiogram for a clinically indicated reason have a decreased long-term survival, regardless of the presence of RLVD. The association between severe sepsis and SCM-basal warrants future studies to determine their potential synergistic effect on left ventricular systolic dysfunction among SAH patients.
| S-EPMC4857194 | biostudies-literature
Project description:ObjectivesThe different etiology of HF has different prognostic risk factors. Prognosis assessment of ICM and NICM has important clinical value. This study is aimed to explore the predicting factors for ICM and NICM.Methods1082 HFrEF patients were retrospectively enrolled from Jan. 01, 2016 to Dec. 31, 2017. On Jan. 31, 2019, 873 patients were enrolled for analysis excluding incomplete, unfollowed, and unexplained data. The patients were divided into ischemic and non-ischemic group. The differences in clinical characteristics and long-term prognosis between the two groups were analyzed, and multivariate Cox analysis was used to predict the respective all-cause mortality, SCD and rehospitalization of CHF.Results873 patients aged 64(53,73) were divided into two groups: ICM (403, 46.16%) and NICM. At the end, 203 died (111 in ICM, 54.68%), of whom 87 had SCD (53 in ICM, 60.92%) and 269 had rehospitalization for HF(134 in ICM, 49.81%). Independent risk factors affecting all-cause mortality in ICM: DM, previous hospitalization of HF, age, eGFR, LVEF; for SCD: PVB, eGFR, Hb, revascularization; for readmission of HF: low T3 syndrome, PVB, DM, previous hospitalization of HF, eGFR. Otherwise; factors affecting all-cause mortality in NICM: NYHA III-IV, paroxysmal AF/AFL, previous hospitalization of HF, β-blocker; for SCD: low T3 syndrome, PVB, nitrates, sodium, β-blocker; for rehospitalization of HF: paroxysmal AF/AFL, previous admission of HF, LVEF.ConclusionsBoth all-cause mortality and SCD in ICM is higher than that in NICM. Different etiologies of CHF have different risk factors affecting the prognosis.
| S-EPMC7296233 | biostudies-literature
Project description:BackgroundPatients with ischemic cardiomyopathy (ICM) may continue to experience persistent chest pain and/or dyspnea despite pharmacologic therapy and revascularization. We hypothesized that ranolazine would reduce anginal symptoms or dyspnea in optimally treated ICM patients.MethodsIn this randomized, double-blind, crossover-design pilot study, 28 patients with ICM (ejection fraction less or equal 40%) were included after providing informed consent. A total of 24 patients completed both placebo and ranolazine treatments and were analyzed. All patients were on treatment with a beta blocker, an angiotensin-converting enzyme inhibitor (or angiotensin receptor blocker), and at least one additional antianginal drug. After randomization, patients received up to 1,000 mg ranolazine orally twice a day, as tolerated, versus placebo. The primary end point was change in angina as assessed by the Seattle Angina Questionnaire (SAQ), or in dyspnea as assessed by the Rose Dyspnea Scale (RDS). Change in the RDS and SAQ score from baseline was compared, for ranolazine and placebo, using the Wilcoxon signed rank test or paired t-test.ResultsPatients had the following demographic and clinical variables: mean age of 71.5 years; male (82.1%); prior coronary bypass surgery (67.9%); prior coronary percutaneous intervention (85.7%); prior myocardial infarction (82.1%); diabetes (67.9%); and mean ejection fraction of 33.1%. No statistical difference was seen between baseline RDS score and that after placebo or ranolazine (n=20) (P≥0.05). There was however, an improvement in anginal frequency (8/10 patients) (P=0.058), quality of life (8/10 patients) (P=0.048), and mean score of all components of the SAQ questionnaire (n=10) (P=0.047) with ranolazine compared with placebo.ConclusionIn optimally treated ICM patients with continued chest pain or dyspnea, ranolazine possibly had a positive impact on quality of life, a reduction in anginal frequency, and an overall improvement in the mean SAQ component score compared with baseline. Ranolazine did not change the dyspnea score compared with baseline.
| S-EPMC4376266 | biostudies-literature