Predicting therapeutic benefit from myocardial revascularization procedures: are measurements of both resting left ventricular ejection fraction and stress-induced myocardial ischemia necessary?
BACKGROUND
We hypothesized that ejection fraction (EF) best predicts cardiovascular death but only measures of ischemia predict relative survival benefit from revascularization compared with medical therapy.


RESULTS
We followed up 5366 consecutive patients without prior revascularization who underwent stress electrocardiography-gated myocardial perfusion single photon emission computed tomography (MPS) for 2.8 +/- 1.2 years, during which 146 cardiac deaths occurred (2.7%, 1.0%/y). The treatment received within 60 days after MPS was used to define the subgroups (revascularization in 402 patients, with cardiac death occurring in 6.2%, vs medical therapy in 4964 patients, with cardiac death occurring in 2.4%; P < .0001, chi2 = 18.7). Adjustment for nonrandomized treatment assignment used a propensity score based on logistic regression modeling of referral to revascularization. The percent of myocardium that was ischemic was the most important predictor of revascularization. The overall model (multivariate chi2 = 728, c index = 0.89, P < 10(-5)) was used as a propensity score. Cox proportional hazards analysis, assessing the relationship between MPS results, non-MPS covariates, and cardiac death, revealed that EF was superior to percent ischemic myocardium in the prediction of cardiac death after adjustment for pre-MPS data and the propensity score. However, an interaction between percent ischemic myocardium and revascularization was present such that, irrespective of EF, patients with little or no ischemia had an improved survival rate with medical therapy, whereas with increasing ischemia, progressive improvements in survival rate were noted with revascularization.


CONCLUSIONS
Although EF predicts cardiac death, only inducible ischemia identifies which patients have a short-term benefit from revascularization.
Hachamovitch
Rory
R
Cardiovascular Division, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, Calif, USA.
Rozanski
Alan
A
Hayes
Sean W
SW
Thomson
Louise E J
LE
Germano
Guido
G
Friedman
John D
JD
Cohen
Ishac
I
Berman
Daniel S
DS
D003324:Coronary Artery Disease / Q000401:mortality* / Q000601:surgery*; D005080:Exercise Test / Q000706:statistics & numerical data; D017202:Myocardial Ischemia / Q000401:mortality* / Q000517:prevention & control; D009204:Myocardial Revascularization / Q000706:statistics & numerical data*; D017063:Outcome Assessment, Health Care / Q000379:methods*; D015995:Prevalence; D011379:Prognosis; D019275:Radiopharmaceuticals; D015203:Reproducibility of Results; D012146:Rest; D018570:Risk Assessment / Q000379:methods; D012307:Risk Factors; D012680:Sensitivity and Specificity; D013318:Stroke Volume; D016019:Survival Analysis; D015996:Survival Rate; D017256:Technetium Tc 99m Sestamibi; D015899:Tomography, Emission-Computed, Single-Photon / Q000706:statistics & numerical data; D014481:United States / Q000453:epidemiology; D018487:Ventricular Dysfunction, Left / Q000401:mortality / Q000517:prevention & control
D019275:Radiopharmaceuticals; D017256:Technetium Tc 99m Sestamibi