scholarly journals Routine Revascularization Versus Initial Medical Therapy for Stable Ischemic Heart Disease

Circulation ◽  
2020 ◽  
Vol 142 (9) ◽  
pp. 841-857 ◽  
Author(s):  
Sripal Bangalore ◽  
David J. Maron ◽  
Gregg W. Stone ◽  
Judith S. Hochman
Keyword(s):  
Heart Failure ◽  
Heart Disease ◽  
Ischemic Heart Disease ◽  
Unstable Angina ◽  
Medical Therapy ◽  
Left Ventricular ◽  
Ischemic Heart ◽  
Cochrane Central Register ◽  
Stable Ischemic Heart Disease

Background: Revascularization is often performed in patients with stable ischemic heart disease. However, whether revascularization reduces death and other cardiovascular outcomes is uncertain. Methods: We conducted PUBMED/EMBASE/Cochrane Central Register of Controlled Trials searches for randomized trials comparing routine revascularization versus an initial conservative strategy in patients with stable ischemic heart disease. The primary outcome was death. Secondary outcomes were cardiovascular death, myocardial infarction (MI), heart failure, stroke, unstable angina, and freedom from angina. Trials were stratified by percent stent use and by percent statin use to evaluate outcomes in contemporary trials. Results: Fourteen randomized clinical trials that enrolled 14 877 patients followed up for a weighted mean of 4.5 years with 64 678 patient-years of follow-up fulfilled our inclusion criteria. Most trials enrolled patients with preserved left ventricular systolic function and low symptom burden, and excluded patients with left main disease. Revascularization compared with medical therapy alone was not associated with a reduced risk of death (relative risk [RR], 0.99 [95% CI, 0.90–1.09]). Trial sequential analysis showed that the cumulative z-curve crossed the futility boundary, indicating firm evidence for lack of a 10% or greater reduction in death. Revascularization was associated with a reduced nonprocedural MI (RR, 0.76 [95% CI, 0.67–0.85]) but also with increased procedural MI (RR, 2.48 [95% CI, 1.86–3.31]) with no difference in overall MI (RR, 0.93 [95% CI, 0.83–1.03]). A significant reduction in unstable angina (RR, 0.64 [95% CI, 0.45–0.92]) and increase in freedom from angina (RR, 1.10 [95% CI, 1.05–1.15]) was also observed with revascularization. There were no treatment-related differences in the risk of heart failure or stroke. Conclusions: In patients with stable ischemic heart disease, routine revascularization was not associated with improved survival but was associated with a lower risk of nonprocedural MI and unstable angina with greater freedom from angina at the expense of higher rates of procedural MI. Longer-term follow-up of trials is needed to assess whether reduction in these nonfatal spontaneous events improves long-term survival.

scholarly journals Initial Invasive Versus Conservative Management of Stable Ischemic Heart Disease in Patients With a History of Heart Failure or Left Ventricular Dysfunction

Circulation ◽  
2020 ◽  
Vol 142 (18) ◽  
pp. 1725-1735
Author(s):  
Renato D. Lopes ◽  
Karen P. Alexander ◽  
Susanna R. Stevens ◽  
Harmony R. Reynolds ◽  
Gregg W. Stone ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Heart Disease ◽  
Ischemic Heart Disease ◽  
Primary Outcome ◽  
Cardiovascular Death ◽  
Left Ventricular ◽  
Ischemic Heart ◽  
Conservative Strategy ◽  
Stable Ischemic Heart Disease ◽  
History Of

Background: Whether an initial invasive strategy in patients with stable ischemic heart disease and at least moderate ischemia improves outcomes in the setting of a history of heart failure (HF) or left ventricular dysfunction (LVD) when ejection fraction is ≥35% but <45% is unknown. Methods: Among 5179 participants randomized into ISCHEMIA (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches), all of whom had left ventricular ejection fraction (LVEF) ≥35%, we compared cardiovascular outcomes by treatment strategy in participants with a history of HF/LVD at baseline versus those without HF/LVD. Median follow-up was 3.2 years. Results: There were 398 (7.7%) participants with HF/LVD at baseline, of whom 177 had HF/LVEF >45%, 28 HF/LVEF 35% to 45%, and 193 LVEF 35% to 45% but no history of HF. HF/LVD was associated with more comorbidities at baseline, particularly previous myocardial infarction, stroke, and hypertension. Compared with patients without HF/LVD, participants with HF/LVD were more likely to experience a primary outcome composite of cardiovascular death, nonfatal myocardial infarction, or hospitalization for unstable angina, HF, or resuscitated cardiac arrest (4-year cumulative incidence rate, 22.7% versus 13.8%; cardiovascular death or myocardial infarction, 19.7% versus 12.3%; and all-cause death or HF, 15.0% versus 6.9%). Participants with HF/LVD randomized to the invasive versus conservative strategy had a lower rate of the primary outcome (17.2% versus 29.3%; difference in 4-year event rate, −12.1% [95% CI, −22.6 to −1.6%]), whereas those without HF/LVD did not (13.0% versus 14.6%; difference in 4-year event rate, −1.6% [95% CI, −3.8% to 0.7%]; P interaction = 0.055). A similar differential effect was seen for the primary outcome, all-cause mortality, and cardiovascular mortality when invasive versus conservative strategy–associated outcomes were analyzed with LVEF as a continuous variable for patients with and without previous HF. Conclusions: ISCHEMIA participants with stable ischemic heart disease and at least moderate ischemia with a history of HF or LVD were at increased risk for the primary outcome. In the small, high-risk subgroup with HF and LVEF 35% to 45%, an initial invasive approach was associated with better event-free survival. This result should be considered hypothesis-generating. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01471522.

