Severe Left Ventricular Dysfunction: Evolving Revascularization Strategies

Transcription

1 Severe Left Ventricular Dysfunction: Evolving Revascularization Strategies Robert O. Bonow, MD, MS, MACC Northwestern University Feinberg School of Medicine Bluhm Cardiovascular Institute Northwestern Memorial Hospital No Relationships to Disclose

2 1 Year Survival Rate (%) Prognosis in Chronic CAD Influence of LV Ejection Fraction 88 74% % 5% 62% 56% % 2 2 Medical Surgical Medical Surgical Medical Surgical EF >5% EF 35-5% EF <35% from Muhlbaier et al, Circulation 1992;86:II-198

3 Increase in Survival (%) Prognosis in Ischemic LV Dysfunction Increase in Survival by Revascularization 6 55% 57% % 41% 44% 3 3% 2 1 1%

4 Increase in Survival (%) Prognosis in Ischemic LV Dysfunction Increase in Survival by Medical Therapy % [43,91] 9% [7,96] % [2,68] 1 ACEi / ARB ACEi / ARB + β blocker ACEi / ARB + β blocker + ICD / CRT from Yancy CW, J Am Heart Assoc 212;1:16-26

5 Surgical Treatment for Ischemic Heart Failure

6 STICH Trial 1212 patients with EF <35% 99 sites in 22 countries Primary Endpoint: All-cause mortality Secondary Endpoints: CV mortality Death + CV hospitalization Death + HF hospitalization

7 Mortality Rate STICH Primary Outcome All-Cause Mortality.8 Medical therapy 1212 patients EF <35%.6 HR 95% CI P =.123 Medical therapy Years After Randomization Velazquez et al. N Engl J Med 211;364:

8 CV Mortality Rate STICH Secondary Outcome Cardiovascular Mortality.8 Medical therapy.6 HR 95% CI P =.5 Medical therapy Years After Randomization Velazquez et al. N Engl J Med 211;364:

9 Death or CV Hospitalization STICH Secondary Outcome Death + CV Hospitalization.8 Medical therapy Medical therapy HR 95% CI P < Years After Randomization Velazquez et al. N Engl J Med 211;364:

10 Mortality Rate STICH Secondary Outcome All-Cause Mortality Treatment Received.8 Medical therapy.6.4 HR 95% CI.7.58,.84 P <.1 Medical therapy Years After Randomization Velazquez et al. N Engl J Med 211;364: Doenst et al. Circ Heart Fail 213;6:443-45

11 Mortality Rate STICH Secondary Outcome All-Cause Mortality Per Protocol.8 Medical therapy.6.4 HR 95% CI.76.62,.92 P =.5 Medical therapy Years After Randomization Velazquez et al. N Engl J Med 211;364: Doenst et al. Circ Heart Fail 213;6:443-45

12 STICH Quality of LIfe KCCQ: Overall Summary KCCQ Overall Summary Medical Medical alone Medical Is STICH a negative trial or a positive trial? 55 Baseline 4 mo 12 mo 24 mo 36 mo Mark et al, Ann Intern Med 214;161:

13 Myocardial Revascularization in Patients with LV Dysfunction The STICH Trial: Are there subsets who benefit from? Myocardial viability

14 Mortality Rate Myocardial Revascularization in Patients with LV Dysfunction The STICH Trial: Are there subsets who benefit from? Myocardial viability.8 Without Viability With Viability.6 MED (33 deaths) (25 deaths).56 MED (95 deaths) (83 deaths) Years Following Randomization Interaction P value Years Following Randomization Bonow et al. N Engl J Med 211;364:

15 Mortality Rate Myocardial Revascularization in Patients with LV Dysfunction The STICH Trial: Are there subsets who benefit from? Myocardial viability The Heart Trial.8 8 With Viability With Viability.6 6 Medical therapy (n=69) Revascularization (n=69) MED (95 deaths) (83 deaths) n=138 p=ns Years Following Randomization Years Following Randomization from Cleland et al, Eur J Heart Fail 211;13: Bonow et al. N Engl J Med 211;364:

16 Patients with ESVI 84 ml/m 2 Bonow et al, JACC Cardiovasc Imaging 215;8:

17 Patients with ESVI 84 ml/m 2 Patients with ESVI >84 ml/m 2 Bonow et al, JACC Cardiovasc Imaging 215;8:

18 3-Year Mortaltiy (%) Revascularization vs Medical Therapy in Patients with Left Ventricular Dysfunction 8 6 n=36 Medical p=ns Revascularization Amount of Compromised Viable Myocardium (%) from Tarakji et al, Circulation 26;113:23-237

19 Myocardial Revascularization in Patients with LV Dysfunction The STICH Trial: Are there subsets who benefit from? Myocardial ischemia

20 Mortality Rate Myocardial Revascularization in Patients with LV Dysfunction The STICH Trial: Are there subsets who benefit from? Myocardial ischemia No Ischemia Ischemia.6.4 MED (31 deaths) (22 deaths).39 MED (56 deaths) (47 deaths) Years Following Randomization Years Following Randomization Panza et al. J Am Coll Cardiol 213;61:

21 Log hazard ratio Impact of Ischemia and Scar on Therapeutic Benefit of Coronary Revascularization N=13,555 Medical therapy.5. P<.1 Revascularization Magnitude of ischemic myocardium associated with survival benefit with revascularization Total myocardium in ischemic (%) patients without prior MI No such benefit in patients with prior MI Role of ischemia not significant in patients with >1% myocardial scar Hachamovich et al, Eur Heart J 211;32:

22 Mortality Rate Myocardial Revascularization in Patients with LV Dysfunction The STICH Trial: Are there subsets who benefit from? Biomarkers.8.6 BNP Tertile 1 Tertile 2 Tertile 3.39 BNP Tertile 1 Tertile 2 Tertile 3 Medicine Tertile HR 95% CI Tertile HR 95% CI T2 : T ,3.34 T3 : T ,4.5 T2 : T ,3.9 T3 : T , Years Following Randomization Years Following Randomization Feldman et al. Circ Heart Fail 213;6:

23 Mortality Rate Myocardial Revascularization in Patients with LV Dysfunction The STICH Trial: Are there subsets who benefit from? Functional capacity PAS >55 + 6MW 3m PAS MW <3m.6.4 MED HR 95% CI P value.71.52, MED HR 95% CI P value.95.75, P= P= Years Following Randomization Years Following Randomization Stewart et al. JACC Heart Fail 214;2:

24 Mortality Rate Myocardial Revascularization in Patients with LV Dysfunction The STICH Trial: Are there subsets who benefit from? CAD severity, EF, ESV Factors 1 Factor MED (31 deaths) (22 deaths) HR 95% CI P value.71.36, P= MED (56 deaths) (47 deaths) HR 95% CI P value , P= Years Following Randomization Years Following Randomization Panza et al. J Am Coll Cardiol 214;64:

25 Myocardial Revascularization in Patients with LV Dysfunction Factors to consider: More important Severity of LV dysfunction Severity of LV remodeling Angiographic severity of CAD Functional capacity Less important Extent of myocardial viability Severity of myocardial ischemia Biomarkers Velazquez and Bonow. J Am Coll Cardiol 215;65: