how to assess reversible ischemia in lv dysfunction

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Dr. Andrés Iñiguez

How to assess reversible ischemia in LV Dysfunction ?

Speaker's name: Andrés Iñiguez

I do not have any potential conflict of interest related to the issue of this presentation.

q I have the following potential conflicts of interest to report:

Honorarium:Institutional grant/research support:Consultant: Employment in industry: Owner of a healthcare company: Stockholder of a healthcare company: Other(s):

Conflict of Interest

SEC 2015-2017

1 Introduction

Revascularization & Left Ventricular Dysfunction

2 LV Dysfunction and Revascularization- CABG / PCI

3 New Onset CHF and Revascularization

4 LVD and haemodynamic support

SEC 2015-2017

1 Introduction


SEC 2015-2017Revascularization & Left Ventricular Dysfunction

ü The optimal treatment for patients with severe coronary artery disease (CAD) and reduced LV function remains controversial.

ü The impact of having revascularization by CABG or PCI on survival in patients with left ventricular (LV) dysfunction, particularly severe LV dysfunction, remains a subject of considerable debate and uncertainty.

SEC 2015-2017

Still remain questions to be solved


ü In how many P. with CHF/severe LV dysfunction:- we know their coronary anatomy ?.- we know status of myocardial viability ?.

ü How many P. with CHF/severe LV dysfunction & severe coronary artery disease:- being revascularized (CABG-PCI) ?.

ü What is the prognosis of P. with CHF / severe LV dysfunction according to subgroups ? :- Revascularized vs non revascularized.- Complete Revasc. Vs. Incomplete Revasc.- With Myocadial Viability Vs. Absence of Viability.


2 LV Dysfunction and Revascularization- CABG / PCI

Impact of Revascularization by CABG on LVEF

Patients with Impaired Left Ventricular FunctionImprovement of LVEF postCABG

Med Arh. 2014 Oct; 68(5): 332-334

40 P.LVEF <35%

Basal1m. post

Impact of Revascularization by CABG on LVEF


The updated 2014 European guidelines for myocardial revascularization continue to recommend that CABG surgery in patients with LV dysfunction be considered in the presence of viable myocardium.

(Eur Heart J. 2014;35:2541-619)

The European guidelines for management of heart failure do not recommend CABG (class III) surgery in patients with LV dysfunction without angina and without myocardial viability.

(Eur Heart J. 2012;33:1787-847)

CABG Vs PCI Revascularization & Left Ventricular Dysfunction

Am J Cardiol 2014;114:988e 996

(NO LVEF)

Am J Cardiol 2014;114:988e 996

Cardiac Death


Am J Cardiol 2014;114:988e 996

Readmission for Heart Failure


ü (STICH) trial emerges as the first and only prospective randomized trial designed to determine the impact of CABG when it is added to evidence-based medical therapy in patients with CAD and an EF 35%.

ü The STICH trial investigated 2 hypotheses: a) Survival is enhanced with CABG plus evidence-based medical

therapy compared with medical therapy alone in patients with ischemic heart failure (the revascularization hypothesis); and

a) CABG plus surgical ventricular reconstruction (SVR) provides a survival advantage compared with CABG alone, in patients with an EF<35% undergoing revascularization who have dominant LV anterior akinesia or dyskinesia (the SVR hypothesis).

Velazquez EJ, et al. N Engl J Med. 2011;364:1607-16.

CABG Revascularization Vs. Medical Therapy & Left Ventricular Dysfunction


The primary outcome was all-cause mortality.

The principal result was the lack of significant difference in all-cause mortality between the 2 groups during the 56-month mean follow-up period, with 41% and 36% mortality in those assigned to medical therapy and CABG, respectively.

Bonow RO, et al. N Engl J Med. 2011;364:1617-25.





It is at all ?




STICH substudy.(601 of the 1212 patients imaged with single-photon emission tomography or low-dose dobutamine echocardiography to determine the magnitude of viable myocardium)- Patients with predominately viable myocardium had reduced mortality compared with those with predominately nonviable myocardium: 37% versus 51%, respectively, over a median 5.1-year follow-up period.





Complete Vs. Incomplete Revascularization & Left Ventricular Dysfunction

J Korean Med Sci 2014; 29: 1501-1506

92,7 %

82,5 %

54,9 %

65,3 %

Complete Vs. Incomplete Revascularization & Left Ventricular Dysfunction


European Heart Journal (2014) 35, 3004–3012



A strong relationship between LV function and mortality.A worse LV function independently predicting 30-day and long-term mortality outcomes across all indications for PCI.

There is a differential impact of LV function on mortality outcomes across different indications for PCI, with the greatest adverse prognostic association between worse LV function and mortality outcomes observed in patients undergoing PCI in the STEMI setting.



Elective PCI NSTEMI PCI STEMI PCI


Catheterization and Cardiovascular Interventions DOI: 10.1002/ccd.25732

The impact of LV dysfunction on mortality is attenuated across all age groups (even after adjustments). The attenuation is related to the increased prevalence of comorbid conditions and adverse procedural characteristics in the elderly cohort, but may be related to incident frailty which increases with age, and is a strong independent predictor of worse outcomes post PCI, which may serve to further diminish the importance of LV function on prognosis in such elderly patients.

Catheterization and Cardiovascular Interventions DOI: 10.1002/ccd.25732

Prognosis of LVEF after PCI Revascularization & Age


3 New Onset CHF and Revascularization

ü Patients presenting with CHF had consistently higher mortality rates than those without (irrespective of revascularization procedures) both in the hospital and from discharge to 6 months after hospitalization.

Steg PG et al. Circulation 2004;109:494-9.

Relevance of New Onset Left Ventricular Dysfunction

ü New-Onset Acute Heart Failure in Patients with Acute Myocardial infarction Underwent Successful Revascularization

6 Months Mortality rates

Steg PG et al. Circulation 2004;109:494-9.

GRACE: 1778 patients (13%) had HF (Killip class II or III) at hospital admission.

Recent & New Onset Left Ventricular Dysfunction

x4

7,064 AMI patients with Killip class I at admission underwent successful PCI from KAMIR between Oct. 2005 and Jan. 2008

Keun-Ho Park and KAMIR investigators

Death

No AHF 6,944 (98.3%)

New–onset AHF 120 (1.7%)

Relevance of New Onset Left Ventricular Dysfunction


4 LVD and haemodynamic support

Hemodynamic Support PCI in P. with Left Ventricular Dysfunction

J Interven Cardiol 2015;28:32–40

Improvement of Hemodynamic Conditions


Improvement of Global Adverse Events




No Improvement in Death rate

Conclusions

① Complete Myocardial Revascularization should be recommended in patients with LV dysfunction in presence of viable myocardium.

② A strong relationship exists between LV function and mortality. A worse LV function independently predict 30-day and long-term mortality outcomes across all indications for PCI, with the greatest adverse prognostic association in patients undergoing PCI in the STEMI setting.

③ Impact of LV dysfunction on mortality is attenuated across all age groups. The attenuation may be related to the increased prevalence of comorbid conditions, adverse procedural characteristics, and frailty in the elderly cohort which may serve to further diminish the importance of LV function on prognosis in such elderly patients.

④ Patients presenting with new onset CHF had consistently higher mortality rates than those without (irrespective of revascularization procedures) both in the hospital and at mid-term after hospitalization.

⑤ Use of hemodynamic support techniques during revascularization may improve hemodynamic conditions, but will not modify short or late death rate.

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how to assess reversible ischemia in lv dysfunction

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