scholarly journals The Use of Selective Inhibitor of If-Channels Ivabradine in Patients with Ischemic Heart Disease, Heart Failure with High Heart Rate

Kardiologiia ◽  
2019 ◽  
Vol 59 (10) ◽  
pp. 60-65 ◽  
Author(s):  
Yu. N. Belenkov ◽  
I. S. Ilgisonis ◽  
Yu. I. Naymann ◽  
E. A. Privalova ◽  
A. V. Zhito
Keyword(s):  
Heart Failure ◽  
Heart Rate ◽  
Heart Disease ◽  
Ischemic Heart Disease ◽  
Prognostic Significance ◽  
Left Ventricular ◽  
Ischemic Heart ◽  
Left Ventricular Ejection ◽  
High Heart Rate ◽  
Ventricular Ejection Fraction

Ischemic heart disease (IHD) and chronic heart failure (CHF) belong to leading causes of death among patients with cardiovascular diseases (CVD). Modern medical approaches to the treatment of patients with CHF do not always provide a significant improvement in the quality of life, a decrease in the frequency of CHF exacerbations and hospitalizations, and an improvement of the long-term prognosis. According to the neurohumoral theory of IHD and CHF development, the blockade of the sympathoadrenal system with β-adrenoblockers (β-AB) is pathogenetically substantiated, and preparations of this group are recommended as one of the main classes of drugs for the treatment of patients with CHF. However, selection of heart rhythm slowing therapy in patients with CHF of ischemic genesis is often difficult due to the development of undesirable side effects of β-AB, intolerance and/or due to the presence of contraindications for their use. Randomized studies have shown that prescribing a combination of β-AB and If-channel blocker ivabradine for heart rate (HR) reduction or solely ivabradine when use of β-AB is impossible in complex CHF therapy, improves the left ventricle (LV) diastolic function, reducing mortality from CHF decompensation. However, the prognostic significance of the use of ivabradine in patients with CHF with preserved left ventricular ejection fraction of ischemic genesis with heart rate higher than 70 beats/min receiving maximum tolerated doses of β-AB remains not fully investigated.

scholarly journals The natural history of myocardial disease in dialysis patients.

1991 ◽  
Vol 2 (1) ◽  
pp. 2-12 ◽  
Author(s):  
P S Parfrey ◽  
J D Harnett ◽  
P E Barre
Keyword(s):  
Risk Factors ◽  
Heart Failure ◽  
Congestive Heart Failure ◽  
Heart Disease ◽  
Natural History ◽  
Ischemic Heart Disease ◽  
Dilated Cardiomyopathy ◽  
Left Ventricular ◽  
Ischemic Heart ◽  
Dialysis Patients

Among dialysis patients, only 23% have a normal echocardiogram, about 10% have recurrent or chronic congestive heart failure, and 17% have asymptomatic ischemic heart disease. The predisposing factors for congestive heart failure are dilated cardiomyopathy, hypertrophic hyperkinetic disease, and ischemic heart disease. Dilated cardiomyopathy, a disorder of systolic function, includes among its risk factors age, hyperparathyroidism, and smoking. Hypertrophic disease results in diastolic dysfunction, and its predictors include age, hypertension, aluminum accumulation, anemia, and, perhaps, hyperparathyroidism. Ischemic heart disease is due to the presence of coronary artery disease and also to nonatherosclerotic disease caused by the reduction in coronary vasodilator reserve and altered myocardial oxygen delivery and use. The clinical outcome of congestive heart failure is comparable to that of nonrenal patients with medically refractory heart failure. Left ventricular hypertrophy is an important independent determinant of survival. A subset have hyperkinetic disease with severe hypertrophy and have a bad survival, as low as 43% have a 2-yr survival after the first admission to hospital with cardiac failure. The prognosis for those with dilated cardiomyopathy is less severe but is worse than those with normal echocardiogram. The survival of patients with symptomatic ischemic heart disease was little different from that of patients without symptoms, suggesting that the underlying cardiomyopathies had an adverse impact on survival independent of ischemic disease. Much research needs to be undertaken on the risk factors, natural history, and therapy of the various types of cardiac disease prevalent in dialysis patients.

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