Abstract
The most common cause of heart failure with reduced ejection fraction (HFrEF) is coronary artery disease. A multitude of factors come into play when deciding
whether a patient with HFrEF and coronary artery disease should have coronary artery bypass graft (CABG) surgery,
percutaneous coronary intervention, or medical therapy alone. For candidates for percutaneous
coronary intervention and CABG, evidence from large registries would suggest that
patients with 2-vessel coronary artery diseases and proximal left anterior descending
disease and all patients with 3-vessel coronary artery disease do better with CABG.
For patients that are candidates for medical therapy with or without CABG, the results
of the Surgical Treatment for Ischemic Heart Failure (STICH) trial indicate that with CABG, the reduction of mortality is
not statistically significant (hazard ratio [HR], 0.86; P = 0.12). However, CABG is superior in reducing cardiovascular deaths (HR, 0.81; P = 0.05), and the combination of cardiovascular deaths and cardiovascular hospitalizations
(HR, 0.74; P < 0.001). Patients undergoing CABG have an upfront risk that is eliminated by 2 years
and thereafter do better. The assessment of cardiac viability or reversible ischemia
does not appear to be helpful in determining which individuals will improve more with
CABG. Patients with severe mitral regurgitation who undergo CABG appear to benefit
from simultaneous valve repair but not from the addition of surgical ventricular reconstruction
of the left ventricle, although in specific patients this might be considered. The
totality of evidence would thus suggest that patients with HFrEF should be evaluated for the possibility of coronary revascularization if they are
candidates for CABG.
Résumé
La coronaropathie est la cause la plus fréquente de l’insuffisance cardiaque à fraction
d’éjection réduite (ICFER). De nombreux facteurs entrent en jeu lorsque vient le temps
de décider si un patient ayant une ICFER et une coronaropathie devrait subir un pontage
aortocoronarien (PAC), une intervention coronarienne percutanée ou un traitement médical
seul. Pour ce qui est des candidats à l’intervention coronarienne percutanée et au
PAC, les données scientifiques provenant d’importants registres ont montré que les
patients ayant des coronaropathies bitronculaires et une sténose de l’artère interventriculaire
antérieure proximale, et que tous les patients ayant une coronaropathie tritronculaire
bénéficieraient plus d’un PAC. Pour ce qui est des patients qui sont des candidats
au traitement médical associé ou non au PAC, les résultats de l’étude STICH (Surgical Treatment for Ischemic Heart Failure) indiquent qu’avec le PAC la réduction de la mortalité n’est pas statistiquement
significative (rapport de risque [RR], 0,86; P = 0,12). Cependant, le PAC est supérieur en ce qui a trait à la réduction des décès
liés à la maladie cardiovasculaire (RR, 0,81; P = 0,05), et à la combinaison des décès et des hospitalisations liés à la maladie
cardiovasculaire (HR, 0,74; P < 0,001). Les patients subissant un PAC ont un risque à court terme qui est éliminé
au cours des 2 années subséquentes et s’améliorent par la suite. L’évaluation de la
viabilité cardiaque ou de l’ischémie réversible n’apparaît pas utile pour déterminer
les individus qui s’amélioreront le plus après un PAC. Les patients ayant une régurgitation
mitrale grave qui subissent un PAC semblent bénéficier de la réparation valvulaire
simultanée, mais non de la reconstruction chirurgicale du ventricule gauche, bien
que cela puisse être envisagé chez certains patients. L’ensemble des données scientifiques
montrerait donc que les patients ayant une ICFER devraient être évalués quant à la
possibilité de revascularisation coronarienne s’ils sont candidats au PAC.
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Article info
Publication history
Published online: November 18, 2013
Accepted:
November 11,
2013
Received:
October 9,
2013
Footnotes
See page 286 for disclosure information.
Identification
Copyright
© 2014 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
