Heart disease is the most frequent cause of heart failure and, in some observational studies, transluminal coronary angioplasty (TCA) could help improve ventricular function.
The only major randomized study to compare myocardial revascularization surgery (MRS) vs. medical treatment in patients with ventricular function impairment was the STICH study, which showed no difference at 5 years, but benefit in favor of MRS at 10 years.
Available evidence on angioplasty is scarce, as it has been excluded from most analyses on ventricular function impairment.
The (randomized, prospective, multicenter) REVIVED study included 700 patients with ventricular impairment who underwent TCA plus optimal medical treatment (OMP) vs. patients who received OMP.
The study randomized 347 patients to TCA and 353 to OMT.
Inclusion criteria were left ventricular ejection fraction ≤35%, extensive coronary artery disease (defined by BCIS classification ≥6), and demonstrated viability in at least 4 disease areas eligible for TCA.
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The primary endpoint (PEP) was all-cause mortality or hospitalization within 24 months.
There was no difference between groups; the mean age was 70 years old, about 90% of patients were men, 40% had diabetes, 53% had prior acute myocardial infarction (AMI), 20% had undergone TCA, and 4% had undergone MRS.
Functional class for heart failure was I-II in more than 70% of patients, NT-proBNP was 1400 pg/mL, 66% of patients had no angina, and 30% angina I-II.
Ejection fraction was 27%, complexity of coronary artery disease was 10; 14% of patients had left main coronary artery lesion, 40% had 3-vessel disease, and 50% had 2-vessel disease.
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The PEP was 37.2% vs. 38% (hazard ratio [HR]: 0.99; 95% confidence interval [CI]: 0.78 to 1.27, p = 0.96) for TCA and OMT, respectively. There was also no difference in all-cause mortality: 31.7% vs. 32.6% (HR: 0.98; 95% CI: 0.75 to 1.27). There was also no difference in re-hospitalizations for heart failure: 14.7% vs. 15.3% (HR: 0.97; 95% CI: 0.66 to 1.43). The rates for AMI, need for an implantable cardioverter-defibrillator, and bleeding were similar, but the need for unplanned revascularization was greater in those who received OMT.
There were also no differences in the increase in ejection fraction at 6 months and at 1 year.
The quality of life (measured through the Kansas City Cardiomyopathy Questionnaire, KCCQ) was superior for TCA at 6 months and 12 months, but there were no differences at 24 months.
Conclusion
Patients with severely impaired left ventricular function receiving optimal medical treatment did not experience lower incidence of death from any cause or hospitalization for heart failure.
Dr. Carlos Fava.
Member of the Editorial Board of SOLACI.org.
Original Title: Percutaneous Revascularization for Ischemic Left Ventricular Dysfunction.
Reference: Divaka Perera, et al. NEJM August 27,2022, at DOI: 10.1056/NEJMoa2206606.
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